Two surgical instruments.

The only instruments for opening the cranium considered in this chapter are drills, and in some cases facilitated with a special chisel called a lenticular. There were two kinds of trepan. The modiolus was the Latin name for a crown trepan which had a circular base with teeth which sawed a hole. Then there were the non-penetrating trepans which had a bit shaped to prevent unwanted penetration. They made small openings which could be joined by chisels to remove altogether larger areas of bone than were accessible to modioli. They were the favored instrument from the ancient world up to the Renaissance. At the beginning of the Renaissance, there was a move toward greater use of crown trepans and various methods were applied to stop them sinking too far inward. These included wings in the outer wall and changing the shape of the bit from cylindrical to conic. In time preferences returned to the cylindrical shape and larger diameters. There was also two instruments called lenticulars, the illustrations of which have been confused in the literature. It is now clear that the Roman instrument was shaped to cut the cranium and minimize the need for trepanation. The Renaissance instrument had a different shape and was used to smooth rough bone edges and excise spicules penetrating the meninges. They were simply two different instruments to which the same name was applied.

The enlightenment.

The period begins with the work of Richard Wiseman who was associated with royalists in the English Civil War. A little later Dionis was the first to note a relationship between a disturbance of consciousness and extravasation of blood. This notion was continued and expanded by Le Dran, Pott, and Benjamin Bell, with Pott providing a pathophysiological explanation of the phenomenon. Daniel Turner commented on how confusing Galenic teaching was on the topic of consciousness. Heister further emphasized the relationship between clinical disturbance and the extravasation of blood. Le Dran stated that symptoms following cranial trauma related to cerebral injury, an opinion supported by Pott and never subsequently challenged. Latta noted the importance of meningeal arteries in the development of hematomas. Benjamin Bell considered trepanation only appropriate for a clinical deterioration consistent with hemorrhagic extravasation. The two Irish surgeons made it clear that the presence of periosteal separation was not in fact a reliable indicator of an extravasation. The most striking change of instruments was disappearance of simple straight trepans with non-perforating tips for making small holes safely. The use of scrapers gradually declined as did that of lenticulars. There was a great debate about the value of a conical rather than a cylindrical crown. The former was said to be safer. But this opinion faded and the cylindrical crown became preferred. Another improvement in technique involved the use of constant probing to check the depth of the drilled groove.

Renaissance-Europe-16th Century continued.

This chapter is limited to the text of Della Cruce, which contains the most comprehensive account of the instruments used in cranial surgery at the time. Of particular importance is Della Cruce's attitude to what he called non-perforating straight trepans, which in general he disliked. It may be noted that his text was the last to describe this sort of instrument. In the succeeding centuries, changes to penetrating instruments were all variations on the shape of different kinds of crown trepan. Like Berengario, Della Cruce described brace and bit trepans with interchangeable bits. Various methods were employed to prevent them penetrating too deeply.

Use of siphon irrigation during burr-hole craniostomy to evacuate chronic subdural hematoma: A retrospective cohort comparison study.

Burr-hole craniostomy (BHC) is a widely accepted treatment for chronic subdural hematomas (CSDHs). This study adopted siphon irrigation to evacuate CSDHs and investigated its efficacy and safety as compared with the traditional irrigation used in BHC.A retrospective cohort study was conducted at a center between January 2017 and December 2018. The data of 171 patients who underwent burr-hole craniostomy for CSDH were collected and analyzed. A total of 68 patients underwent siphon irrigation (siphon group) and 103 patients were treated by a traditional method (control group). A follow-up was conducted 6 months after the surgery.No significant difference was observed in the baseline characteristics and preoperative computed tomography (CT) features of the 2 groups (P > .05). The postoperative CT features of the siphon group, which included the volume of hematoma evacuation (P = .034), hematoma evacuation rate (P < .001), recovery rate of the midline shift (P = .017), and occurrence of pneumocephalus (P = .037) were significantly different and better than those of the control group. The length of hospital stay after surgery of the siphon group was significantly shorter than that of the control group (P = .015). The Markwalder score of the siphon group was significantly superior to that of the control group on postoperative day 1 (P = .006). Although the recurrence rate in the siphon group (2/68, 2.5%) was lower than that in the control group (11/103, 8.9%), no statistically significant difference was observed between them (P = .069). Moreover, no significant differences were observed in terms of complications and mortality rate between the 2 groups.There was no significant difference in the recurrence rate between the groups that underwent siphon irrigation and traditional irrigation. However, in comparison, siphon irrigation can better improve postoperative CT features, promote early recovery of neurological dysfunction after surgery, and shorten the length of hospital stay. This indicates that siphon irrigation may be a better therapeutic option in BHC for CSDH.

