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A commercially available mechanical twist drill system was modified and evaluated in 35 craniotomies for frontal ventriculostomy in 31 trauma patients. The modified mechanical twist drill enabled faster and seemingly easier and safer craniotomy. It can be used as a safer alternative to common mechanical twist drill trephines, and is particularly recommended in difficult emergency conditions.
A surgical technique was devised to treat chronic subdural haematomas (SDH) in elderly patients. Initial good results encouraged the author to use this technique in elderly patients with acute SDH. This small group is also reported. The goal was to do definitive, not expectant or incremental surgery on these fragile patients who have a high incidence of co-morbid conditions and cerebral atrophy, and to obliterate the subdural space by allowing the skin to sink into the cranial defect. The surgical technique consists of trephine craniotomy and not closing the dura or replacing the bone plate. Experience with six elderly patients with acute SDH and 23 patients with chronic SDH is reported. Of six patients with acute SDH, mean age 80 years, 2 months, three died, all with a Glasgow Coma Score (GCS) less than 9. Three recovered to preoperative status, one with initial GCS of 7 and the other of 8. Of 23 patients with chronic SDH, mean age 77 years, 21 recovered to preoperative status. The two deaths were in patients with GSC of 5 and 7. There were no recurrent SDH or postoperative surgical or cosmetic complications. All patients were followed for at least 6 months. These excellent results suggest that the procedure could be considered as a first procedure in the elderly patient. At first glance, the operation appears to be overly aggressive, but it is an example of 'aggressive-conservative' treatment which produces good long-term results with few complications and no need for second operations.
The first nine clinical cases using endoscopic dissection of dura and craniotomy with minimal trephines were performed from June to August 1997 after trial dissection of 19 fresh cadavers conducted at the University of Brno's Pathology Institute in the Czech Republic. These procedures involved the refinement of craniofacial and intracranial surgical techniques using the endoscope and prototype instruments. These dissections demonstrated that intracranial structures can be explored using an endoscope without encumbrance, and that major craniofacial surgeries may also be performed with minor incisions and minimal craniotomies. Furthermore, we seek to illustrate that use of the endoscope in craniofacial surgery provides improved visualization and protection of vital structures while simultaneously allowing the surgeon to perform delicate maneuvers. This permits minimal brain retraction with less subsequent morbidity. This minimally invasive craniofacial-intracranial surgical technique using the endoscope is performed with minimal cutaneous incisions, avoiding wide exposure of subcutaneous tissue, cranium, and meningeal structures. The ultimate goal is to perform endoscopic intracranial osteotomies and obtain advancement of craniofacial skeleton with gradual distraction. Potential neurosurgical advantages include improved postoperative recovery, decreased cerebral edema, and decreased risk of hemorrhage and infection.
Today, the sinus floor elevation procedure is not only being used on a routine basis, but clinicians are reporting high success rates. The sinus floor graft has become an important option in the treatment of the edentulous posterior maxilla, where vertical bone height is less than ideal. A review of maxillary sinus floor elevation as an integral part of restoring the posterior maxillary is discussed. The related anatomy of the area and current osteotomy techniques are reviewed. This article describes a trephine osteotomy, which is an alternative technique to the existing lateral antrostomy approach currently being used.
Bone marrow trephine biopsies are becoming increasingly common in routine surgical pathology. Familiarity with normal marrow histology plays an important part in understanding and interpreting marrow pathology. The aim of this article is to describe the histological features of normal human bone marrow, in particular those features which are relevant to the diagnostic pathologist. The advantages and disadvantages of different technical aspects, such as choice of embedding material and type of stain, are discussed. The use of immunochemistry in identifying different cell types within the marrow is illustrated.
Evidence exists that trephination was performed in Germany as early as the Stone Age. Late medieval barber surgeons further developed instruments and techniques for this procedure. Various surgeons performed individual cranial operations before the 1870s, and neurosurgery evolved as a distinct discipline in Germany around 1934. Before the 20th century, most cranial operations in Germany, as in other European countries, were performed for trauma. Since approximately 1870, a few individuals with a devoted interest in surgery of the nervous system have developed operative techniques for the brain and spinal cord. Wilhelm Wagner, Fedor Krause, Ernst von Bergmann, and Otfrid Foerster were among these pioneers. Through independent research based on careful clinical observation, these physicians contributed significantly to an understanding of the pathophysiology of nervous system disorders that could be treated surgically. They designed techniques, such as those used for intracranial pressure regulation, and developed operative procedures, such as the osteoplastic flap of Wagner, and cortical stimulation, which was performed by Krause and Foerster.
The outcome of two groups of patients wtih midline aneurysms exposed by two different approaches was compared. The initial results support a clinical impression that a trephine approach has the following advantages: (1) adequate exposure with the best possible anatomical orientation and (2) a reduced morbidity.
For three years, we have performed craniotomy with a 5 cm diameter trephine through a linear incision. 53 craniotomies were done in 49 patients. This simple and time-saving method produced little bleeding and slight injury to the brain. The technique allowed the surgeon to spend most of his time at the management of lesion. Healing of wound was rapid and brain edema was minimal.
A well performed and processed trephine renders a perfect idea about tissue and cellular structure of bone marrow. Gentle taking and adequate processing of a sample are a prerequisite for successful biopsy. The most convenient and often sufficient is the paraffine technique with an entry evaluation of the first section and setling up the group diagnosis. Another time, it stimulates further choice of immunohistology and electron microscopy. There are presented detailed evaluation schemes for marrow suppression, hyperplasias, myelofibroses and tumours. They were checked in a group of 400 cases.
