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Trepanning

Trepanning, also known as trepanation or trephination, is a surgical procedure that involves creating an opening in the skull through drilling, scraping, cutting, or sawing to access the brain, historically performed as one of the earliest known forms of surgery.^[1] This practice, documented across diverse cultures, aimed to treat conditions such as head trauma, intracranial pressure, epilepsy, or headaches, or served ritualistic purposes like releasing spirits or enhancing spiritual awareness.^[2]^[3] The origins of trepanning trace back to the Mesolithic and Neolithic periods, with the oldest healed examples dating to approximately 10,000–5,000 BC in regions including Europe, the Middle East, and Africa.^[1] Archaeological evidence reveals widespread adoption during the Neolithic era (around 4000–2000 BC) in Western Europe, particularly France, and its continuation into the Bronze Age, where up to 5–10% of examined skulls from certain sites show trepanation marks.^[2]^[4] In the Americas, the procedure emerged independently by the 5th century BC in Peru, where it became especially prevalent, with over 1,500 trepanned skulls documented globally, including from ancient Indian sites like the Indus Valley during the Harappan period (c. 2600–1900 BC).^[2]^[5] The practice persisted through antiquity, the Middle Ages, and into Renaissance Europe, influenced by figures like Hippocrates, before declining with advancements in medical understanding.^[1]^[6] Techniques evolved from prehistoric methods using stone tools such as flint scrapers or obsidian blades for grooving and rectangular incisions, to more precise boring and drilling with metal chisels and saws in later civilizations, including Inca "tumi" knives.^[4]^[3] Procedures were often performed on living patients, as indicated by bone remodeling and healing edges observed in CT analyses of ancient remains, which mirror modern healing timelines of edge smoothing within months and full bevelling after years.^[1] Survival rates were notably high, with many cases showing complete recovery, demonstrating ancient surgeons' knowledge of anatomy and post-operative care despite the absence of modern aseptic techniques and limited technology.^[2]^[4] While therapeutic motivations dominated in medical contexts—such as relieving pressure from fractures or treating neurological disorders—cultural and spiritual rationales were equally significant, including rituals to exorcise demons, cure mental illnesses, or even create skull amulets in societies like the Maya or ancient Ecuadorians.^[6]^[3] In ancient Indian texts attributed to Sushruta, trepanning is described for brain-related ailments, linking it to early neurosurgical traditions.^[3] Today, though superseded by safer craniotomy methods, trepanning's legacy underscores humanity's longstanding quest to intervene in brain function, informing bioarchaeological studies of prehistoric medicine.^[1]^[6]

Overview

Definition and Etymology

Trepanning, also known as trepanation or trephination, is a surgical intervention involving the deliberate drilling, scraping, or cutting of a hole into the skull to expose the dura mater, access the brain, or alleviate intracranial pressure.^[7]^[8] This procedure represents one of the earliest forms of neurosurgery and serves as a precursor to modern craniotomy techniques, where a larger section of skull is temporarily removed and replaced.^[9]^[10] The terminology originates from the ancient Greek word trypanon (τρύπανον), meaning "borer" or "auger," referring to a drill-like tool used for boring holes.^[9]^[11] This evolved through Medieval Latin trepanum and Old French trépaner, entering English around 1400 as "trepan" to describe boring into the skull.^[12] The variant "trephine," coined in the 16th century by anatomist Hieronymus Fabricius ab Aquapendente, derives from Latin tres fines ("three ends"), describing a triangular-pointed instrument for perforation.^[10]^[11] While the terms are now largely synonymous in medical contexts.^[3] In its basic historical form, the procedure begins with marking the intended site on the skull, followed by the creation of an opening using manual tools to remove a disc or section of bone, often resulting in circular, linear, or rectangular shapes.^[11]^[7] Unlike contemporary practices, it was conducted without anesthesia, antiseptics, or imaging, relying on direct observation and rudimentary instruments to avoid penetrating the underlying brain tissue.^[9]^[10]

Purposes Across Eras

Trepanning has served multiple primary purposes throughout human history, primarily aimed at addressing physical trauma and neurological ailments, as well as ritualistic interventions believed to expel malevolent forces. In cases of head injuries, the procedure was performed to alleviate intracranial pressure and prevent complications from fractures or hematomas, a practice evidenced in ancient medical texts and archaeological findings.^[13] For neurological conditions such as epilepsy and migraines, trepanning was thought to provide relief by allowing the escape of pathological humors or fluids, as described in early surgical writings.^[14] Additionally, in ritual contexts, it was employed to release "evil spirits" or demonic influences believed to cause mental disturbances or erratic behavior, reflecting a supernatural interpretation of illness.^[15] The indications for trepanning evolved significantly over time, shifting from predominantly empirical and spiritual motivations in prehistory to more anatomically informed applications in antiquity and evidence-based emergency uses in modernity. Prehistoric practices focused on treating cranial trauma or perceived spiritual possession, where the goal was often survival or exorcism rather than precise diagnosis.^[15] In ancient periods, therapeutic uses expanded to include conditions like hydrocephalus, with Hippocrates recommending decompression trepanation to drain excess cerebrospinal fluid and reduce brain swelling.^[16] By the modern era, the procedure adapted into emergency burr-hole trephination or decompressive craniectomy, primarily to rapidly lower elevated intracranial pressure in cases of traumatic brain injury or stroke, improving outcomes in acute neurosurgical settings.^[17] Beyond medical rationales, cultural motivations for trepanning often centered on symbolic acts of liberation, encompassing both physical and spiritual dimensions, as well as rites marking social transitions. The act symbolized the release of internal pressures—whether accumulated blood, humors, or ethereal entities—serving as a metaphor for restoring balance in the individual and community.^[11] In some societies, it formed part of initiation rites, where the resulting cranial scar or trepanned fragment was retained as a talisman against misfortune or as evidence of endurance in shamanic or warrior traditions.^[18] Furthermore, healed trepanations occasionally signified elevated status, denoting the bearer's survival of a perilous ordeal and integration into elite spiritual or societal roles.^[15]

