Neurosurg Focus 36 4 E11 2014 AANS 2014 Expanding the borders the evolution of neurosurgical approaches Malte Ottenhausen M D Imithri Bodhinayake M D Alexander I Evins M D Matei Banu M D John A Boockvar M D and Antonio Bernardo M D Department of Neurological Surgery Weill Medical College of Cornell University New York New York In this article the authors discuss the development of neurosurgical approaches and the advances in science and technology that influenced this development throughout history They provide a broad overview of this interesting topic from the first attempts of trephination by ancient cultures to the work of the pioneers of neurosurgery and the introduction of microsurgery http thejns org doi abs 10 3171 2014 2 FOCUS13547 Key Words craniotomy approaches neurosurgery W and how men first opened the skull remains a matter of speculation It cannot be determined for certain whether they were attempting to treat medical conditions as postulated by the English surgeon Sir Victor Horsley 1857 1916 10 or performing religious and cultural rituals as suggested by the French physician Pierrre Paul Broca 1824 1880 2 7 Archaeological findings from 3000 bce25 and earlier show that various cultures practiced opening the skull Early evidence of trephination comes from the famous discovery of the Incan skull by Ephraim George Squier 1821 1888 in the 1860s 11 which dated to 1530 ce as well as from several other skulls showing evidence of premortem trephination found across Europe 29 Asia 25 28 and the Americas 23 Examination of these skulls suggest that most of the individuals survived the operation suggesting that these procedures were actually attempted as medical treatments rather than religious rituals 2 Archeological evidence from such skulls suggests the existence of different techniques for trephination As explained in detail by Charles Gross 15 a technique used across various regions such as Peru France Israel and Africa involved the use of rectangular intersecting cuts Initially these cuts were made using hard stone tools and later using metal tools Other techniques for trephination included abrasion with a rough tool until the dura was exposed carving out a circular piece of bone using sharp stone tools and the creation of multiple small holes in a circumferential manner to facilitate the cutting of a small disk of bone with sharp instruments Fig 1 More detailed information about early operations on the skull can be found in documents providing insight on hy Neurosurg Focus Volume 36 April 2014 history skull base overview beliefs and techniques of early skull surgery The Corpus Hippocraticum a collection of more than 60 medical texts originating from between 500 bce and 200 ce contains the first description of trephination and provides detailed instructions in the chapter On Head Wounds 18 The Greek physician Galen of Pergamon 129 200 ce further developed and described the technique and contributed tremendously to the understanding of neuroanatomy In particular he stressed the importance of maintaining the integrity of the dura mater 27 Evidence of the practice of trephination has also been found in many cultures outside of Greece and Rome From ancient times through antiquity and the Middle Ages trephination and removal of bone fragments were established as treatments for head trauma Subsequently cranioplasty using metal plates1 31 or even xenografts33 was developed and described After the fall of the Roman Empire education was largely based in religious institutions and it was not until the 11th century ce that the first universities University of Bologna est 1088 and medical schools were established However cadaveric dissections were forbidden inhibiting complete understanding of cranial anatomy It was not until the Renaissance in the 16th century and the cadaveric dissections of Leonardo Da Vinci 1452 1519 and Andreas Vesalius 1514 1564 that the contents of the cranial vault including the cranial nerves became known 14 Several detailed illustrations of neuroanatomy were subsequently printed for the first time and the first public dissections of the cranium were performed 17 This growing knowledge of cranial anatomy was communicated through organized societies including the Acad mie des Sciences in Paris the Royal Society of London 1 M Ottenhausen et al Fig 1 A cranium from the Andahualyas province Peru 1000 1200 ad demonstrating trepanations made by scraping upper left inset shows evidence of healing and by drilling multiple small holes likely postmortem to practice and optimize technique Reproduced from Kurin DS Trepanation in South Central Peru during the early late intermediate period ca AD 1000 1250 Am J Phys Anthropol 152 484 494 2013 Used with permission from John Wiley Sons and others that formed around the 17th century 14 These societies which originated from small scientific circles and grew in the Age of Enlightenment were dedicated to expanding knowledge and making it publicly available Throughout the 17th and 18th centuries surgeons with extensive practical experience from the battlefields helped advanced surgical technique 14 One well known example is the surgeon Antoine Louis 1723 1792 who became secretary of the Acad mie Royale de Chirurgie in Paris Louis introduced the use of ligatures to amputate a tumor at its base and successfully removed an extraaxial brain tumor meningioma in as early as 1774 14 From Cranial Surgery to Brain Surgery In the period that followed anatomical and medical knowledge continued to grow but the practice of cranial surgery remained largely unchanged It was not until the 19th century that more sophisticated approaches through the skull were developed This period was marked by scientific advancement in many fields which allowed surgeons to perform more extensive skull openings including openings that extended beyond the dura The development of anesthesia antisepsis radiography hemostasis and new operating instruments enabled a deeper understanding of neuroanatomy pathology and physiology that laid the ground for the evolution of modern neurosurgery After several failures and unacknowledged initial successes William Thomas Green Morton 1819 1868 publicly demonstrated the successful use of ether as an anesthetic on October 16 1846 35 This so called Ether Day marks the birth of modern anesthesia and the start of longer more complex procedures Infection was the most common cause of mortality related to trephination during the
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