Skull Trephination Research Articles

A review on sinoscopy in the horse: Traditional and minimally invasive techniques and sinoscopic treatment of paranasal disease

SummarySinoscopy consists of direct visualisation of the paranasal sinuses and was first conceived for diagnostic purposes using a rigid endoscope through a skull trephination. Since then, the use and approaches to perform it have evolved thanks to current advancements in knowledge (sinus anatomy and pathology) and technology. The aim of this article is to review the techniques reported to perform traditional and minimally invasive sinoscopy and to review the current use of sinoscopy to treat paranasal sinus disease. The history of sinoscopy, as we know it today, is relatively recent, but its use among clinicians is not necessarily widespread despite the invasiveness of the traditional technique when compared to imaging techniques. This limitation could be bypassed using the newer intranasal or extranasal minimally invasive sinoscopic approaches. These techniques allowed sinoscopic visualisation through natural orifices or minimally invasively created openings. Despite the potential of these techniques, case selection is still crucial as visualisation can be limited in selected disorders (i.e. sinus cyst), some sinuses (i.e. rostral maxillary with intranasal approaches) and if haemorrhage or severe exudate accumulation is found. Nevertheless, sinoscopy offers a diagnostic rate superior to traditional imaging and it is an alternative diagnostic tool when advanced imaging techniques, such as CT, are not available. In recent years, sinoscopic treatment has been progressively replacing the use of sinusotomies to treat most sinus disorders. Sinoscopic treatment yields a high‐resolution rate while complications are kept low. Familiarisation with sinoscopic techniques and in‐depth anatomic sinus knowledge will likely make sinoscopy the gold standard technique to treat sinus disease in the near future.

Emergency department burr hole simulation using 3D-printed model

BackgroundTraumatic epidural hematoma (EDH) with the potential to displace the brain tissue and increase intracranial pressure (ICP), is a life-threatening condition that requires emergent intervention. In rare circumstances, Emergency Physician (EP) may have to do skull trephination to reduce the ICP as a temporary measure. Specific aimsTo evaluate emergency medicine (EM) residents' comfort in performing emergency department (ED) burr holes and to assess their difficulties and evaluate comfort level before and after simulated EDH cases. Materials and methodsA 3D-printed skull, electrical and manual drills were used for the simulation. Subjective comfort level pre and post-procedure, as well as objective procedural skills and time to complete the drill, were recorded. ResultsTwenty EM residents participated in the simulation study. The median time to perforate through the skull was 4 s for the electric drill and 10 s for the manual drill. A comfort level of 5 and above was reported by 12 participants for the manual drill and by 17 participants for the electric drill. Six participants had mild and 2 participants had moderate observed difficulty in handling the manual and electric drill. Most participants performed both procedures successfully with one attempt only. Three participants have an overall comfort level above 5 before the simulation and 13 participants had overall comfort level above 5 post-simulation. ConclusionThe 3D-printed model assisted the ED burr hole simulation and the residents could perform the procedure with minimum difficulties.

Craniotomy Burr Hole Covers: A Comparative Study of Biomechanical, Radiological, and Aesthetic Outcomes Using 3 Different Plug Materials.

Burr holes in the cranial vault are usually made during trephination for craniotomy or drainage of chronic subdural hematomas. The resulting cranial defect might bring to unsatisfactory esthetic outcome. In the current study the authors report clinical data regarding a cohort of patients who were treated with 3 different types of burr hole covers; autologous bone dust from skull trephination, and 2 different types of cylindric plug made out of porous hydroxyapatite in order to evaluate medium and long-term esthetic and radiological outcomes. Twenty patients were consecutively enrolled in the study and in each patient all 3 types of materials were used to cover different holes. Clinical and radiological outcomes at 6 and 12 months, were analyzed for all 3 types of plugs in terms of thickness of the graft coaptation of margins, remodeling, fractures, mobilization, and contour irregularities. In all craniotomy holes filled with autologous bone dust the authors have observed partial or complete bone reabsorption at 1 year and in 60% of the cases a visible and palpable cranial vault contour irregularity was reported. Both types of bone substitutes gave satisfactory results, comparable to autologous bone dust at 6 months and superior at 12 months, especially in terms of thickness and esthetic appearance. Hydroxyapatite plugs have shown better esthetic and biomechanical results and higher patients' satisfaction compared to autologous bone dust while not giving any additional complications.