Historical Practices

Prehistoric and Neolithic Evidence

The earliest archaeological evidence of trepanning dates to the Mesolithic period in eastern Europe, with trepanations identified on skulls from sites in Ukraine dated between 8,020 and 7,620 BC.^[19] During the subsequent Neolithic period, the practice became more prevalent, exemplified by the oldest unequivocal case of a healed trepanation at the Ensisheim site in Alsace, France, where a 50-year-old male's skull shows signs of successful surgery dated to approximately 5,100–4,900 BC.^[20] Globally, prehistoric evidence extends to other regions, including early instances in Peru around 1000–500 BC, indicating the procedure's independent development across continents.^[21] In Neolithic Europe, trepanation appears to have been relatively common, with studies indicating that 5–10% of skulls from certain burial sites exhibit evidence of the procedure, ranging from 2.5% to 19% across various locations.^[15] This prevalence underscores its integration into prehistoric societies, potentially for therapeutic purposes such as treating head trauma. The types of trepanations varied but were predominantly circular, comprising the majority of documented cases (often around 80%), achieved through repetitive scraping with flint or obsidian tools to remove sections of cranial bone.^[11] Survival is frequently evidenced by well-healed bone margins, with new bone growth forming smooth edges around the openings, demonstrating that many individuals lived for weeks or months post-operation.^[20] Demographic analysis of prehistoric trepanned skulls reveals patterns favoring adult males, who account for the majority of cases, with openings most often located on the parietal bones, particularly the left side.^[22] Remarkably, many healed trepanations show no osteological signs of infection or inflammation, implying the employment of effective rudimentary techniques to mitigate postoperative complications, such as clean tools or natural antimicrobial agents.^[11] Survival rates in these Neolithic samples are estimated at 50–90%, highlighting the sophistication of early surgical knowledge despite the absence of modern anesthesia or sterilization.^[11]

Ancient and Regional Variations

In Mesoamerican cultures such as the Olmec and Maya, spanning roughly 1000 BCE to 1500 CE, trepanation was practiced using sharp obsidian tools to create openings in the skull, frequently linked to ritual bloodletting ceremonies aimed at appeasing deities or facilitating spiritual communication.^[8] Archaeological evidence from sites like those in pre-Hispanic Mexico reveals over 40 trephined skulls, indicating the procedure's integration into both therapeutic and ceremonial contexts, with obsidian blades serving as primary cutting instruments due to their precision and availability.^[23] Among the Inca, who flourished from the 13th to 16th centuries CE, trepanation employed obsidian, bronze, and copper tools for scraping or incising the cranium, often to treat head trauma, with gold plates sometimes applied post-procedure to cover the openings and promote healing.^[24] Survival rates in Inca cases reached up to 75%, as evidenced by healed cranial edges in archaeological remains from the Cuzco region.^[25] In ancient China, texts dating to around 200 BCE, including the Huangdi Neijing (Yellow Emperor's Inner Canon), describe trepanation as a method to alleviate epilepsy by releasing trapped winds or fluids from the skull, performed by physicians using stone or early metal implements.^[26] Archaeological finds, such as healed biparietal openings from the same era, suggest successful outcomes, with some individuals undergoing multiple procedures and showing bone regeneration.^[27] On the Indian subcontinent, archaeological evidence from the Indus Valley Civilization (around 3300–1300 BC) includes rare trepanned skulls, while the Sushruta Samhita, composed around 600 BCE, outlines cranial surgery techniques for treating head injuries, including trepanation with specialized instruments like scalpels and drills to remove fractured bone fragments and drain accumulations.^[28]^[3] These methods emphasized precision to avoid damaging underlying tissues, reflecting an advanced understanding of neurosurgical principles documented in this foundational Ayurvedic text.^[29] In Greek and Roman traditions, Hippocrates (circa 460–370 BCE) detailed trepanation in his treatise On Wounds in the Head, classifying skull fractures into types such as linear and depressed, recommending the procedure to elevate fragments, drain fluids, and prevent complications like epilepsy.^[30] Roman physician Celsus (circa 25 BCE–50 CE) further refined these techniques in De Medicina, advocating the use of trephines and drills for similar indications, with archaeological evidence from sites like Akanthos showing a 62.9% survival rate among treated individuals.^[31]

