All posts by : admin_hrs

Over the last few decades, scientific advancements and innovations have led to appreciable
changes in our lifestyle. Substantial developments and technological evolution in the healthcare
industry have made medical treatments more accessible and affordable. Medical tourism is being
promoted by the government and stimulated by the corporate boom in medical care. As a result,
India is fast emerging as a medical tourism hub for patients from across the world. International
tourists coming to India for medical treatment demand high-quality care and world-class
devices/equipment. High-end medical technology products are largely imported to India constituting
about 75% of the Indian medical technology market.
The complexity in surgeries faced by surgeons declined as new innovations were evolved; such
evolution’s in the computer-assisted technologies effectuated navigation based surgeries around the
globe.
However navigation in surgery still remains a fantasy for surgeons working in low budget hospitals
and patients demanding affordable surgeries. This drawback is due to the high pricing and bulky
structuring of the imported navigation systems specifically built for foreign infrastructure.
Considering these circumstances we proudly developed the first navigation system in India with a
compact, affordable and consumable less architecture.
Some of the main surgical challenges posed uneasiness in locating & reaching the anatomical
targets and positioning the implants. Surgical navigation met these complexities and resulted in safer
and less invasive navigation.
The exponential growth of computer processing capabilities in connection with the advent of medical
imaging led to the precision and safe targeting of anatomy a reality.
Navigation has quickly become an integral part of the surgical routine of clinicians and an important
surgical decision-making tool.
The idea of navigation has gained primary significance in operating on the most delicate organ of the
human body, the brain. Surgical removal remains difficult in patients with small and deep-seated
brain lesions, multiple tumors or tumors in important functional areas of the brain. These challenges
associated with the risks of operating on a delicate organ in a minimally invasive manner has made
neuro-navigation and important aspect of neurosurgery.
In the forthcoming years we can experience considerable advancements in this field for mitigating
further surgical risks and enhancing the patient outcomes.

HRS Navigation has been recognized for its innovative and finest navigation systems ever since the
Director Mr. Arpit Paliwal began his inception in 2015 to turn his vision into reality. Starting up the
first computer-assisted navigation system in India with the most promising technology has granted
the privilege to win numerous accolades. On account of its accomplishments in accordance with the
high-quality services, the company was honored to receive NASSCOM’s EMERGE 50 award for India’s Most Innovative Top 50 Emerging Software Product Companies in the year 2017. The
National Association of Software and Service Companies(NASSCOM) is a trade association of
Indian Information Technology and Business Process Outsourcing industry. NASCOM’s EMERGE 50
awards compendium covers the most promising and innovative startup initiatives by a mixed genre
of companies, honoring the top 50 high potential product outcomes in software and technology. This
award was a milestone in the proliferating journey of our team. NASSCOM Product Conclave
evaluated and assessed software-based companies on numerous parameters, including product
value, market differentiators, customer satisfaction, market visibility, scalability, financial growth and
most importantly innovation impact. They screened and scrutinized the submissions on more than
30 business and technology parameters. The winners are chosen after the scrutiny process by a
panel of eminent jury.
Breaking through the milestone with flying colors Arpit Paliwal commented “We are extremely
honored and humbled to be receiving such a prestigious award of NASCOM’s recognitions for our
efforts and services. I’m earnestly grateful for the recognition HRS team received and we will stay
committed to advance further at the forefront of the technology in the coming years.“