Current Status of Global Neurosurgery in SouthEast Asia

Evidence of neurosurgery dates to the bronze age with records of skull trephination; it is one of the youngest specialties, e volvingrapidly over the last century (1). Although neurosurgery developed rapidly globally, education, training, and service delivery standardsare heterogeneous worldwide. In a world with unequal distribution of wealth and natural resources, what can be done to improv e thehealth care service delivery in resource-limited nations? Historical analysis shows that cooperation among species dominantlycontributes to the evolution of life in its current forms. Events at any scale have global impacts, and collaboration among t hepopulation has been critical in the survival of our species at different challenging timelines in the Earth's history.

CORR Insights®: Is Botulinum Toxin Type A a Valuable Adjunct During Femoral Lengthening? A Randomized Trial.

Where Are We Now? The history of medicine is replete with instances of failed extrapolations. Bloodletting, for instance, may have started when an ancient healer observed the beneficial effect of blood loss in cases of congestive heart failure. Extrapolating to all maladies resulted in two millennia of induced hypovolemia, anemia, and premature death. Likewise, the clear-cut benefit of skull trephination in the presence of a subdural hematoma resulted in all manner of craniotomies for an assortment of ill-considered indications in long ago epochs. We have not improved all that much in this regard with the passage of time. The known benefits of botulism toxin on the spasticity of cerebral palsy suggested to some practitioners that this poisonous substance could overcome muscle resistance to elongation during limb lengthening. Hence, the technique was adopted into practice in several centers around the world without prospective clinical research. The experiment is easy enough to perform. As Park and colleagues have done, randomly assigning patients to either Botulinum toxin Type A (BtX-A) or saline injections during limb lengthening readily answers the question. They found that, with the dose they selected, BtX-A provides no benefit when compared to saline, eliminating any justification for BtX-A injections. This is no surprise because, for the most part, it appears that the progressive contractures, subluxations, and dislocations associated with limb lengthening are a consequence of resistance to elongation from fascial structures (tendons, thickened membranes—like the fascia lata and interosseous membrane—and epimysium) rather than muscle cells themselves. Where Do We Need to Go? Nevertheless, clinicians emotionally invested in BtX-A usage during limb lengthening could reasonably claim that the dosage used by Park and colleagues (200 IU BtX-A) was substantially less than the recommended quantity of 10 IU/kg body weight for individuals weighing more than 20 kg. However, once a randomized prospective study has been presented, the naysayers who find that one or another fault with the experimental design must now set about repeating the study in a randomized prospective manner while simultaneously eliminating those specific features of the project (perhaps like dosage) that they find objectionable. How Do We Get There? More than a decade ago, Moseley and colleagues [1] demonstrated in a randomized, prospective blinded study that arthroscopic knee surgery (or joint lavage) in the presence of radiographic osteoarthritis of the knee results in no greater benefit than did sham surgery. The reactionary hoots and howls by arthroscopic surgeons continue to reverberate in conferences and workshop around the world, yet nobody has refuted Moseley's findings with a well-designed sham-surgery-controlled study. If any reader intends to continue using BtX-A injections to reduce complications during limb lengthening, (s)he now bears the burden of proof to justify such an intervention.

Early medical skull surgery for treatment of post-traumatic osteomyelitis 5,000 years ago.