Medieval to Pre-Modern Developments

In medieval Europe, trepanning was employed to address perceived humoral imbalances, such as excess black bile causing melancholy or mania, as described in Roger of Salerno's Practica Chirurgiae (c. 1170), where he advocated a cruciate incision in the skull to release noxious humors.^[11] This procedure aligned with Galenic humoral theory, which dominated medical thought, and was extended to cases interpreted as demonic possession, though exorcism was more common for overt supernatural symptoms; surgical texts like the 13th-century Quattuor magistri recommended trephining epileptics to expel trapped humors or air, reflecting a blend of physiological and spiritual rationales.^[32] Ethnographic evidence from Bantu-speaking communities, such as the Kisii in western Kenya, indicates traditional trepanation primarily to alleviate severe migraines or headaches following head trauma, using scraping techniques with sharp knives to relieve intracranial pressure, possibly rooted in earlier traditions.^[11]^[33] During the Islamic Golden Age, trepanning advanced through systematic documentation in key texts. Avicenna's Canon of Medicine (c. 1025) detailed the procedure for treating cranial abscesses and injuries, emphasizing the drilling of a circle of holes connected by cuts to remove depressed bone fragments while preserving the dura mater, building on earlier Greek and Persian traditions.^[34] Al-Zahrawi (Abulcasis), in his 30-volume Kitab al-Tasrif (c. 1000), further refined neurosurgical techniques, including trephination for skull fractures and the use of cautery irons to control bleeding and prevent infection in head wounds, innovations that influenced subsequent Ottoman practitioners who integrated these methods with herbal anesthetics and refined instruments for battlefield trauma.^[35]^[36] In pre-modern Europe (16th–18th centuries), Ambroise Paré revolutionized trepanning amid rising firearm use, expanding indications to include depressed skull fractures from gunshot wounds and innovating tools like a protective bar on the trepan to avoid dura penetration, as outlined in his Traicté de la tête (1561); he also advocated conservative management, applying mixtures of alum and honey post-procedure to promote healing.^[37] Despite these advances, trepanning's popularity waned by the late 18th century due to alarmingly high mortality rates—often exceeding 50% in hospital settings from sepsis and hemorrhage—leading elite surgeons to abandon it for non-traumatic conditions like epilepsy or headaches, though it persisted in folk medicine among rural healers for similar ailments into the 19th century.^[11]

Techniques and Tools

Prehistoric Methods

In prehistoric times, the scraping technique was the predominant method for trepanning, involving the gradual abrasion of cranial bone using sharp-edged lithic tools such as flint or obsidian flakes to create an opening with characteristic beveled or scalloped edges.^[38]^[11] This labor-intensive process, performed without anesthesia, is estimated to have taken several hours to days depending on bone thickness and tool sharpness, as replicated experiments with similar materials suggest prolonged effort to penetrate the skull.^[11] Archaeological evidence from Neolithic sites in France, including over 70 locations like those in the Lozère region and Paris Basin, reveals ovoid perforations indicative of this scraping method, often identified through the irregular, abraded margins on preserved crania.^[38]^[13] Drilling variants, though less common in European Neolithic contexts than scraping, employed rotary motion with simple pointed tools, such as hand-rotated drills, to bore small conical pits, potentially forming a series of holes connected by scraping or grooving.^[1] Microscopic analysis of tool wear patterns from French Neolithic assemblages supports the use of such rotary techniques, with striations on flint points consistent with bone perforation.^[11] These methods were likely adapted for therapeutic purposes, such as relieving cranial injuries or pressure, based on the positioning and nature of the openings.^[1] Prehistoric practitioners typically selected accessible sites on the parietal or occipital bones for trepanation, favoring the left parietal in many cases for ease of access during the procedure.^[38] There is no archaeological evidence indicating manipulation of brain tissue following the creation of the cranial opening, suggesting the focus remained on bone removal alone.^[11]

Historical Instruments

In ancient civilizations, trepanning instruments evolved from basic stone tools to more refined metal implements, enabling greater precision in cranial surgery. In the Americas, particularly among pre-Columbian cultures in regions like Peru, obsidian blades were commonly used to make incisions and rectangular cuts into the skull, as archaeological evidence from burial sites demonstrates their application in creating openings for therapeutic or ritual purposes.^[11] Around 400 BCE in ancient Greece, physicians such as Hippocrates employed bronze trephines—crown-shaped cylindrical tools with serrated edges—to bore circular holes in the cranium, primarily to relieve intracranial pressure from fractures or trauma. These instruments, rotated manually or with a bow mechanism, represented a significant advancement in controlled bone removal while aiming to avoid damage to underlying tissues.^[13] Medieval European surgeons further refined these practices with iron saws and chisels, which allowed for more efficient grooving and scraping of bone, often in cases of head injuries or to access depressed fractures. In parallel, ancient Indian texts like the Sushruta Samhita (circa 600 BCE) describe needles used by Sushruta for precise punctures and exploratory procedures in cranial surgery, emphasizing minimal invasion to treat conditions such as sinus-related headaches or skull deformities.^[39] By the pre-modern period in the 18th century, British surgeon William Hey introduced an innovative oscillating saw known as Hey's saw, designed with a flexible, double-edged blade to enlarge trephine openings while minimizing jarring movements that could harm the brain. These later instruments often incorporated durable metals like iron and steel for the cutting edges, enhancing longevity and reliability in surgical kits.^[40]