The history of bone marrow in orthopaedic surgery (part I trauma): trepanning, bone marrow injection in damage control resuscitation, and bone marrow aspiration to heal fractures.

PURPOSE: One of the oldest procedures performed by man is trepanning of the bone and yet it was only in the last 40 years that bone marrow aspiration has been used to treat nonunion disorders. MATERIAL AND METHODS: These advances were possible due to improvements in instruments and in techniques to make holes in the bone, an history that began with skull trephinations around 8000-10,000 years ago, and continued with sternum bone marrow injection for trauma resuscitation in the beginning of the twentieth century; this procedure had improved at the beginning of the twenty-first century to allow pelvis bone marrow aspiration for the treatment of nonunion. RESULTS: Trephined skulls from antiquity have been found in many parts of world, showing that trephining was ancient and widespread. Beginning with Neolithic period and the pre-Columbian Andean civilizations, the authors have traced the development of this surgical skill by describing the various surgical tools used to perform holes in the skull. These tools (trephines or trepan) were proposed at the end of the nineteenth century to study the bone marrow. At the beginning of the twentieth century, the sternum became the center of interest for the "in vivo" study of the bone marrow and the fluid injection in the sternum's bone marrow was described for resuscitation from shock during the World War II. With the introduction of plastic catheters and improved cannulation techniques, the need for intraosseous infusion as an alternative route for intravenous access diminished and sometimes abandoned. However, during the mid-1980s, James Orlowski allowed renaissance of the use of intraosseous infusion for paediatric resuscitation. Since then, this technique has become widespread and is now recognized as an alternative to intravenous access in adult emergencies; particularly, the intraosseous access has received class IIA recommendation from the Advanced Trauma Life Support program supported by the American College of Surgeons Committee on Trauma and bone marrow infusion is now recommended for "Damage Control" resuscitation. Although the pelvis bone contains half of the body's marrow volume, it was only in 1950 that the pelvis was proposed as a source for bone marrow aspiration and bone marrow-derived mesenchymal stem cells to improve healing of fractures. CONCLUSION: It will be many years before doing holes in the bone as orthopaedic trauma procedure will be relegated to the annals of history.

COveRs to impRove AesthetiC ouTcome after Surgery for Chronic subdural haemAtoma by buRr hole trepanation (CORRECT-SCAR): protocol of a Swiss single-blinded, randomised controlled trial.