Here we describe the findings of a unique example of the early techniques adopted in neurosurgery around 5000 years ago, consisting in a double well healed skull trephination associated with a post-cranial traumatic event occurring intra vitam to a young male from the Early Chalcolithic cemetery of Pontecagnano (South Italy, ca. 4,900 - 4,500 cal BP). Morphological, X-ray and 3D-CT scan skull-cap evaluation revealed that the main orifice was produced by scraping, obtained by clockwise rotary motion of a right-handed surgeon facing the patient, while the partial trephination was carried out by using a stone point as a drilling tool. In both cases, bone regrowth is indicative of the individual's prolonged postoperative survival and his near-complete recovery. The right femur shows a poorly healed mid-shaft fracture presumably induced by a high energy injury, and a resulting chronic osteomyelitis, affecting both femurs by hematogenous spread of the infection. Our observations on the visual and radiological features of skull and femur lesions, along with evidence on the timing of experimental bone regrowth vs. healing of lower limb fractures associated to long-term bone infections now suggest that this young man underwent a double skull trephination in order to alleviate his extremely painful condition induced by chronic osteomyelitis, which is thought to have been the cause of death.

Quantitative Computed Tomography and Cranial Burr Holes

Current methods to evaluate the biologic development of bone grafts in human beings do not quantify results accurately. Cranial burr holes are standardized critical bone defects, and the differences between bone powder and bone grafts have been determined in numerous experimental studies. This study evaluated quantitative computed tomography (QCT) as a method to objectively measure cranial bone density after cranial reconstruction with autografts. In each of 8 patients, 2 of 4 surgical burr holes were reconstructed with autogenous wet bone powder collected during skull trephination, and the other 2 holes, with a circular cortical bone fragment removed from the inner table of the cranial bone flap. After 12 months, the reconstructed areas and a sample of normal bone were studied using three-dimensional QCT; bone density was measured in Hounsfield units (HU). Mean (SD) bone density was 1535.89 (141) HU for normal bone (P < 0.0001), 964 (176) HU for bone fragments, and 453 (241) HU for bone powder (P < 0.001). As expected, the density of the bone fragment graft was consistently greater than that of bone powder. Results confirm the accuracy and reproducibility of QCT, already demonstrated for bone in other locations, and suggest that it is an adequate tool to evaluate cranial reconstructions. The combination of QCT and cranial burr holes is an excellent model to accurately measure the quality of new bone in cranial reconstructions and also seems to be an appropriate choice of experimental model to clinically test any cranial bone or bone substitute reconstruction.

Trephination and Intentional Cranial Deformations in Ancient Pre-Columbian Cultures (P04.008)

Objective: The aim of this study is to analyze trephination and intentional cranial (ICD) deformation techniques in ancient pre-Columbian cultures. Background Trephination and ICD are the oldest known surgical techniques developed by some pre-Columbian cultures. ICD is defined as the product of the dynamic distortion of the normal vectors of infantile neurocranial growth through the agency of externally applied forces. Design/Methods: An anthropological field study was performed in the Andean region of South America. Skulls from Inca, Nazca and Paracas Peruvian cultures, Tiwanaku and Cochabamba Bolivian cultures were analyzed. Results: The practice of ICD was performed by the application of either boards or bandages to the infant9s head to change the shape of the growing skull. The circular Aymara type was the most common ICD in the Peruvian and Bolivian Andes. On the coast, the application of boards to the front and back of the head was the preferred deformation method. In pre-Columbian Peru, permission to shape the heads of children was an act of kindness granted by the rulers to some nobles. This practice also had the intention of altering the shape of the head in accordance with certain preconceived ideas of beauty. The earliest trephined skulls in the Americas were found in the burial caves of Paracas, Peru. Craniotomy was performed by abrasion, scraping, crosscut sawing, and drilling. Trephining was initially performed with a triangular knife-like instrument made of obsidian and fixed in a wooden handle. Later, t-shaped tumis were used. The holes outlined a large bone excavation, which was filled with a sheet of silver or gold. Bone reactions around the various trephinations suggest differing durations of long-term survival. Conclusions: The practice of ICD was common and persisted until Spanish colonial period. Success of skull trephination was frequent in spite of rudimentary methods and instruments. Disclosure: Dr. Carod has received personal compensation for activities with Allergan, Inc., Merck Sharp & Dohme Limitd, Lundbeck, Biogen Idec, Esteve, and Pfizer Inc. Dr. Vazquez Cabrera has nothing to disclose.