Modern Adaptations

In contemporary neurosurgery, burr hole trephination has evolved into a refined procedure primarily used for evacuating chronic subdural hematomas and performing ventriculostomy to alleviate intracranial pressure. The technique involves creating a small circular opening in the skull using electric or high-speed pneumatic drills under local anesthesia, allowing for targeted access to intracranial spaces while minimizing tissue disruption. For subdural hematomas, a single or double burr hole is drilled at the site of maximum hematoma thickness, followed by irrigation and insertion of subdural drains to facilitate drainage over 48 hours.^[41] Similarly, ventriculostomy employs a burr hole or twist-drill method at standardized entry points like Kocher's point to insert an external ventricular drain, enabling cerebrospinal fluid diversion for conditions such as hydrocephalus or traumatic brain injury.^[42] Technological advancements enhance the precision and safety of these procedures through imaging guidance and specialized instruments. Preoperative computed tomography (CT) or magnetic resonance imaging (MRI) scans inform burr hole placement, while intraoperative neuronavigation systems provide real-time trajectory guidance, reducing variability in catheter or drain positioning. High-speed craniotomes, which automatically stop upon breaching the inner skull table, are standard for efficient bone removal, and minimally invasive variants incorporate endoscopy through the burr hole for direct visualization and evacuation of hematomas, often via a small 11-14 mm opening.^[43]^[44]^[45] Recent developments as of 2024 include adjunct middle meningeal artery embolization, often performed alongside burr hole evacuation, to reduce recurrence rates in chronic subdural hematoma cases by targeting vascular sources of hematoma expansion.^[46] These adaptations are integrated into standardized neurosurgical protocols, particularly for intracranial pressure relief in trauma settings, as outlined in guidelines from organizations like the Joint Trauma System. The procedure's efficiency is evidenced by short operative times, typically around 30-40 minutes, enabling rapid intervention in emergency contexts without requiring general anesthesia in many cases.^[47]^[41]

Medical and Cultural Contexts

Therapeutic Applications

In ancient Greek medicine, trepanning was primarily employed to treat skull fractures, as detailed in the Hippocratic corpus, where it was recommended to relieve intracranial pressure from splintered bone fragments in cases of closed head trauma.^[13] This procedure, first recorded by Hippocrates around 460–355 BC, involved careful drilling to avoid damaging the dura mater, aiming to prevent complications such as convulsions or death from pressure buildup.^[13] During the medieval period, trepanning extended to the evacuation of intracranial accumulations, including pus from abscesses and excess fluid associated with hydrocephalus, as described by physicians like Abulcasis (Al-Zahrawi) in the 10th century.^[48] In his surgical compendium, Al-Zahrawi outlined methods for draining superficial cerebrospinal fluid in hydrocephalic children through cranial perforation, emphasizing the removal of purulent matter to alleviate symptoms like swelling and neurological impairment.^[48] Similarly, trepanning was used for simple fractures and to extract blood or pus, reflecting a therapeutic focus on restoring cranial equilibrium without exacerbating tissue damage.^[49] In pre-modern Europe, Ambroise Paré, a 16th-century French surgeon, advanced trepanning for battlefield head wounds, applying it to trephined injuries from gunpowder weapons to expose and debride damaged tissue.^[50] Paré's Oeuvres documented numerous cases where the procedure facilitated recovery by reducing infection risk and relieving pressure, often incorporating improved trepan designs for precision during military campaigns.^[50] In ancient Indian medicine, archaeological evidence from sites like Adichanallur (circa 1500 BC–775 AD) indicates cranial trepanation, potentially linked to Ayurvedic practices in the Sushruta Samhita for treating severe head conditions, including sinus-related headaches, though textual descriptions emphasize general neurosurgical instruments rather than explicit perforation techniques.^[39] By the 19th century, trepanning saw validation for epilepsy relief, particularly in posttraumatic cases, where it was used to reduce intracranial pressure and excise scar tissue, as evidenced in surgical series like Benjamin Winslow Dudley's 1819–1832 reports on six patients showing seizure alleviation.^[51] However, outcomes were often confounded by placebo effects and high mortality, limiting its broader adoption beyond trauma-related epilepsy.^[11]

Ritual and Symbolic Roles

In prehistoric societies, trepanation was hypothesized to serve a role in reviving prominent individuals from conditions resembling death, such as after head trauma, by allowing spirits to enter or leave the body.^[15] This rationale, distinct from purely physical treatments, positioned trepanation as a ritualistic intervention likely reserved for key community members to ensure survival and social continuity.^[15] Among ancient Mesoamerican cultures, such as the Maya and Aztecs, trepanation intersected with broader bloodletting rituals aimed at divine communication and appeasement of gods. Historical accounts describe perforating the skull to alleviate head pain through controlled bleeding, a practice that aligned with sacrificial blood offerings to foster spiritual connections or honor deities.^[52] These acts, often performed by ritual specialists, symbolized offerings of life force, integrating trepanation into ceremonial contexts where blood served as a medium for supernatural interaction.^[52] Symbolically, trepanned skulls and bone fragments from the procedure carried talismanic value across various ancient cultures, believed to possess protective or magical properties against harm. In Neolithic Europe, for instance, fragments from healed trepanned skulls were fashioned into perforated amulets, worn as pendants to ward off evil or invoke luck, reflecting beliefs in the enduring spiritual power of survivors.^[53] Among the Incas, trepanned crania from burial sites, such as those examined in the 19th century, suggest similar symbolic retention, where the altered skulls may have been revered as emblems of resilience or kept as relics honoring the deceased's spiritual journey.^[3] In modern countercultures, voluntary trepanation has reemerged as a symbolic act for spiritual enhancement, particularly associated with "pineal gland activation" to achieve heightened consciousness. Pioneered by Dutch advocate Bart Huges in the 1960s, self-trepanation was promoted as a means to restore primal brain pulsation, akin to an open fontanelle in infants, thereby unlocking altered states and countering societal stagnation.^[54] This practice, embraced by fringe groups like the International Trepanation Advocacy Group, symbolizes rebellion against conventional medicine and a quest for transcendent awareness, though it remains marginal and unverified.^[54] Contrary to popular myths, trepanation was not primarily performed to treat chronic headaches, with archaeological and historical evidence indicating low support for this interpretation. Victorian-era speculations, such as those linking Neolithic skull holes to migraine relief, lack substantiation from ancient texts or skeletal analyses, which instead point to trauma, epilepsy, or ritual purposes.^[55] Occasional folk claims persist, but they do not align with the procedure's predominant non-therapeutic roles.^[55]