INTRODUCTION: Outcomes rated on impairment scales are satisfactory after burr hole trepanation for chronic subdural haematoma (cSDH). However, the surgery leads to bony defects in the skull with skin depressions above that are frequently considered aesthetically unsatisfactory by the patients. Those defects could be covered by the approved medical devices (burr hole covers), but this is rarely done today. We wish to assess, whether the application of burr hole covers after trepanation for the evacuation of cSDH leads to higher patient satisfaction with the aesthetical result at 90 days postoperative, without worsening disability outcomes or increasing the complication rate. METHODS AND ANALYSIS: This is a prospective, single-blinded, randomised, controlled, investigator-initiated clinical trial enrolling 80 adult patients with first-time unilateral or bilateral cSDH in Switzerland. The primary outcome is the difference in satisfaction with the aesthetic result of the scar, comparing patients allocated to the intervention (burr hole cover) and control (no burr hole cover) group, measured on the Aesthetic Numeric Analogue scale at 90 days postoperative. Secondary outcomes include differences in the rates of skin depression, complications, as well as neurological, disability and health-related quality of life outcomes until 12 months postoperative. ETHICS AND DISSEMINATION: The institutional review board (Kantonale Ethikkommission Zürich) approved this study on 29 January 2019 under case number BASEC 2018-01180. This study determines, whether a relatively minor modification of a standard surgical procedure can improve patient satisfaction, without worsening functional outcomes or increasing the complication rate. The outcome corresponds to the value-based medicine approach of modern patient-centred medicine. Results will be published in peer-reviewed journals and electronic patient data will be safely stored for 15 years. TRIAL REGISTRATION NUMBER: NCT03755349.

Frank Clifford Rose Memorial Lecture: The tale of three trephines: Surgeons and their surgical-instrument makers in Britain, France, and America in the nineteenth century.

Trephines and trepanning date to ancient times, but a "modern" form of instruments was codified by the seventeenth century. This did not preclude efforts to "improve" the trephine in the late-eighteenth and nineteenth centuries. Surgeons and instrument makers in Britain (Jardine and Savigny), France (Thomson and Charrière), and America (Galt and Otto & Reynders) endeavored to make the trephine safer and more precise. In exploring their interactions, this presentation shows the evolving role of the instrument makers not only as fabricators of tools, but as creative design collaborators of surgeons and physicians.

Novel Burr Hole Dilator for Endoscopic Surgery for Intracranial Hemorrhagic Lesion: Technical Note.

OBJECTIVE: When performing burr hole endoscopic neurosurgery, it is necessary to get enough surgical corridor. We have used various instruments to extend burr hole size, but it was cumbersome to use so many tools. METHODS: In this report, we describe a novel instrument-a dilator attachment with a cordless handle to make it simple and safe to extend a burr hole. We developed this burr hole dilator attachment with blades on the side and an arc form on the bottom to prevent dural damage. It can be used to drill safely and efficiently. We describe some experiences of using this device. RESULTS: It is important to balance the maximization of the operation range and surgical invasiveness for endoscopic neurosurgery. This new dilator for extending a burr hole is a safe, useful device to get enough surgical view and easily perform a surgical procedure in endoscopic surgery. CONCLUSIONS: Our dilator for expanding a burr hole improves the work of endoscopic surgery on intracranial hemorrhagic lesions.

The Siberian Lancet: One More Possible Innovative Example of Scalpel's Contribution to the Evolution of Surgical Anatomy and Neurosurgery.

BACKGROUND: Several primitive scalpels were used since the eve of surgical procedures. Numerous bronze knifes discovered in the Altai mountains region from the Xiongnu-Xianbei-Rouran period mold a hypotheses for a possible medical use. METHODS: On-sight archaeologic excavation brought into light the tools in question. RESULTS: Knifes, similar to modern lancets, were unearthed alongside with a series of skulls demonstrating signs of trepanation. CONCLUSIONS: Strong indications imply that those cutting tools, except for domestic usage, were one more example of scalpel's contribution to the evolution of surgical anatomy and neurosurgery.

3-D printing for constructing the burr hole ring of lead fixation device in deep brain stimulation.