Medical devices of different brands or models may vary greatly in terms of their design, function,
operation, price, quality and user-friendliness. Currently the Indian medical device industry is
dominated by MNC’s with nearly 85% of the demand being met through imports.
The Indian medical device industry appreciates the Government for the initiatives taken to increase
the manufacturing and productivity of medical devices in our country. ‘Make in India’ is one of the flagship campaigns intended to bring self sufficiency and develop India as a global manufacturing
hub. ‘Make for India’ is also an important aspect that has to be considered by medical companies as
it specifies R&D and innovation that results in a product designed to meet India’s appropriate needs
and price points.
How do you know if the investment on the medical device is apt and beneficial to you?
Medical device manufacturing is expanding at a significant double digit growth rate in India. Hence it
is mandatory to compare relevant features and certifications of imported devices and the Indian
made devices to get an indepth idea of the product.
▪ Device Quality :- Quality in medical device is a significant factor considered as it can have a direct
impact on the patient safety and satisfaction by superior treatment. High quality denotes accuracy,
precision and durability. It is graded easily based on the documents prepared by the manufacturer.
▪ Technology :- Convenience and comfortability is directly proportional to the technological
advancements. User friendliness is at the forefront of medical device development. Hence cross
checking the technology used in different brands will help in evaluating the device outcomes.
Technical expertise also adds value to the credibility of the company and precision in the device
readings or outcomes.
▪ Certifications :- Relevant quality certifications and warranty cards are two key pointers that add
value to the status of the company. Hence it is necessary to make sure that the device is certified
and accredited by authorized certifying bodies.
▪ After Sales Support and Service :- Smooth functioning at your medical facility depends on how fast
things get fixed. Hence after sales, support, service maintenance and repairs must be ensured.
▪ Compatibility :- The medical equipments and instruments must be compatible with other devices
and architecture of the health unit. The Indian infrastructure, methods used in the operation and
procedures may differ from other foreign countries depending on the function of the device.
▪Customer Satisfaction :- Reviewing about the customer satisfaction, happiness and relationship with
the medical device company will give you a better idea of how they are going to deal with you in the
future if you purchase their product.
▪ Cost :- This is one of the determining factors for healthcare providers. If the model you are planning
to purchase has all the features necessary for your needs and promises the above mentioned six
factors then its better to not get caught up by the hype of extensive features or architecture of
expensive imported products.

World Parkinson’s Day is celebrated on April 11th every year, an occasion hosted with different
themes every year to unite, raise awareness and advance treatment. The day marks the birthday of
Dr. James Parkinson as he was the first person to medically describe this disease as a neurological
syndrome in 1817.
Parkinson’s disease is a neurodegenerative disorder that mainly affects the motor system. The
breakdown or death of certain nerve cells or neurons that produce a chemical messenger in your
brain called dopamine causes the symptoms of this disease.
In the initial stages of the disorder small tremors and rigidity in movements occur. But in later stages
individual may experience hallucinations, delusions, confusion and emotional fluctuations.
Some of the other main complications in the later stages include thinking difficulties, chewing and
swallowing problems, sleep disorders and consitpation.
The cause of this disorder is unknown but researchers have identified that specific genetic mutations
may cause Parkinson’s disease. Exposure to certain toxins or environmental factors may also
increase the risk of developing this disease.
Though the prevalence of this disease is much more prominent in other countries compared to India,
the total number of cases is much higher as a result of a large population. The current incidence of
this disease is around 70 out of 100,000 people in India.
In India studies were conducted to understand the symptomatic variations and severity in patients.
Some of them are mentioned below
▪A study by Muthane et.al, at NIMHANS compared the normal human brains of India and United
Kingdom. The neurons which were melanized in substantia nigra with respect to their age were
compared. Indians had a lower level of melanised neurons compared to UK citizens. Which gives us
an idea of relatively lesser incidence of this disease in India.[1]
▪Denny and Behari from AIIMS studied about motor fluctuations and found that more than half were
affected with LID (Levodopa-induced dyskinesia)[2]
▪Naskar et.al studied the effect of deep brain stimulation (DBS) on long latency event-related
potentials, which showed an increased N100 latency, reflecting the worsening of orientation
response with STN stimulation.[3]
▪To explore the functional somatotopy of globuspallidus (GPi), Kishore et.al conducted a study in
which 29 patients underwent pallidotomy.[4]
Since the symptoms vary to a large extent depending on the patient, a comprehensive
multidisciplinary approach is used in India to slow down the disease process.
Some of them include
▪Drug therapy:- medications to treat dopamine levels are used in this therapy.
▪Occupational therapy:- therapeutic activities to manage the daily routine of a patient.
▪Speech and swallow therapy:- Pathologist will work on improving speech and swallowing.
▪Respiratory therapy:- therapist works on increasing the functioning of respiratory muscles.
In India, different modes of treatments are gaining importance. Ayurveda is one of the most common
alternative medicine available in the country. Their treatment includes a mixture of cow’s milk,
Mucuna pruriens, Hyoscyamus reticulatus seeds, withania somnifera, and Sida cordifolia roots.[5]
Physical therapy, which is noninvasive, is another mode of treatment. Srikumar from AIIMS
conducted a study on 28 patients with pharmacological therapy. They found that consistent and
systematic program of exercises improves the activities of daily living, and gait.[6]
Fetal cell transplants, stem cell or gene therapy are other procedures that can reduce the symptoms
and need for dopamine replacement drugs.
This condition cant be cured, but through these approaches the levels of symptoms can be varied
and controlled to a large extend. Strategic execution to slow down or reverse the progression of this
disease has always helped the patients to overcome the disabilities.
References
1.Muthane U, Yasha TC, Shankar SK. Low numbers and no loss of melanised nigral neurons with
increasing age in normal human brains from India.[Google Scholar]
2.Denny AP, Behari M. Motor fluctuations in Parkinson’s disease.[Google Scholar]
3.Naskar S, Sood SK, Goyal V. Effect of acute deep brain stimulation of the subthalamic nucleus on
auditory event related potentials in Parkinson’s disease.[Google Scholar]
4.Kishore A, Panikar D, Balakrishnan S, Joseph S, Sarma S. Evidence of functional somatotopy in
GPi from results of pallidotomy.[Google Scholar]
5.Nagashayana N, Sankarankutty, Nampoothiri MR, Mohan PK, Mohankumar KP. Association of
L-Dopa for recovery following Ayurveda medication in Parkinson’s Disease. [Google Scholar].
6.Srikumar V, Wadhwa S, Singh U, Yadav S, Behari M, Dwivedi SN. Structured Rehabilitation
exercise program in Parkinson’s Disease.[Google Scholar]