Risks and Outcomes

Surgical Complications

Trepanning, as a procedure involving the creation of openings in the skull, carries significant immediate risks primarily due to its invasive nature and proximity to critical neurovascular structures. Hemorrhage is a prominent hazard, often resulting from injury to dural vessels or arteries such as the middle meningeal, particularly when the trephine penetrates deeply into the cranial cavity; ancient practitioners like Hippocrates and Galen recognized this danger and advised avoiding areas near major sinuses to mitigate fatal bleeding.^[56] Brain tissue damage represents another acute biological risk, occurring through direct trauma to the parenchyma or dura mater perforation during scraping, drilling, or cutting techniques, which could lead to irreversible neurological deficits if the protective layers are breached.^[26] Infection, including severe forms like osteomyelitis in non-sterile prehistoric environments, exacerbates these issues, as evidenced by archaeological findings of suppuration around trepanation sites in prehistoric Peruvian skulls, where unsterilized stone tools likely introduced pathogens directly into bone and soft tissues.^[57] Historical complications extend beyond the immediate postoperative period, with seizures frequently reported as a sequela of trepanation, potentially triggered by irritation to the motor cortex or underlying trauma in regions like the temporal bone, as documented in ancient Greek medical texts and later observations.^[56] Cerebrospinal fluid (CSF) leaks constitute another procedural hazard, arising from unintended dural tears that allow fluid escape and increase vulnerability to meningitis or further intracranial pressure imbalances, a risk Hippocrates associated with relieving contusions but which often complicated recovery.^[56] In modern contexts, despite advancements, cerebral edema persists as a complication, manifesting as brain swelling post-procedure even with antibiotic prophylaxis, due to inflammatory responses to surgical manipulation.^[58] The severity of these complications is heavily influenced by procedural factors across eras, such as the absence of effective hemostasis in prehistoric cases, where reliance on rudimentary tools like flint scrapers led to uncontrolled bleeding without cautery or ligation, contrasting with controlled bleeding management in contemporary surgery using electrocautery and hemostatic agents.^[57] Tool-related issues, including the risk of dura perforation from sharp-edged prehistoric instruments, further amplified biological hazards by facilitating direct brain exposure.^[26] Additionally, anatomical knowledge played a pivotal role; early avoidance of vascular-rich areas like the superior sagittal sinus reduced hemorrhage incidence in successful prehistoric Peruvian trepanations, while ignorance of such structures in less refined historical practices heightened procedural dangers.^[56]

Survival and Healing Evidence

Archaeological evidence from prehistoric trepanations indicates high survival rates, often estimated between 70% and 90%, based on signs of bone remodeling and healing around the surgical sites. In Neolithic France, analysis of 72 trepanned skulls revealed survival rates of 87% for scraping techniques, 59.3% for grooving, and 12.5% for drilling, with long-term healing characterized by extended osteogenesis and margin rounding that demonstrate post-operative recovery.^[59] These findings suggest that ancient practitioners achieved substantial success, as evidenced by the formation of new bone tissue in a majority of cases.^[59] Historical outcomes from the medieval period show variable survival rates, often lower than prehistoric eras and approximately 50% in broader surveys, primarily attributable to postoperative infections that compromised healing. In early medieval southwestern Germany, while some cases exhibited low infection rates, broader surveys indicate that mortality was elevated compared to prehistoric eras due to limited antisepsis, with healing incomplete in many instances.^[60]^[61] In contrast, modern elective trepanation procedures, akin to craniotomies in neurosurgery, achieve near-100% survival rates, with overall mortality as low as 0.55% across age groups in well-selected patients.^[62] Key indicators of survival in trepanation cases include radiographic evidence of osteogenesis, such as complete or partial bone regeneration observed via X-ray and CT scans on ancient skulls. A 2022 study from the Carpathian Basin documented six trepanation cases from the 10th century CE, with four exhibiting long-term healing through advanced remodeling, including one individual with multiple trepanations (one surgical and four symbolic) that survived the procedures.^[63]

