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5.03.2016

Dr. David S. Kushner Contributes to Book on History of Trepanation

David S. Kushner, M.D., associate professor of physical medicine and rehabilitation and a neurologist with substantial experience in post-surgical care of patients who have had a trepanation — boring a hole in the skull to treat intracranial disease or to help reduce swelling following a traumatic brain injury — has contributed a chapter providing a modern perspective on the procedure to an upcoming book describing its history dating back more than 2,000 years.

“Ancient Trepanation from the Perspective of Modern Neurosurgery,” the ninth chapter of Holes in the Head: The Art and Archaeology of Trepanation in Ancient Peru (Dumbarton Oaks, June 2016), was written by Kushner and Anne R. Titelbaum, Ph.D., a biological anthropologist at the University of Arizona College of Medicine, with CT scans provided by Robert Quencer, M.D., professor and Chair of the Department of Radiology, and Jose Romano, M.D., professor of neurology, used to illustrate some of their discussions. The book’s main author and editor, John W. Verano, Ph.D., professor of anthropology at Tulane University, invited Kushner to contribute the chapter.

“I was excited to receive the invitation,” said Kushner, who holds faculty positions at the Miller School of Medicine and the University of Miami School of Nursing and Health Studies. “I have always been interested in the history of medicine, and this was my first foray into an investigation of prehistoric trepanation.”

The book examines trepanation in Peru from about 400 B.C. through the time of the Incas in the mid-1400s to 1500s.

“The procedure was performed elsewhere, but Peru was selected as the focus because more trepanned skulls in good condition have been found there than anywhere else in the world,” said Kushner. “We don’t, of course, know the precise reasons the procedures were performed, but we believe the majority of them were due to traumatic brain injuries during times of war, such as blows to the head during battles.”

Kushner says the success rates for the procedure were surprisingly high and nearly comparable to those at the start of the modern surgical era.

“We can gauge the level of success by the condition of the skull and evidence of healing,” he said. “There were some regional differences within Peru, but it appears that long-term survival rates were nearly 40 percent in the 400 to 200 B.C. period, with steady improvements to about 55 percent in the A.D. 1000 to 1400 era, and as high as 75 percent to the time of the Incas in A.D. 1400 to 1500. That last figure rivals and exceeds the outcomes of early head surgeries at the start of the twentieth century, when cranial neurosurgery had average mortality rates of 30 to 50 percent.”

Given the Incas’ lack of modern infection control, medications and perioperative treatments, Kushner calls those patient outcomes astonishing.

“It is possible that they had some medical practices of which we are unaware,” he said, “and they clearly improved their technique over time.”

Still, he notes, there are some aspects to trepanation that are timeless.

“All of these procedures begin with a burr hole in the skull,” Kushner said. “After that, it’s up to the skill of the surgeon.”

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