BACKGROUND: As the bearing structure of fixation device in deep brain stimulation (DBS), burr hole ring is fixed on the skull and used in conjunction with Stimloc and plastic cap. But in patients with traumatic event, excessive movements are likely to bring strain on the anchoring system, which will finally cause the fixation device to fall off from the skull. METHOD: AutoCAD was used to construct two-dimension (2-D) images for traditional burr hole ring and innovative burr hole ring, respectively. According to the 2-D image, pro/Engineer (Pro/E) will be applied to construct the three-dimension (3-D) geometries. And then, 3-D printing technology was used to build the solid model. These two kinds of burr hole rings were divided into two groups: Innovative group (N = 21) and Traditional group (N = 21). Pull-out strength of these two groups of burr hole rings will be measured by manual tensile force testing machine on the full-size skull model, and the data were transmitted to the notebook in real time for recording and further analyzing. RESULT: The fixation strength of the innovative group is stronger than traditional group, pull-out strength value of traditional group and innovative group were 34.08 ±â€¯1.31 N and 99.73 ±â€¯2.14 N, respectively. (P < 0.001). CONCLUSION: We provide an innovative burr hole ring, which can fix on the burr hole steadily. Moreover, 3-D printing technology may be suitable for personalized and customized medical treatment in the future.

Improving the aesthetic outcome with burr hole cover placement in chronic subdural hematoma evacuation-a retrospective pilot study.

BACKGROUND: The aesthetic outcome after burr hole trepanation for the evacuation of chronic subdural hematomas (cSDH) is often unsatisfactory, as the bony skull defects may cause visible skin depressions. The purpose of this study was to evaluate the efficacy of burr hole cover placement to improve the aesthetic outcome. METHODS: We reviewed consecutive patients treated by burr hole trepanation for cSDH with or without placement of burr hole covers by a single surgeon between October 2016 and May 2018. The clinical data, including complications, were derived from the institution's prospective patient registry. The primary endpoint was the aesthetic outcome, as perceived by patients on the aesthetic numeric analog (ANA) scale, assessed by means of a standardized telephone interview. Secondary endpoints were skin depression rates and wound pain, as well as complications. RESULTS: From n = 33, outcome evaluation was possible in n = 28 patients (n = 24 male; mean age of 70.4 ± 16.1 years) with uni- (n = 20) or bilateral cSDH (n = 8). A total of 14 burr hole covers were placed in 11 patients and compared to 50 burr holes that were not covered. Patient satisfaction with the aesthetic outcome was significantly better for covered burr holes (mean ANA 9.3 ± 0.74 vs. 7.9 ± 1.0; p < 0.001). Skin depressions occurred over 7% (n = 1/14) of covered and over 92% (n = 46/50) of uncovered burr holes (p < 0.001). There was no difference in wound pain (p = 0.903) between covered and uncovered sites. No surgical site infection, cSDH recurrence, or material failure was encountered in patients who had received a burr hole plate. CONCLUSIONS: In this retrospective series, placement of burr hole covers was associated with improved aesthetic outcome, likely due to reduction of skin depressions. A randomized controlled trial is developed to investigate whether adding burr hole covers results in superior aesthetic outcomes, without increasing the risk for complications.

The view through the ventricle catheter - The new ShuntScope for the therapy of pediatric hydrocephalus.

PURPOSE: Correct placement of the ventricle catheter directly influences the function of cerebral shunt systems. The incidence of proximal catheter misplacement reaches up to 45%. To avoid misplacements and revisions a new intra-catheter endoscope for precise ventricle catheter placement in children was evaluated. METHODS: The semi-rigid ShuntScope (Karl Storz GmbH & Co.KG, Tuttlingen, Germany) with an outer diameter of 1.0 mm and an image resolution of 10,000 pixels was used in a series of 27 children and adolescents (18 males, 9 females, age range 2 months-18 years). Indications included catheter placement in aqueductal stenting (n = 4), first time shunt placement (n = 5), burr hole reservoir insertion (n = 4), catheter placement after endoscopic procedures (n = 7) and revision surgery of the ventricle catheter (n = 7). RESULTS: ShuntScope guided precise catheter placement was achieved in 26 of 27 patients. In one case of aqueductal stenting, the procedure had to be abandoned. One single wound healing problem was noted as a complications. Intraventricular image quality was always sufficient to recognize the anatomical structures. In case of catheter removal, it was helpful to identify adherent vessels or membranes. Penetration of small adhesions or thin membranes was feasible. Postoperative imaging studies demonstrated catheter tip placements analogous to the intraoperative findings. CONCLUSIONS: Misplacements of shunt catheters are completely avoidable with the presented intra-catheter technique including slit ventricles or even aqueductal stenting. Potential complications can be avoided during revision surgery. The implementation of the ShuntScope is recommended in pediatric neurosurgery.