Modern Interpretations

Contemporary Medical Uses

In contemporary neurosurgery, decompressive craniectomy serves as a critical emergency intervention for traumatic brain injury (TBI) patients with refractory intracranial hypertension, as outlined in the Brain Trauma Foundation's 2020 guidelines and subsequent 2024 reviews emphasizing its role in reducing mortality when medical management fails.^[64] This procedure, evolving from ancient trephination techniques, involves removing a portion of the skull to allow brain expansion and alleviate pressure, particularly in cases of diffuse swelling or mass lesions.^[65] Similarly, burr hole trephination is employed in field or emergency department settings for acute epidural hematomas, providing rapid decompression in patients deteriorating before neurosurgical transfer, with studies reporting uniformly favorable neurological outcomes and no procedure-related complications.^[66]^[67] For elective applications, diagnostic burr holes are routinely used to evacuate chronic subdural hematomas (CSH), where blood accumulates slowly under the dura, often in elderly patients following minor trauma; this minimally invasive approach involves creating one or two small skull openings to irrigate and drain the effusion, achieving clinical improvement in over 90% of cases.^[68] Burr hole trephination also integrates with ventriculoperitoneal shunting for hydrocephalus management, where the hole facilitates catheter insertion into the lateral ventricle to divert excess cerebrospinal fluid, serving as a standard entry point in shunt implantation procedures.^[69]^[70] Recent case reports from 2020 to 2023 highlight decompressive craniectomy's application in COVID-19-associated intracranial hypertension, such as in malignant cerebral infarction or severe cerebral edema post-infection, where it has proven life-saving by mitigating herniation risks in critically ill patients.^[71]^[72] Modern mortality rates for these trephination-derived procedures, including burr hole drainage for CSH and emergency trephination for epidural hematomas, are generally below 5%, reflecting advances in perioperative care and patient selection.^[73]^[74]

Recent Research Findings

Recent archaeological studies have provided updated insights into trepanation practices in prehistoric Europe. A 2022 analysis of six cases from the Great Hungarian Plain in the Carpathian Basin revealed varied trepanation sizes, ranging from small oval openings (20 mm × 25 mm) to larger round or rectangular ones (up to 60 mm × 100 mm), with evidence of long-term healing in four instances indicating patient survival and therapeutic intent, such as trauma correction. Complementing this, a 2024 study of 41 Neolithic skulls from France quantified trepanation dimensions, reporting average minimum diameters of 29.5 mm and maximum diameters of 54.3 mm (approximately 3–5.4 cm), with a strong correlation between these measurements (R² = 0.558) that aids in reconstructing incomplete specimens.^[75] Anthropological research has further illuminated the cultural diffusion and multifaceted roles of trepanation. A 2022 review traced the practice's global history, highlighting ancient Indian contributions through Sushruta's Samhita, which described advanced cranial surgery techniques using specialized instruments, likely influencing Eurasian spreads via trade and migration routes, as evidenced by similar methods in Harappan and Central Asian sites dating back 4,000 years.^[3] In southern Italy, a study of 54 trepanated individuals from 43 sites spanning the IV century BCE to the VI century CE demonstrated hybrid ritual-medical applications, with healed parietal and frontal openings suggesting both therapeutic interventions for head injuries and symbolic acts to release spiritual forces, based on contextual burial analysis. Medical investigations have reevaluated trepanation's efficacy in trauma contexts and explored modern voluntary applications. Recent comparisons indicate historical trepanation mortality rates of 15–30% in well-documented ancient cases (e.g., Inca period survival of 70–85%), contrasting with modern decompressive craniectomy for traumatic brain injury, where mortality rates are approximately 20-30% due to advanced imaging and antibiotics, as reported in post-2020 neurosurgical studies.^[76] Additionally, a 2000-2002 pilot study of voluntary trepanation for purported psychosomatic benefits, involving MRI observations in 15 participants, reported subjective improvements in well-being and mental clarity, though findings remain anecdotal and lack robust empirical validation.^[77]