In the Indian health care industry the demand for refurbished medical devices are intensifying at a
faster rate. As the health care centers face potential funding cuts in this era refurbished devices
would be a decisive resource in providing required facilities with considerable savings. The care
providers view these devices as an alternative to new medical devices. It appears attractive due to
the affordability or reduction in the price as compared to a new equipment.
Constantly evolving technological developments of a device is one of the major reasons for boosting
the growth of refurbished medical devices. Refurbishing of a medical device involves conditioning,
installation of hardware/software updates and repairing without varying the intended use of the device.
Vetting the manufacturer that sells standard refurbished products is a hard process, but if executed
properly can end up in a reliable and affordable product. The cost associated with a refurbished
device will be 70-80% lesser than a new device with the same operational functions.
Major players operating in the global refurbished medical equipment market include Siemens
Healthineers, Soma Technology, GE Healthcare and Philips
It seems interesting and affordable is’nt it?
However the refurbished medical device business varies from manufacturers and vendors to a large
extend. There is no universal acceptance, certifications or warranty coverage that is common to all
the remanufacturers. Some may follow a standardized workflow of disassembling, inspecting,
replacing the worn parts and conditioning it to look as good as new, concurrently there will be
vendors that sell reconditioned medical devices with no thorough inspection or replacements
spruced up to look like new devices.
How to make sure that you are purchasing from a reputable refurbishment medical device company?
Its very essential to ensure that the vendors sell high quality refurbished devices. Here are some
important points you should consider during the purchase
▪Replacement parts:- The parts that are replaced should be original certified manufacturer parts.
Usage of substitute low-quality replacements shouldn’t be accepted.
▪Documentation:- Make sure that the company and device hold relevant certifications.
▪Model number:- The model number, software and accessories should be related to the original
equipment.
▪Repair and Testing:- Servicing and calibration after sales must be certified and ensured.
▪Warranty:- Confirm that there is warranty coverage for a considerable period of time at least.
▪Manuals:- Ensure detailed manuals are provided along with the device for easier operation.
Even if these points are satisfied refurbished devices can’t be better than a new medical device due
to its better durability and fresh components. Another determining factor can be the role played by
that device. Generally, care providers prefer new devices when a vital piece of equipment that can
jeopardize a life or well being of a patient and can be used for a long time purpose is purchased.
However, extra time doing the research on the company, quality documents, certifications and other
above mentioned points are well inspected then buying a refurbished medical device for your
practice is also an option.