Reuse of a Reversed "Bone Pad" to Perforate Incompletely Penetrated Burr Holes Created by Automatic-Releasing Cranial Perforators.

BACKGROUND: It can be difficult to make complete burr holes using a perforator with automatic releasing systems in cases of a soft diploe or thick calvarial bone. OBJECTIVE: To demonstrate the utility of a flipped "bone pad" (BP) in recovery of penetration failure when using an automatic releasing perforator. METHODS: For craniotomy or ventricular drainage, the first step is to make 1 or more burr holes using a craniotome. Neurosurgeons sometimes incompletely penetrate the skull using the latest tools. As a countermeasure for such cases, we have developed a simple and practical method. When making a perforation using a high-speed perforator, a round bone piece we call the BP is formed just above the dura. We pulled the BP from a completed burr hole, and placed the reversed BP in position at the bottom of the incompletely perforated burr hole. The BP acted as a new hard surface, preventing the automatic releasing system from activating, and allowed the burr hole to be completed by the craniotome without the need for additional tools. RESULTS: With this technique, we have successfully completed 6 out of 7 imperfectly perforated burr holes using a perforator with an automatic releasing system. There were no technique-related complications, such as plunging or dural laceration. CONCLUSIONS: The method has the advantage that the BP can be obtained without drilling an additional burr hole, and can be completed without the need for increasing cost, time, or instrument usage.

Clinical Observation of Treatment of Chronic Subdural Hematoma With Novel Double Needle Minimally Invasive Aspiration Technology.

OBJECTIVE: The aim of the present study was to explore the clinical effects, including the prevention of complications, of the treatment of chronic subdural hematoma with double needle aspiration. METHODS: The clinical data of 31 patients with chronic subdural hematoma treated by double YL-1 needle double skull drilling and 31 controls treated by traditional drilling and drainage were analyzed retrospectively. RESULTS: In the YL-1 needle group, only 1 patient was with hematoma recurrence, 1 patient was with intracranial pneumocephalus, and the remaining patients who were followed up for 3 months achieved a clinical cure. In the traditional drilling and drainage group, 13 patients were with hematoma recurrence within 3 months after the operation and 7 patients were with postoperative intracranial pneumocephalus. CONCLUSIONS: The method of double YL-1 needle is better than the traditional drilling and drainage method for the treatment of chronic subdural hematoma because it reduces the postoperative recurrence rate and complications.

Endoscopic-Assisted Burr Hole Reservoir and Ventricle Catheter Placement.

BACKGROUND: Accurate positioning of a ventricle catheter is of utmost importance. Various techniques to ensure optimal positioning have been described. Commonly, after catheter placement, additional manipulation is necessary to connect a burr hole reservoir or shunt components. This manipulation can lead to accidental catheter dislocation and should be avoided. Here, we present a new technique that allows direct endoscopic insertion of a burr hole reservoir with an already mounted ventricle catheter. METHODS: Before insertion, the ventricle catheter was slit at the tip, shortened to the correct length, and connected to the special burr hole reservoir. An intracatheter endoscope was then advanced through the reservoir and the connected catheter. This assemblage allowed using the endoscope as a stylet for shielded ventricular puncture. To confirm correct placement of the ventricle catheter, the endoscope was protruded a few millimeters beyond the catheter tip for inspection. RESULTS: The new technique was applied in 12 procedures. The modified burr hole reservoir was inserted for first-time ventriculoperitoneal shunting (n = 1), cerebrospinal fluid withdrawals and drug administration (n = 2), or different stenting procedures (n = 9). Optimal positioning of the catheter was achieved in 11 of 12 cases. No subcutaneous cerebrospinal fluid collection or fluid leakage through the wound occurred. No parenchymal damage or bleeding appeared. CONCLUSIONS: The use of the intracatheter endoscope combined with the modified burr hole reservoir provides a sufficient technique for accurate and safe placement. Connecting the ventricle catheter to the reservoir before the insertion reduces later manipulation and accidental dislocation of the catheter.