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Trephination is the oldest known surgical technique. Peru has been recognized as a major source of ancient trephined skulls, many of which date back 2300 years.Missing: earliest trepanning
[21]
Early Medical Skull Surgery for Treatment of Post-Traumatic ...
May 27, 2015 · The most frequently trepanned bone is the parietal followed by the frontal, and the left side of the skull is involved more often than the right ...
[22]
Contrast Between Global Ancient Civilizations and Pre-Hispanic ...
May 14, 2025 · Tools used for Trephination, I. This picture shows different obsidian artifacts used for sharpening cutting tools. II. Obsidian knives were ...
[23]
Trepanation Reveals the Success of the Incas | ACS
Trepanation, a skull surgery, was successful for the Incas, with a 75-83% survival rate, possibly due to open-air procedures and herbal medication.Missing: 11000 | Show results with:11000
[24]
[PDF] Depressed Fracture and Trephining of the Skull by the Incas of Peru
Stone and copper instruments used by. Incas in the operation of trephining. Surg. Clin. Chicago, p. 211, 1920. Studies in paleopathology, xiv; a pre historic ...
[25]
[PDF] Trepanation Procedures/Outcomes: Comparison of Prehistoric Peru ...
Ancient literature documents the practice of trepanation in China and Europe. A Chinese text from 2697. BC called “Huang Ti Nei Jing” mentions a physician ...
[26]
A Hole in the Head: A History of Trepanation - MIT Press Direct
Trepanation in Ancient China. The possibility that trepanation was practiced in ancient China is suggested by the following story about Cao Cao and Hua Tua ...
[27]
(PDF) Cranial trepanation in ancient India - Academia.edu
Surgical instruments from 'Susruta Samhita' align with findings of trepanation, showcasing ancient surgical expertise. Fifteen percent of trepanated skulls ...Missing: injuries | Show results with:injuries
[28]
https://www.academia.edu/40825056/Cranial_trepanation_in_ancient_India
[29]
(PDF) Drilling Away the Spirits : A Worldwide Study of Trepanation
... 2500 BCE) that had several trepanations. There was some bone regeneration ... Rectangles, irregular shapes, triangles, linear cuts, and incomplete ...
[30]
[PDF] Know Thyself: A History of Ancient Neuroscience - Eagle Scholar
Apr 22, 2025 · In many histories of neuroscience and/or psychology, authors begin with Hippocrates or Aristotle and after a few sentences, skip directly to the ...
[31]
Trepanations in the ancient Greek colony of Akanthos: Skull surgery ...
In Greek antiquity trepanation was performed predominantly in males, principally as a surgical treatment of cranial injuries. The survival rate was 62.9 %.
[32]
Demonic possession and mental disorder in medieval ... - PubMed
Western European belief in demonic possession as a cause of mental disorder has been traced through the medieval and early modern periods.
[33]
Ibn Sina's (Avicenna) Contributions in the Treatment of Traumatic ...
Here, Avicenna emphasizes on evacuating the blood as soon as possible, or else the hematoma prevents the wound from healing and grave outcomes as mentioned ...
[34]
Al-Zahrawi (936–1013 AD): On the Surgical Treatment of ...
He developed innovative surgical techniques for trephination and spinal traction, which are still used in modern neurosurgery. His insights make him worthy of ...Missing: trepanning | Show results with:trepanning
[35]
Abu Al Qasim Al Zahrawi (Albucasis): Pioneer of Modern Surgery - NIH
He utilized cauterization, usually to treat skin tumors or open abscesses. ... Al Zahrawi contributed early descriptions of neurosurgical diagnoses and treatment ...Missing: trepanning cautery
[36]
Management of injuries on the 16th-century battlefield: Ambroise ...
Paré's first publication was a revolutionary 1545 treatise on gunshot wounds (Fig. 2A). He detailed the mechanisms of gunpowder weapons and communicated his ...
[37]
[PDF] The Size of Trepanations During the Neolithic Period in France
Sep 10, 2024 · The earliest evidence dates back to the. Mesolithic,16,17 and then became increasingly frequent in the Neolithic.13,18. Numerous ancient ...<|control11|><|separator|>
[38]
Cranial trepanation in ancient India - LWW
Jun 22, 2019 · Trepanation is considered as the oldest known surgical procedure that was practiced from the Neolithic period and was reported from North and South America, ...
[39]
Hey's Saw (From the Collection #14) — Museum of Health Care at ...
It may have been used as therapy for headaches, epilepsy, or insanity. What is certain is that by the time of Hippocrates trepanation was used to treat skull ...Missing: 18th | Show results with:18th
[40]
Burr-Hole Evacuation of Chronic Subdural Hematoma - NIH
Under local anesthesia, one burr hole is placed in the area above the maximum hematoma thickness. One drain is inserted into the dorsal direction to the deepest ...
[41]
Ventriculostomy - StatPearls - NCBI Bookshelf - NIH
The insertion of the device is aided by the placement of either a burr hole or a twist drill technique. Kocher's point is the choice for the ventriculostomy.
[42]
The Effectiveness of Burr Hole Surgery with a High Speed Drill for ...
Since October 2020, we have performed burr hole creation using a high-speed drill for patients with Chronic Subdural Hematoma (CSDH). This method is more cost- ...
[43]
Neuronavigation: Principles, Clinical Applications and Potential Pitfalls
Neuronavigation systems have been developed for image-guided neurosurgery to aid in the accurate resection of brain tumors.Missing: trephination | Show results with:trephination
[44]
Endoscope-Assisted Surgery vs. Burr-Hole Craniostomy for ... - NIH
Nov 5, 2020 · This article aims to evaluate the safety and effectiveness of endoscope-assisted surgery for chronic subdural hematoma (cSDH) in comparison with the burr-hole ...
[45]
Joint Trauma System Clinical Practice Guideline: Traumatic Brain ...
EXPLORATORY BURR HOLES (if no neurosurgeon or CT scan is available). “Exploratory burr holes have limited practical utility.” They should “only be performed ...
[46]
The scientific history of hydrocephalus and its treatment - PubMed
Evacuation of superficial intracranial fluid in hydrocephalic children was first described in detail in the tenth century by Abulkassim Al Zahrawi.Missing: trepanning evidence
[47]
[PDF] The History and Practice of Surgery in Ancient and Mediæval Times
by " contre-coup." Trepanning was practised for simple, but not depressed, fractures and for the removal of accumulations of pus and blood ;.
[48]