Fiducial markers gained importance in the medical device industry as it added ease and accuracy to
the surgical procedures. Skull fixated fiducial markers are used as points of reference in the field of
view of an imaging system. This helps in providing a navigation integrated surgery with a 3-D map.
Skin mounted fiducials and bone implanted fiducials are the main two modes of competing versions
in markers. Bone implanted fiducial markers are gold seeds or stainless steel screws that act as
radiologic landmarks. Cylindrical gold fiducials are commonly used as bone implanted fiducials for
references, due to the high levels of contrast resulting in better accuracy. Skin mounted fiducials
require normal sticking on to the anatomical fiducial points of the patient for preoperative registration.
Registration is the central operation required to align the physical head and radiographic images of the patient prior to a surgery. Hence advancements for a better modality of preoperative registration
has been taking place world wide.
What are the main complications and drawbacks caused while using fiducial markers in a brain
surgery?
Fiducial markers has become outdated and aren’t tolerated by some of the patients and surgeons
due to the following reasons.
▪Invasive surgical procedure:- The bone-implanted fiducials are invasive as it involves a scalp
incision for each marker placement followed by screwing into the exposed bone.
▪Fiducial localization error:-Fiducial localization is the process of estimating the geometrical position
of a fiducial point, such as the centroid of a fiducial marker. Skin affixed fiducial markers are mostly
prone to these errors when the skin moves, swells or shrinks, efficacy is based on the fixed position of the marker before and during the treatment.
▪There are extra costs associated with Fiducial marker implantation. The implantation requires gold
seeds, needle placement, and transrectal ultrasound. The consumables make the surgery even
more pricey.
▪Time consumption:- Added time is required in the operating room for the fiducial implantations. If the
image is acquired pre-operatively with bone implanted fiducials then it requires a more complex
workflow of imaging procedures with the implants, outside the operating room. Skin affixed markers
have a simpler and easier workflow but the accuracy may or may not get affected as the skin is
movable. Increased brain swelling/shrinkage or stretching of the skin by the pinning of the head on
to the Mayfield are some examples.
Fiducial-less navigation systems have evolved with technical feasibility and standard automation
procedures lately. easyNav is a fiducial-less and consumable-less navigation system that uses autoclaved patient trackers for pre-operative registrations. In this modality anatomical landmarks are
taken on the prominent points of the physical head such as tragus, canthus and nose junction for
point registration. The procedure is followed by surface registration for sub-millimeter accuracy. This
mode of surgical navigation does not involve loss of potential time, discomfort caused to the patient
or surgeon, expensive consumables and morbidity of extra-operative skull-fixated fiducial placement.

A surgical C-arm and an Optical Navigation system works together in synergy to facilitate a Spinal
surgery platform. Continuous guidance of surgical tools relative to any pre and intra-operatively
acquired 2D and 3D datasets assures reduced operative time, less radiation, and enhanced
precision.

Why should you consider easyNav for C-arm integration?
Calibration and Navigation of other surgical tools such as drill and screwdriver with
● Reduced X-ray radiation exposure:- It assures less radiation by minimizing the number of
C-arm shots taken and real-time guidance with the acquired 2D, 3D images.
● Increased Accuracy:- The automatic registration of the anatomical structures with reference
to the spine marker delivers more accurate pedicle screw placement and real-time image
guidance.
● An approach of minimally invasive spine surgery:- real-time guidance with navigable
instruments.
● Accurate planning of incisions and screw placement trajectories.
● Reduced Anatomical shift error.
● Improved ergonomics for multi-planar imaging due to greater C-arm mobility in comparison
to conventional fluoroscopy.
● Standardized Clinical Workflow.
● Calibration and navigation of other surgical tools with our custom attachment spine trackers.

● Minimizes the continuous repositioning of the C-arm during the case, which in turn reduces
the intra-operative imaging time.
The prime factor of easyNav Spine Navigation comes from the capacity to be integrated with any
version of C-arm ranging from flat panel or conventional C-arms to the latest versions.