[Cranial trepanation in primitive cultures]. / La trepanación craneal en las culturas primitivas.

A review is presented on cranial trepanations performed by primitive cultures. The scientific interest in this topic began after the discovery in 1965 by Ephraim G. Squier of a pre-Columbian trepanated skull, and studied by Paul Broca in Paris. Pseudotrepanation and other types of cranial manipulation are reviewed. The techniques, technology, and instruments for every type of trepanation are well known. There are a surprisingly high percentage of cases showing signs of post-trepanation survival. Indications for trepanation are speculative, perhaps magic. Although trepanation in primitive cultures is widespread around the world, and throughout time, the main fields of interest are the Neolithic Period in Europe, the pre-Columbian Period in Andean South America, and some contemporaneous Pacific and African tribes. This particular trepanation procedure has no relationship with modern Neurosurgery, or with trepanations with therapeutic purposes performed since the Greco-Roman period in Europe, and afterwards around the world.

[COMPARATIVE ESTIMATION OF THE SURGICAL TREATMENT RESULTS IN CYSTIC MENINGIOMAS OF THE BRAIN, USING THE STANDARD METHODS AND NEW TECHNOLOGIES].

The results of surgical treatment of 54 patients, suffering the brain cystic meningiomas of various localization, were analyzed. The patients were operated on in universal conditions by neurosurgeons of one operative team, of them 24 ­ using new technologies. Wide application of new technologies in surgery of the brain cystic meningiomas have permitted to reduce the surgical intervention invasiveness essentially, and, as a consequence, to reduce trustworthily the operation time essentially, as well as the intraoperative blood loss severity.

Trepanation in the Late Bronze Age and Early Iron Age in Armenia.

In this study, trepanations in ancient Armenia are discussed. In total, 10 cases were studied. Seven were male, 1 female and 2 were children. Age of the individuals ranged from 6 to 65 years. Among nine cases of surgical trepanations four had possible healing signs. In these cases the individuals showed evidence of previous trauma to the skull or infection (mastoiditis, tuberculosis), suggesting that the operation had been carried out for therapeutic purposes. This provides further support for the suggestion that trepanation (or trephination) was performed primarily for therapeutic purposes, and because of cranial infection or injury. In one case, a symbolic trepanation could imitate real penetration into the skull cavity. This study shows that archaeological sites of Armenia and anthropological materials have a potential to supply essential information on ancient history of the Armenian people and the region.

Autologous cranial bone graft use for trepanation reconstruction.

BACKGROUND: Esthetic deformities in the human skull are a subject of concern among neurosurgical patients and neurosurgeons; they can be disfiguring and harm the patient's social relationships. To access inner structures, neurosurgical operations require skull trepanation, a process that frequently involves loss of bone tissue and leads to esthetic problems. Satisfactory reconstruction is a challenge, and neurosurgeons search for an implant which ideally is organic and low cost and does not cause an immunological or allergic reaction. Therefore, autologous bone tissue remains the gold standard for reconstruction. OBJECTIVES: To develop a technique that allows neurosurgeons to rebuild the trepanation hole with a better esthetic outcome. METHOD: Craniotomy orifices in 108 patients were closed with a graft obtained from the cranial bone inner layer. In order to remove the graft a specially made trephine was used. RESULTS: No grafts dislocated during follow-up. Cosmetic outcomes and results seen on image examinations were favorable for this new technique when compared with others previously described in medical literature. CONCLUSION: The authors present a new and feasible trepanation reconstruction technique that allows a better esthetic outcome without increasing the surgical risk for the patient, or making the surgical procedure longer or more expensive.