BACKGROUND: The advances in endoscopic sinus surgery have revolutionized the management of frontal sinus disease. Despite the successes, the purely endoscopic approach has its limitations, especially in patients with alterations in anatomy caused by previous surgical intervention or complex frontal sinus pneumatization patterns. The purpose of this study was to evaluate the efficacy of combined endoscopic trephination and endoscopic frontal sinusotomy (the above and below approach) in the management of these difficult cases. METHODS: Chart review was performed on patients undergoing the combined approach from October 1999 to June 2004. Demographic data, symptomatology, comorbidity, previous surgery, and primary pathology were determined. Outcome was assessed based on subjective symptom relief and objective endoscopic patency. RESULTS: Twenty-two patients with a mean age of 49.2 years underwent the combined approach. The primary pathology included mucoceles (15 patients), frontal sinusitis (2 patients), inverted papilloma (2 patients), osteoma (1 patient), fibrous dysplasia (1 patient), and pneumocephalus (1 patient). A total of 25 above and below procedures (22 primary and 3 revision procedures) were performed to manage the pathology. Postoperatively, headaches resolved in 47%, improved in 35%, and remained unchanged in 18% of the patients. Orbital symptoms resolved in 63%, improved in 25%, and remained unchanged in 12% of the patients. Endoscopic patency of the frontal sinusotomy was confirmed in 19 of 22 cases (86%) at a mean follow-up of 16.2 months. CONCLUSION: Management of complex frontal sinus pathology may require adjunct approaches in conjunction to the standard endoscopic techniques. In this series, the above and below approach was used successfully in 22 patients. The combined approach may serve as an important adjunct for management of complex frontal sinus disease.
The routine study of bone marrow trephine biopsies involves fixation, decalcification, paraffin-embedment, sectioning and staining. However, this process creates artifacts, produces shrinkage of tissue, consumes time and can result in sections of unsatisfactory cytological quality. It also renders the tissue unsuitable for enzyme-histochemical and immunohistochemical analyses. Frozen section of bone marrow without decalcification was evaluated as an alternative method for the study of bone marrow. This method was found to give sections with comparable cytological quality to that of paraffin-embedment, yielded sections for interpretation within 24 hours, and allowed enzyme-histochemical and immunohistochemical analyses to be applied successfully.
Thirty-one patients suffering from acute frontal sinusitis were treated by trephination. The patency of the nasofrontal duct was measured daily via the ventilation tube by computerized rhinomanometry until the tube was removed. According to the air flow changes inside the frontal sinus during normal nasal breathing, the duct was assessed as open, partially open or obstructed. The further healing process was assessed by clinical and radiological examination during a two-month postoperative follow-up. Statistical analysis of the results shows that both the favourable healing process and recurrences can be predicted with this method to a very high level of significance. The method is simple and rapid and it helps to determine the correct time for the withdrawal of the irrigation tube in individual patients.
The internal configuration of the skull in the fronto-parietal-temporal region was examined in 40 victims of extracranial pathology. Among them were 22 brachycephalics, 8 mesocephalics, and 10 dolichocephalics. A flattened part of the vault of the skull was revealed in the parieto-temporal area and its size depended little on the shape of the skull. The size of this part of the skull was measured and found to be 61 X 72 mm in males and 60 X 67 mm in females. The advantage of forming the trephination window within the boundaries of the flattened part of the vault of the skull is shown.
Large disposable circular trephines have been developed specially for circular excision biopsy of the skin. This technique is a simple and practical alternative to the traditional method of excision. It has the advantages of aligning the incision in the direction of the maximum skin tensions and reducing the length of the final wound closure.
Beta tricalcium phosphate (TCP) was employed as a nonimmunogenic biodegradable delivery system for bovine bone morphogenetic protein (BMP). A BMP/TCP composite was implanted in adult dogs with skull trephine defects of a critical size of 1.4 cm that would otherwise remain unhealed in the lifetime of the individual. BMP/TCP implants induced 91%-100% incorporation by deposits of new bone. In comparison, control implants of TCP impregnated with bovine serum albumin (BSA/TCP) induced 0%-8% incorporation, or only marginal host bed reactive bone formation. The retention of unabsorbed TCP in the host bone four months after implantation suggests that further research should be encouraged to obtain a formulation of sintered calcium phosphate that could be resorbed more rapidly and in the process more completely replaced by bone.
A new office technique for frontal sinus trephination is described. The procedure is simple, expedient, and inexpensive. Our experience with 16 patients suggests that this procedure is reasonably safe and, in addition, avoids the often-seen complications of supratrochlear nerve injury and persistent noticeable scar.
Infection of the anterior ethmoids and recessus frontalis causes swelling of the mucosa and obstruction of the nasofrontal duct, impairing the drainage of the frontal sinus. During the healing process the obstruction diminishes gradually. Prolongation of this process can lead to chronic infection of the nasofrontal region causing recurrent or chronic frontal sinusitis. In our everyday work we need a simple and reliable method to evaluate the patency of the nasofrontal duct, in order to be able to assess the recovery and to find those patients whose disease tends to become chronic. For this purpose we have measured the patency of the nasofrontal duct in 58 patients with frontal sinusitis after trephination with computerized rhinomanometry (RM) and with a simple salinemanometry (SM). The validity of the two methods to predict the further outcome of the patients has been compared in order to find out if SM would prove to be at least almost as reliable as rhinomanometry. Our statistics prove that SM is a useful aid in assessing the short-term recovery process of the patients. The long-term predictive value still remains to be seen.
A modification of the "figure 8" ipsilateral autokeratoplasty uses a silicone wafer beneath a portion of a standard sized corneal trephine to limit its cutting edge. This procedure eliminates the necessity of a custom-made instrument in a seldom-performed operation.