Craniotomy: To a veteran neurosurgeon, it’s just another day in the office, not even close to the most complex procedure one will perform in a given week. But a modern neurosurgeon has access to a variety of state-of-the-art imaging studies, precisely machined tools made specifically for neurosurgery, and thousands upon thousands of hours of practice.
Given the difficulty of safely removing part of a patient’s skull, the craniotomy must be a relatively recent invention. How far back could it possibly go; 50 years, maybe 100 years?
Try 8,000 or more.
The craniotomy is one of the oldest medical treatments known to man. Let’s take a journey through time to see how this procedure has evolved alongside modern medical science.
There is evidence that craniotomy—more accurately, trepanation, or creating a permanent hole in the skull as opposed to replacing the skull fragment—was in use up to 8,000 years ago. Skulls between 5,000 and 8,000 years old with marks of trepanation had been found in France as early as 1685¹.
Skulls bearing evidence of trepanation that are thousands of years old have been found all over the world. For instance, two skulls with evidence of brain surgery were excavated in Henan province, China and are believed to be from the Shang dynasty some 3,000 years ago. These skulls had very small, very precise holes that researchers believe came from craniotomies. Other ancient skulls with craniotomy evidence have been found in Peru and Mexico², North Africa and eastern Europe.
Most researchers believe these earliest brain surgeries were done for religious reasons³. Primitive drills were probably used to create the holes. Ancient humans may even have practiced their technique on cows, as evidenced by a bovine skull from about 5,000 years ago with a craniotomy found in France.
It’s almost impossible to tell if the earliest craniotomies were effective at relieving whatever condition they were employed to treat. However, by looking at evidence of healing around the trepanation site, researchers can determine if the procedure was likely to kill those early patients. In that respect—considering the risks of surgery even today, with sterilization and other infection control procedures—the survival rate of prehistoric craniotomy was fairly astounding; at least 50 percent of patients survived, some of them for years⁴, researchers believe.
Hippocrates, the so-called father of Western medicine, was one of the first to put into writing craniotomy technique. He did so extensively, documenting craniotomies in his seminal work Corpus Hippocraticum in a book dedicated to head injuries. He recommended craniotomies be performed within the first three days of head trauma, using two types of drill.
Hippocrates set the standard by which craniotomies would be performed for hundreds of years. Other writers would later improve on his technique. The Roman doctor Celso, five hundred years after Hippocrates, both revised Hippocrates’ indications and refined his technique. Galen, a Greek who lived around the same time as Celso, also wrote about trepanation.
After the classical period, craniotomy was seldom performed in the West outside of exceptional circumstances and in more “enlightened” places like the Byzantine empire and Arabic countries. Europe was in the throes of the Dark Ages and most people were focused on day-to-day survival.
Thank the widespread use of guns for the renaissance of trepanation in the West during the Renaissance. Wars and skirmishes across Europe were responsible for a great uptick of head trauma, and 16th century physicians turned to craniotomy to clear out skull fragments, relieve pressure on the brain, get rid of blood clots and drain pus⁶.
The tools used—drills, scalpels and other specialized instruments—remained virtually unchanged from the Classical period. Manufacturing materials and techniques, however, were much more advanced, which led to higher quality tools being produced⁷.
Enlightenment and Industrial Revolution
After the Renaissance, craniotomy once again fell out of favor, this time due to surging rates of infection. It wasn’t until the advent of antiseptics and—crucially, mercifully—anesthetics in the 19th century that the practice became popular again⁸.
At this point, despite the raging of the American Civil War, trepanation was mainly used not for skull injuries but to treat brain lesions and other central nervous system conditions such as trigeminal neuralgia⁹.
The Modern Era
In the 21st century, craniotomy is a vital part of neurosurgery. Any time a neurosurgeon needs access to the brain, he or she can perform a craniotomy. Craniotomies can now be guided by advanced imaging, specialized tools can be employed, and the patient can be sedated with anesthesia. Although our distant ancestors had an impressive survival rate (all things considered) of 50 percent, modern patients are all but guaranteed to come through craniotomies with no adverse effects.
If you need a craniotomy—complete with general anesthesia—as part of another neurosurgical procedure, request an appointment at Neurosurgical Associates of Central Jersey. Our neurosurgeons have thousands of hours’ worth of experience in the operating room and can perform craniotomies with minimal side effects and minimal recovery time.