Neurosurgery: From Trepanation to Robots

Holes drilled in prehistoric skulls, Harvey Cushing's revolution, the dark chapter of lobotomy, awake brain surgery, Gamma Knife radiosurgery and focused ultrasound — a history of operating on the nervous system.

Trepanation

Trepanation — drilling or scraping a hole in the skull — is one of the oldest surgical procedures. Trepanned skulls dating back thousands of years have been found worldwide, and many show healed bone edges, meaning patients survived. Ancient Peruvian (Inca and earlier) surgeons had notably high survival rates. Reasons probably included treating head injuries and possibly headaches, seizures or spiritual afflictions.

The birth of modern neurosurgery

In the late 19th century, anaesthesia, antiseptic technique and localisation of brain functions made brain surgery feasible. In 1884 Rickman Godlee removed a brain tumour localised by symptoms. The British surgeon Victor Horsley pioneered operations on the brain and spinal cord. The American Harvey Cushing (1869–1939), often called the father of modern neurosurgery, cut operative mortality dramatically with meticulous technique, blood-pressure monitoring, electrocautery (with William Bovie) and careful records of over 2,000 tumour operations. He also described Cushing's disease, caused by a pituitary tumour.

A dark chapter: lobotomy

In 1935 the Portuguese neurologist António Egas Moniz introduced the prefrontal leucotomy, cutting connections of the frontal lobes to treat severe mental illness. He received a share of the 1949 Nobel Prize. In the US, Walter Freeman popularised the "ice-pick" transorbital lobotomy, sometimes performed in minutes without proper anaesthesia or surgical setting. Tens of thousands of people were lobotomised, often leaving them apathetic and impaired. With the arrival of antipsychotic drugs in the 1950s and growing evidence of harm, the practice largely ended — a lasting warning about evidence, consent and enthusiasm in medicine.

Modern techniques

Microsurgery with operating microscopes (from the 1960s) and stereotactic frameworks for precise targeting transformed the field. Awake craniotomy with brain mapping preserves language and movement during tumour and epilepsy surgery. Endoscopic surgery reaches deep structures through small openings, and neuronavigation systems track instruments against MRI scans. Gamma Knife radiosurgery, developed by the Swedish neurosurgeon Lars Leksell (first used in 1967), focuses many beams of radiation onto a target without an incision. MRI-guided focused ultrasound can ablate a tiny target deep in the brain through the intact skull, approved in the US for essential tremor in 2016. Spinal surgery and peripheral nerve repair are major parts of the field.