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Trepanation – Procedure, Indications & Risks

Trepanation is a neurosurgical procedure in which a hole or opening is made in the skull bone to gain access to the brain for treatment purposes.

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Things worth knowing about "Trepanation"

Trepanation is a neurosurgical procedure in which a hole or opening is made in the skull bone to gain access to the brain for treatment purposes.

What is Trepanation?

Trepanation (also referred to as trepanning) is a surgical procedure in which an opening is made in the skull bone to access the brain or its surrounding membranes. It is one of the oldest known surgical procedures in human history – archaeological evidence shows that trepanations were performed thousands of years ago. Today, trepanation is a standardized neurosurgical procedure carried out under modern sterile operating conditions.

Types of Trepanation

Modern medicine distinguishes between several forms of trepanation:

Burr hole trepanation: A small hole is drilled into the skull, for example to drain a hematoma or to measure intracranial pressure.
Craniotomy: A larger section of skull bone is temporarily removed and reattached after the procedure. This allows more extensive operations on the brain.
Craniectomy: A section of skull bone is removed and not immediately replaced, for example in cases of severe intracranial hypertension, to provide more space for the swelling brain.

Indications – When is Trepanation Performed?

Trepanation is indicated in a range of medical conditions, including:

Increased intracranial pressure (e.g., following traumatic brain injury)
Epidural or subdural hematoma (accumulation of blood between the skull and brain or beneath the dura mater)
Brain tumors (for biopsy or surgical removal)
Brain abscesses (pus-filled cavities in the brain)
Hydrocephalus (accumulation of cerebrospinal fluid in the brain)
Cerebral aneurysms (abnormal bulging of blood vessels in the brain)
Deep brain stimulation (e.g., for the treatment of Parkinson's disease)

Surgical Procedure

Trepanation is usually performed under general anesthesia. The scalp is shaved, disinfected, and incised, then carefully folded back. A specialized surgical drill called a trephine is used to create the opening in the skull. Depending on the indication, the bone flap is replaced and secured with small titanium plates or screws after the procedure is complete. The scalp is then sutured closed.

Risks and Complications

Like any surgical procedure, trepanation carries potential risks. Possible complications include:

Infections (e.g., meningitis or wound infection)
Bleeding or postoperative hemorrhage
Neurological deficits (depending on the brain region operated on)
Damage to brain tissue
Cerebrospinal fluid leak
Thrombosis or embolism

Aftercare and Rehabilitation

After trepanation, careful medical monitoring is essential. Follow-up care includes imaging controls (e.g., CT or MRI scans), wound care, and – depending on the extent of the procedure – neurological and physiotherapeutic rehabilitation measures. Recovery time varies considerably depending on the underlying condition, the age of the patient, and their overall health status.

Historical Significance

Trepanation is considered one of the oldest surgical procedures known to humankind. Archaeologists have found trepanned skulls from the Stone Age in Europe, Asia, and the Americas. Many of these patients survived the procedure, as evidenced by healed bone margins around the openings. In earlier cultures, trepanation was performed for religious or ritual purposes, as well as to treat head injuries and neurological conditions.

References

Greenberg, M. S. - Handbook of Neurosurgery, 9th Edition, Thieme Medical Publishers, 2019.
Missios, S. - Hippocrates, Galen, and the uses of trepanation in the ancient classical world. Neurosurgical Focus, 23(1), 2007. PubMed PMID: 17608355.
World Health Organization (WHO) - Guidelines for Essential Trauma Care. Geneva: WHO Press, 2004.

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