The Healthcare industry is one of India’s rapidly growing and largest sectors contributing
approximately 60% of the industry’s total revenue. A wide range of employability and startup
innovations associated with the revenue developed to drive the industry. It comprises of hospitals,
medical devices, telemedicine, clinical trials, medical equipment, integration of health insurance and
boom of medical tourism.
In the period of the 1950s to 2000s there was a substantial growth in the facilities provided by the
healthcare industry. But the rapid multiplication in the enormous growth of population affected the
ratio of medical practitioners per number of citizens drastically. However the advancements in the
public and private sectors managed to overcome this challenge by the first decade of the 20th century. The facilities provided by the public sector funded by the Government are provided free of
cost or at subsidized rates to the citizens.
Indian healthcare industries also comprises of homeopathy and ayurveda which are rapidly gaining
prominence overseas. Due to the progressive nature of our nation, several foreign companies are
interested in investing in our country.
2020 marks the beginning of a new decade forecasted to have a multiplied three-fold increase to Rs
6.2 trillion in the healthcare market. The digitalization, emerging diagnostic technologies, tools in
telemedicine and artificial intelligence play a major role in paving the way for this estimate. Remote
consultations of medical professionals through media facilities and digitalization of records in
hospitals for accurate, up to date and detailed information of the patient are being transformed.
Developments of sophisticated robotic surgical interventions and world-class implants in deep brain
surgeries are gaining significance and attracting investors from foreign countries. India also meets
the 15 country-average in the usage of artificial intelligence within the healthcare domain.
Treatment for major surgeries in India costs approximately around 15-20% of that in economically developed countries. Skilled medical professionals, Indian infrastructure and continuous innovations
of world-class affordable medical devices and diagnostic equipments have intensified and escalated
India’s position as a preferred destination for medical tourism. Affordability, accessibility and superior
quality are put forth by the Indian healthcare system attracting medical tourists globally. Indian
medical tourism market is alone developing at the rate of 18 percent year on year and is expected to
reach $9 Billion by the end of this year.
Health and care delivery will be much advanced in 2030 from what we experience today. The
medical workforce, technologies, drugs and devices is expected to have a significant reorganization.
The healthcare industry focuses on making the treatments more precise and minimally invasive
understanding the mutational aspects of drugs and radiational hazards of imaging on a patient.
However amid COVID-19, there is a steep drop in the number of patients approaching the
healthcare centers globally. In India stringent lockdown measures, well-connected health
professionals and precautionary surveillances have helped in controlling the outbreak to a large extend. Since India is one among the largest manufacturers of generic drugs and vaccines in the
world, a nation is confident about the revival.

To confidently perform a spinal fusion and screw fixation with excellence surgical navigation is
consistently used as a powerful tool. Surgical Navigation provides real-time guidance and precise
measurements for accurately placing the pedicle screws to help stabilize the spine. A preoperative
CT scan gives a detailed visualization of the structure decreasing the potential for implant-related complications and verifies that the rods are placed according to the dimensions of the bone
structure. This in turn eliminates the need for a rework and enhances the patient outcomes.
A great deal of anatomical and morphological variability of pedicles makes it more challenging in
complex spinal deformities. Fluoroscopy can assist screw placement; however, it increases the
operative time and radiation exposure to the surgeon and other operation theatre staff.
To tackle this issue of varied pedicle sizes due to anatomical differences or osteoporotic reasons,
surgeons prefer the Axial view over sagittal and coronal view during pedicle screw fixation.
To overcome the problems faced in a thoracic fixation due to shoulder girdle in fluoroscopic C-arm
scans, pre-operative images are preferred for clear visualization of the anatomy in all three axial,
sagittal and coronal planes.
The amount of radiation exposure to surgeons and other staff for a typical scoliosis screw fixation
case is very high and it can have long-term health effects such as cancer and cardiovascular
diseases.
CT-based spine navigation with easyNav assures a radiation-free surgical environment with
world-class real-time guidance of all your tools in three planes simultaneously.

A quick registration process required for this particular modality uses negligible time compared to the
time required for the preparation of numerous C-arm shots during every screw placement. In fact,
the time required is comparatively less and gives an extra advantage of the axial view.
Bone density of older patients is a major concern when it comes to screw-fixation using fluoroscopic
C-Arm shots. For better visualization of the bone and anatomical landmarks, neurosurgeons
generally prefer a pre-operative CT scan over fluoroscopic scans.