Structure of Gastric Wall in Wistar Rats in Health and after Experimental Traumatic Brain Injury

The structure of gastric wall was studied by histological methods in Wistar rats in health and after skull trephination and insertion of a needle into the brain. Experimental brain injury led to the development of destructive changes in the gastric wall (in the lymphoid structures located between the gland bottoms and muscle plate of the mucosa). Changes in the structure of cardiac glands and desquamation of the epithelium were detected. Microcirculation was disordered, signs of inflammation appeared. The counts of medium-sized lymphocytes and plasma cells increased in the layer of lymphoid cells and in the submucosa.

Local Skull Trephination Before Transfer Is Associated With Favorable Outcomes in Cerebral Herniation from Epidural Hematoma

The patient with epidural hematoma and cerebral herniation has a good prognosis with immediate drainage, but a poor prognosis with delay to decompression. Such patients who present to nonneurosurgical hospitals are commonly transferred without drainage to the nearest neurosurgical center. This practice has never been demonstrated to be the safest approach to treating these patients. A significant minority of emergency physicians (EPs) have advised and taught bedside burr hole drainage or skull trephination before transfer for herniating patients. The objective of this study was to assess the effect of nonneurosurgeon drainage on neurologic outcome in patients with cerebral herniation from epidural hematoma. A structured literature review was performed using EMBASE, the Cochrane Library, and the Emergency Medicine Abstracts database. No evidence meeting methodologic criteria was found describing outcomes in patients transferred without decompressive procedures. For patients receiving local drainage before transfer, 100% had favorable outcomes. Although the total number of patients is small and the population highly selected, the natural history of cerebral herniation from epidural hematoma and the best available evidence suggests that herniating patients have improved outcomes with drainage procedures before transport.

Emergency Department Trephination for Epidural Hematoma

Although skull trephination is rarely performed and is no longer part of the core curriculum for emergency medicine, it might be lifesaving for

Emergency Department Skull Trephination for Epidural Hematoma in Patients Who Are Awake But Deteriorate Rapidly

Blunt head trauma patients who have been alert but are deteriorating (talk and deteriorate [T&D]) due to a rapidly expanding epidural hematoma (EDH) usually have poor outcome if they must wait for hospital transfer for evacuation. We therefore have continued to teach skull trephination to emergency physicians (EPs). We are unaware of any literature on EP trephination for EDH in the age of computed tomography (CT) scanning. Patients with EDH from blunt trauma, either in our institution or known to our graduate network, who were T&D with anisocoria despite intubation plus medical therapy, and who had pre-transfer EP trephination, were compared to those who were transferred without trephination. There were 5 patients with blunt trauma and CT-proven EDH who were T&D with anisocoria who underwent Emergency Department (ED) trephination at outlying hospitals before transfer. All 5 had improvement in condition and good outcomes. Three had complete recovery without disability and 2 others had mild disability with good cognitive function. None had complications. Two patients with T&D and anisocoria were transferred without trephination. Both had good neurologic outcomes. The mean time to pressure relief in the trephination group vs. transfer group was 55 vs. 207 min, respectively. In T&D patients with CT-proven EDH and anisocoria, ED skull trephination before transfer resulted in uniformly good outcomes without complications. Time to relief of intracranial pressure was significantly shorter with trephination. Neurologic outcomes were not different.

The Pearls and Pitfalls of Skull Trephination as Described in the Hippocratic Treatise “On Head Wounds”

The purpose of our current study is to describe the guidelines regarding trephination as suggested in the Hippocratic writer's book, “Peri ton en cephali traumaton” (“On Head Wounds”). The ancient Greek text was reviewed as well as two English translations. The Hippocratic author described the indications, timing, and techniques of trephination for patients with head injury. He emphasized that attention should be paid to the details of the employed technique. He also commented on the difference of skull thickness at different anatomical sites and also between different age groups. The Hippocratic recommendations provided details for the performance of trephination by the ancient Greek physicians that are still considered important in modern neurosurgery.

