Neurosurg Focus / Volume 36 / April 2014 Neurosurg Focus 36 (4):E11, 20141©AANS, 2014Why 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 perform-ing 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—sug-gesting that these procedures were actually attempted as medical treatments rather than religious rituals.2Archeological 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 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 antiq-uity 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 estab-lished. 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.17This growing knowledge of cranial anatomy was com-municated through organized societies, including the Aca-démie des Sciences in Paris, the Royal Society of London, Expanding the borders: the evolution of neurosurgical approachesMalte 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 YorkIn 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 • approaches • history • skull base • overview • craniotomy • neurosurgery1M. Ottenhausen et al.2 Neurosurg Focus / Volume 36 / April 2014and 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 ex-panding 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 Académie Royale de Chirurgie in Paris. Louis introduced the use of ligatures to amputate a tumor at its base and successfully removed an extra-axial brain tumor (meningioma) in as early as 1774.14From Cranial Surgery to Brain SurgeryIn 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 sci-entific advancement in many fields, which allowed sur-geons 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
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