Ambroise Paré's contributions to neurosurgery and functional recovery
Notably, trepanation indications increased because of battlefield head injuries, and Paré frequently described this technique and improved the design of the ...Missing: trephination skull
[49]
Benjamin Winslow Dudley and early American trephination for ...
Trephination for posttraumatic epilepsy in six patients (1819-1832). This was the largest recorded series of such cases, and it stimulated other American ...
[50]
[PDF] Cranial Surgery in Ancient Mesoamerica - Mesoweb
In turn, the anthropological definition of trepanation is an intentional and planned open- ing of the skull, carried out with instruments designed for this ...
[51]
5500-Year-Old Neolithic Cranial Amulets Shed Light on Ancient ...
Oct 14, 2023 · Broca believes that the skulls of those who survived trephination were believed to have magical properties, so after the patient died, fragments ...Missing: Inca | Show results with:Inca
[52]
An illustrated history of trepanation | ScienceBlogs
Jan 24, 2008 · The biggest advocate of trepanation for non-medical purposes is a Dutchman named Bart Hughes, who makes pseudoscientific claims that the ...
[53]
No, Getting a Hole Drilled in Your Head Was Never a Migraine Cure
Mar 6, 2018 · If Victorian theories about ancient trepanation for migraine were largely speculative, there is evidence of cutting holes in skulls for migraine ...Missing: chronic low
[54]
Studies in palæopathology. Some recent researches on prehistoric ...
Aug 10, 2025 · Margetts [1967] found in Africa not only prophylactic trepanning but also a widespread use of cranial rondelles as amulets to protect against ...
[55]
The management of cranial injuries in antiquity and beyond
The earliest neurosurgical procedure was trephination, which modern scien- tists believe was used to treat skull fractures in some civilizations. The ...
[56]
[PDF] The History of Craniotomy - Semantic Scholar
—Velpeau. Sir William Osler78 described the modern operation of cerebral decom pression as the oldest known surgical.Missing: complications | Show results with:complications
[57]
Intracerebral Hemorrhage Following Evacuation of a Chronic ... - NIH
However, various complications, such as, hematoma recurrence, infection, seizure, cerebral edema, tension pneumocephalus and failure of the brain to expand ...Missing: trepanning | Show results with:trepanning
[58]
The Size of Trepanations During the Neolithic Period in France
This type of trepanation was initially performed with flint, obsidian, or other hard stone knives, and later with metal tools, resulting in various polygonal ...
[59]
Trepanations from the early medieval period of southwestern Germany
Seven skulls showed clear evidence of healing and survival after trepanation. The mortality and infection rates for trepanation were low during the 6th to 8th ...Missing: trepanning | Show results with:trepanning
[60]
Evidence of trepanations in a medieval population (13th–14th ...
Feb 19, 2011 · The first trepanned European skull was found in 1685 by Bernard de Montfauchon in Cocherel, France (Finger, 1994; Clower and Finger, 2001).
[61]
How safe are elective craniotomies in elderly patients in ... - PubMed
Apr 24, 2020 · Mortality following elective craniotomy was low in all age groups. Today, elective craniotomy for well-selected patients is safe, and for elderly patients, too.
[62]
New insights in the investigation of trepanations from the Carpathian ...
Mar 29, 2022 · The aim of this study is to describe four new cases of trepanation from the Great Hungarian Plain and complement two other previously published cases.
[63]
Updated Review of the Management of and Guidelines for ... - MDPI
The Brain Trauma Foundation's fourth-edition guidelines, updated in 2020 following the Trial of Decompressive Craniectomy for Traumatic Intracranial ...
[64]
Decompressive craniectomy in trauma: What you need to know
The BTF guidelines recommend performing surgical evacuation with a craniotomy with or without replacement of the bone flap but do not specify the exact ...
[65]
Emergency department skull trephination for epidural hematoma in ...
Conclusion: In T&D patients with CT-proven EDH and anisocoria, ED skull trephination before transfer resulted in uniformly good outcomes without complications.Missing: field settings
[66]
Emergency Department Skull Trephination for Epidural Hematoma ...
Brief report. Emergency Department Skull Trephination for Epidural Hematoma in Patients Who Are Awake But Deteriorate Rapidly.
[67]
Efficacy of single burr hole with irrigation and sub-dural drain in the ...
Dec 13, 2023 · A single burr hole with irrigation and leaving a subdural drain is safe procedure in managing subdural hematoma.
[68]
What is the role of burr hole surgery in managing hydrocephalus?
Jul 27, 2025 · Burr hole surgery plays a critical role in the management of hydrocephalus through cerebrospinal fluid (CSF) diversion procedures, ...Missing: trephination | Show results with:trephination
[69]
17 years of experience with shunt systems in normal pressure ...
Feb 25, 2024 · Shunt implantation was performed as per our internal standard via burr-hole trephination at a 2,5 cm lateral pre-coronal location and distal ...
[70]
Case Report: Decompressive Craniectomy for COVID-19 Malignant ...
Feb 21, 2021 · Our results support that decompressive craniectomy, using the current stroke guidelines, should be considered an effective life-saving treatment for COVID-19- ...Missing: intracranial | Show results with:intracranial
[71]
Decompressive craniectomy for intracranial hypertension in vaccine ...
Aug 25, 2022 · National guidance recommended decompressive craniectomies for refractory intracranial hypertension. We describe our neurosurgical experience in managing a ...
[72]
Mortality and Outcome in Patients Older Than 80 Years of ... - PubMed
Mar 9, 2021 · Mortality rate was less than 10% in each group, showing no significant difference between them (P = 0.455). No significant difference in ...
[73]
Emergency Craniotomy and Burr-Hole Trephination in a Low ... - MDPI
May 26, 2022 · The postoperative mortality rate of 10.8% in the study hospital was very low compared with the mortality rate of 34.5% in Thailand (mortality at ...
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https://www.mdpi.com/1660-4601/19/11/6471
[75]
Trepanation Procedures/Outcomes: Comparison of Prehistoric Peru ...
In comparison, the average cranial surgery mortality rate during the American Civil war was 46%–56%, and short- and long-term survival rates are unknown. The ...