Skull Trephination in the Carpathian Basin (8th - 13th Century A.D.)

In memoriam et honorem Professor L. Bartucz From prehistoric times we have a few trephined skulls; from the Roman period, none. A few are found from the time of the Great Migrations. From the 8th and especially the second half of the 9th C. (i.e. from the time of Hungarian conquest) the number of trephined skulls rises suddenly. The trephinings are usually round or oval, but the extent varies: (a) only the tabula externa, (+ diploe) are removed (symbolic trephining), or (b) all the three layers of calvarium (tabula externa. + diploe + tabula interna) are removed (surgical trephining). There are multiple trephinings too. Around half of the trephinings are at the vertex (bregma region). Mortality was less than 31%. The number of trephined skulls diminishes rapidly after the Christian ization of the Hungarian people, but there is a difference in the rate at which the symbolic and surgical forms of trephination disappear. Two maps indicate the location of excavations where trephined skulls were found, covering the major part of the Carpathian Basin which was occupied by the invading Hungarians. A third map indicates the sites in the South Russian steppe region where similar trephined skulls were found, for the most part accompanied by grave furniture similar to that buried with the 9th C. Carpathian Hungarians. The trephination was executed with a fine chisel (Bartucz, Nemeskeri). Most surgical trephinings were made to correct wounds or fractures. By means of recent analogies, we may suppose that the others were made in cases of headache. Sometimes a thin silver or bronze sheet was found, positioned as though to protect the opening. Key words: Trephining, Hungarians, Carpathian Basin, Middle Ages Chronology From prehistoric times - especially from the Copper Age - we have only some trephined skulls from the Carpathian Basin, meanwhile from the several centuries spanning the period of the Roman imperium of Pannonia (West Hungary), Dacia (East Hungary) and the southern parts of the Carpathian Basin is not a single archeological-anthropological finding of trephined skulls. We have again a few findings from the early part of the Great Migration time period. The number of excavated trephined skulls rises slowly in the so-called Late Avarian period (8th-9tli C.). From the end of the 9th C. i.e. from the Hungarian conquest, we can observe a sudden rise of trephined skull's number, and after this peak - lasting three centuries - a similarly sudden decrease of it. (Fig. 1.) The below mentioned investigators attribute the sudden decrease of skull trephining in the 11th C. to the Christianization of the Hungarians, but we do not have any convincing prove of this ,hypothesis. There were some scattered cases in the 12th and 13th centuries, after this period were none, whereas wartime and peacetime cranial traumata and headache might have occurred later on in a similar or in a much greater number too. Types of Trephination From a pathophysiological point of view we may distinguish two main types of in vivo trephinings. (Postmortem trephinings are not available in the Hungarian material): (a) only the tabula externa (+ diploc) are removed in one or more circumscript regions = symbolic trephining. (b) all the three layers of calvarium (tabula externa + diploe + tabula interna) are removed, i.e. the skull vault is opened = surgical trephining. Both types occurred in multiple forms (2 - 7 symbolic trephinings on the same skull) and also in combined forms (symbolic + surgical trephinings on the same skull). The multiple ones were made mostly at different times, i.e. subsequently. In the opinion of L. Bartuez resp. J. Nemeskeri and co-workers, whose results I have outlined, these trephinings were made by a fine chisel. Trephinings made bya trepan or bya saw are unknown in the Hungarian material. The heater worked behind the sitting patient and made numerous fine incisions round the circumference of the planned opening. …

Behavioral and neurochemical asymmetries following unilateral trephination of the rat skull: Is this control operation always appropriate?