Computer-aided surgery is used in a daily clinical workflow for safer surgical interventions.
Navigation systems work based on a tracking model, which helps in the correlation of a patient’s
coordinates to the preoperative or intraoperative digital medical imagery. There are two main types
of navigation systems available in the market today. They are the infrared (optical) systems and
electromagnetic systems. Both systems perform the same functions. However, the technology used
to provide the information to the surgeon is very different.
An electromagnetic tracking system (EMT) uses a magnetic field–generating source, detecting
sensor, and processing software. The registration between the coordinate system of the
pre-interventional patient scan and that of the tracking system happens in an electromagnetic field of known geometry. This is performed by planning about 5 to 9 landmarks in the image coordinates and
the electromagnetic tracking coordinates by measuring their corresponding points with the sensor.
An optical system or infrared system uses patient trackers and probes for registration procedures on
prominent landmarks. The line of sight within the camera range and localizers must be maintained
throughout for real-time navigation. To detect the probe, the patient tracker and probe should be
visible to the camera simultaneously.
Why do Surgeons prefer Optical Navigation over EM Navigation systems?
•Several factors possibly affect the precision of the navigation system, such as the difference in
tracking devices, registration method of anatomical landmarks, and motion centers.
•EMT systems are less recommended due to the following inconveniences faced by medicos.
•These systems are influenced by the EM interferences due to the presence of medical diagnostic
devices or ferromagnetic objects nearby the field generator, distorting the transmitting signal and
resulting in deviated accuracies.

•Registration is a time-consuming process and does not consider the deformations of the airways
caused by the respiratory motion of the patient.
•Wired instruments causing inconvenience in handling.
•Interference with cardiac pacemakers and cochlear implants. Cables are attached to
electromagnetic tracking sensors.
•Instruments free of ferromagnetic properties must be used (eg:- titanium) to maintain accuracy.
Affected by metal artifacts, metal retractors or drilling devices or ultrasonographic probes can cause
electromagnetic navigation errors.
Advancements have reached a point where the preoperative setup, registration time, precision, and
accuracy associated aren’t part of the hassles faced by surgeons or medicos anymore. easyNav™is
a consumables navigation system that works purely based on optical (infrared) tracking of
autoclaved trackers assuring excellent accuracy.

The accuracy and reproducibility of this optical navigation system are higher than those of
electromagnetic navigation systems. This is mainly because the registration and real-time navigation
are only dependent on the tracker and probe visibility to the infrared camera. No continuous
exposure to EM radiation and artifacts caused in the process. The patient registration on the
prominent landmarks of the patient’s anatomy makes it entirely consumables and assures that
superior accuracy is maintained throughout the surgical procedure.

Brain biopsy procedure has been evolving for the last four decades in concurrence with the imaging
developments of the brain. Frame-based stereotactic interventions are considered the conventional
gold reference standard for obtaining biopsy specimens of lesions from the brain. In this modality, a bulky head frame is fixed to the patient’s head before imaging procedures as it is an integral part of a
frame-based biopsy.
The precision, accuracy, and diagnostic yield given by the rigid frame remain excellent. But there are
certain limitations faced in this procedure.
•They include the need to attach headpins prior to obtaining scans for the procedure.
•The discomfort with the bulky frame-based equipment and the calculations involved in deciding the
stereotactic entry points with the coordinates.
•The obstruction of the operative field by components of the head frame and inability to navigate the
operative field.
•The pre-operative procedural time involved is quite higher in this modality due to fixation of the
frame, imaging and calculations required.
•Prolonged surgical time and risk of post-operative infections at the points where the bulky frame
was fixed.
•No real-time imaging feedback of the biopsy needle through the brain and location from where the
specimen is extracted.

However, the consistent evolution of image-guided surgical operations over the past two decades
has led to tremendous advancements in the field of neurosurgery.
The development of Frameless stereotactic biopsy procedures gained importance and was
embraced by most neurosurgeons due to comparable diagnostic yield, accuracy, and
user-friendliness. The frame fixture pins can be avoided and a smaller incision can be made on the
patient’s head using the frameless navigation system. In this procedure, the pre-operative image
acquired is used for landmark planning and the registration is done on the anatomical prominent
landmarks of the patient. The fusion of different radiographic images can be done using navigation
software, making it simpler for the surgeon to operate. Dynamic trajectory planning can be done
from the entry point to the target lesion making the surgery more target-oriented and less invasive.
The real-time imaging of the biopsy needle through the brain with the help of custom trackers
assures the surgeon to confidently extract the biopsy specimen. The simultaneous monitoring of the depth and location of the biopsy needle along with the diagnostic accuracy makes this procedure the
most reliable.