PUNE: Ruby Hall Clinic, a leader in pioneering medical treatments in Pune, has achieved a significant medical breakthrough with the successful performance of Maharashtra’s first Phrenic Nerve Neuromodulation surgery. This rare and complex procedure, led under the expert care of the Intensivist Dr. Kapil Zirpe, Head of the Neuro Trauma Unit at Ruby Hall Clinic, and performed by Dr. Manish Baldia, Consultant Functional Neurosurgeon, has enabled a 58-year-old man, Mr. Sanjay Yashwant Pai, to breathe independently after being dependent on a mechanical ventilator for six months due to a spinal cord injury.

Mr. Pai, who had suffered a high cervical spine injury (C3-C4 fracture) from a fall in his bathroom on July 25, 2024, was initially treated at another hospital. Despite undergoing C4 corpectomy, C3-C4 discectomy, and a range of spinal fusion surgeries, he remained quadriplegic and ventilator-dependent. Imaging studies confirmed a C3-C4 anterior subluxation and spinal cord compression, though no acute brain changes were observed.

Recognizing the need for advanced care, Mr. Pai was transferred to Ruby Hall Clinic on September 19, 2024, for further management, including neuro-monitoring, ventilator weaning support, and rehabilitation. Upon arrival, he was conscious, oriented, on mechanical ventilation, and undergoing PEG (Percutaneous Endoscopic Gastrostomy) feeding and antibiotic therapy.

Aware of the serious risks posed by prolonged ventilator use, including ventilator-associated pneumonia, stress ulcers, deep vein thrombosis, and pulmonary embolism, the medical team (Dr Richa Singh, Dr Manish Baldia, Dr Zirpe with his ICU team,  and Dr Grant) at Ruby Hall Clinic chose to perform the Phrenic Nerve Neuromodulation surgery. This advanced surgical therapy stimulates the diaphragm, the major muscle required for breathing, and provides an essential solution for patients with neuromuscular weakness due to high cervical spinal cord injuries.

Dr. Manish Baldia, Consultant Functional Neurosurgeon at Ruby Hall Clinic, who performed the surgery, said, “Despite all the extensive weaning efforts, we were unable to wean him, but soon after phrenic nerve stimulation surgery, we could notice a remarkable improvement in his breathing.   This was a highly delicate and rare procedure in which we placed a small device near the phrenic nerve. With the help of this device, we were able to activate and control Mr. Pai’s diaphragm externally through a remote and initiate the process of ventilator weaning. We programmed the stimulator as per the patient’s physiological response, gradually enhancing diaphragm strength without inducing fatigue. The success of this surgery provides a new hope for patients with severe spinal cord injuries and long-term ventilator dependence.”

Following the surgery, Mr. Pai showed excellent recovery. Gradually, his ventilator support was reduced, and by April 28, 2025, he was successfully shifted to the general ward for continued rehabilitation.

Dr. Purvez Grant, Chief Cardiologist, Managing Trustee, and Chairman of Ruby Hall Clinic, remarked, “At Ruby Hall Clinic, innovation and patient-centric care are at the heart of everything we do. Successfully performing Maharashtra’s first Phrenic Nerve Neuromodulation surgery showcases our commitment to pushing the boundaries of what is possible in medical care and giving our patients a second chance at life.” This remarkable achievement was made possible through the dedication and expertise of Ruby Hall Clinic’s ICU team (NTU2), setting a new standard for critical care and neurosurgical rehabilitation in Maharashtra

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She presented with a range of critical symptoms, including seizures, drowsiness, and unequal pupils, which indicated a potentially life-threatening brain injury. Suspecting a brain herniation and internal bleeding, the team of doctors led by Dr. Parth Dalal, consultant Pediatric Intensivist, started emergency protocols right away to lower the intracranial pressure (ICP) in her skull and stabilize her condition. A quick CT scan was performed, which confirmed the presence of a left-sided subdural hemorrhage (SDH) and signs of brain herniation.

After diagnosing her condition, doctors performed a craniectomy (brain surgery) to relieve pressure and prevent future brain injury. During the procedure, a large blood clot was removed, and a section of the skull was temporarily removed to allow the brain to enlarge safely without increasing intracranial pressure. After ensuring stability in her intracranial pressure, she underwent orthopedic surgery for a femur fracture, a flexible rod was placed for fracture stabilization, which will be removed in the follow-up procedure.

Anushree was taken to the High Dependency Unit (HDU), where she continued to receive intensive care, including physiotherapy and feeding. She began showing signs of neurological improvement, including recovering consciousness, following orders, and improving motor function. She could open her eyes, recognize her parents, and respond appropriately.

Speaking about the case, Dr. Parth Dalal, consultant Pediatric Intensivist, at Manipal Hospital, Kharadi, Pune, said, “The forced hit on the ground caused brain herniation and subdural hemorrhage on the left side of the brain. In such cases, there’s a pressure created from within the skull that pushes against the brain’s tissues and can lead to paralysis, decreased breathing, and even death. While performing the craniectomy, we removed a large blood clot to release the intracranial pressure. Despite her frequent seizures and hemodynamic instability, with constant observation in the ICU, medication, and therapy, her condition eventually stabilized, including electrolyte control and breathing support. She was discharged after 9 days of hospital stay. While her condition improves, we observe her closely to ensure her steady recovery.”

A multidisciplinary team of pediatric intensivists, neurosurgeons, orthopedicians, anaesthesiologists, nursing staff, and physiotherapists responded quickly, saving Anushree’s life and facilitating her miraculous recovery.

Admission Date of Patient:  9^th June 2024

Discharge Date of Patient: 17^th June 2024

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