The present results are from rats that were intended as sham-operated controls in a study of unilateral lesion of the cortical barrel fields. These animals received a trephime hole through the skull, centered over the barrel fields of one hemisphere. Unexpectedly, they showed time-dependent behavioral and neurochemical asymmetries: 1 + 4 days after unilateral skull trephination they scanned an open field mainly with the contralateral vibrissae. Thereafter (days 7 + 14), scanning recovered to symmetry; however, an ipsilateral asymmetry was induced now by challenge with the dopamine receptor agonist apomorphine. At the same time period after skull trephination, an asymmetry of thigmotactic swimming had developed, with more thigmotactic swimming ipsilateral to the side of skull trephination. Neurochemically, there were indications for changes in neostriatal dopamine metabolism because the tissue levels of dopamine and dihydroxyphenylacetic acid were lower on the ipsilateral side in animals killed 6–16 days after trephination. The time courses of behavioral and neurochemical asymmetries after unilateral skull trephination paralleled those seen following unilateral barrel cortex lesion or unilateral removal of the corresponding contralateral vibrissae; however, without exception, the asymmetries after trephination were in the opposite direction than after cortex lesion or vibrissae removal. The possible mechanisms by which skull trephination might have affected behavior and neurochemistry are discussed, especially with respect to the vibrissae-barrel cortex system and the basal ganglia. Because trephination of the skull is routinely employed, both as a control procedure and for CNS manipulation, these results may have important implications for the design of future experiments.

Experimental evaluation of collagen sponge as a dural graft.

Early collagen products, when used as dural substitutes, promoted severe inflammatory responses and fell into disrepute. A more recent advance, collagen sponge, which is derived from bovine flexor tendons was used in this experimental study. Collagen sponge was surgically implanted as an onlay dural replacement graft following skull trephination and dural excision in 12 primates. Macroscopic, histological and electron-microscopical evaluations were performed at periods of 1, 3 and 9 months. This preliminary animal study indicated that collagen sponge is suitable to use as a graft since it does not induce any inflammatory response or adhesions in the absence of pia arachnoid injury. If forms an ideal scaffold for the early ingrowth of fibroblasts to effect dural repair.

A brief history of epilepsy and its therapy in the western hemisphere

The history of epilepsy and its treatment in the western world dates back at least 4 millennia to the ancient civilizations of the middle east. Past and present treatments have been empirical, usually reflecting the prevailing views of epilepsy, be they medical, theological or superstitious. Ancient physicians relied on clinical observation to distinguish between epileptic syndromes and infer their cause. Early pathophysiological theories of epilepsy correctly identified the brain as the site of the problem, but emphasized incorrect causes such as an excess of phlegm in the brain. Treatments consisted of prescribed diets or living conditions, occasional surgery such as bloodletting or skull trephination and medicinal herbs. These treatments, often ineffective, had the intellectual advantage of being based on pathophysiological principles, unlike current, more empirical, therapies. The unfortunate but widely held view of epilepsy as being due to occult or evil influences gained adherents even in the medical world during ancient times, and the later acceptance of Christianity allowed theological interpretations of seizures as well. Magical or religious treatments were more frequently prescribed as a result, practices which persist to this day. In the Renaissance an attempt was made to view epilepsy as a manifestation of physical illness rather than a moral or occult affliction, but it was during the Enlightenment that epilepsy was viewed along more modern lines, helped by advances in anatomy and pathology and the development of chemistry, pharmacy and physiology. The idea that focal irritation may cause seizures came about from clinical and experimental work, and was supported by the successful control of seizures by the (sedative) bromides and barbiturates in the late 19th century. The introduction of phenytoin showed that non-sedative drugs could be effective in controlling seizures as well, and the development of in vivo seizure models widened the scope of pharmaceutical agents tested for their efficacy against epilepsy. Increasing knowledge of the cellular mechanisms of epilepsy will, hopefully, allow the development and introduction of drugs with increasing specificity against seizure activity and the development of epilepsy.

Osteological evidence of the use of a surgical modiolus in a Romano-British population: An aspect of primitive technology

Although there is evidence of possible skull trephination from the Neolithic through into Medieval times in earlier British populations, there is rarely evidence of the techniques and surgical equipment used. This is because most cases show considerable healing, or when incision marks are seen at the margins of the trephine aperture, there is no indication from them of the kind of instrument used. It would thus seem worth placing on record a Romano-British case which can tentatively be placed in the class of cranial trephination resulting from the use of a cylindrical modiolus of the kind described by Celsus (c. 50 AD).