Skull Trephination


Skull Trephination, Cranial Trephination, Skull Burr Hole, Subdural Hematoma Evacuation, Epidural Hematoma Evacuation

  • Indications
  1. Acute Subdural Hematoma or Epidural Hematoma with rapid deterioration and signs of acute Herniation
  2. Significant delay until definitive management by neurosurgery
  • Technique
  1. Define site of Hematoma on CT Head
    1. If Hematoma site is not accessible via standard landmarks, discuss alternative sites with neurosurgery
  2. Landmarks (standard, safest location without venous sinuses)
    1. Two finger breadths anterior to auditory canal
    2. Two finger breadths above zygoma (level of zygomatic arch)
  3. Procedure
    1. Assistant stabilizes the head position
    2. Mark, prep and anesthetize scalp region
    3. Make a vertical incision (3-5 cm long) down to bone
      1. Incision large enough to expose skull for burr tool application
      2. Self-retaining scalp retractor to expose periosteum
      3. Use periosteal elevator to elevate periosteum from skull
    4. Apply and use Burr tool with care to avoid plunging
      1. Transition from outer to inner skull table will feel like moving from smooth to rough
    5. Epidural Hematoma will drain spontaneously after passing through inner skull table
      1. Additional 3-sided incision flap through dura will be needed in cases of Subdural Hematoma
    6. Apply sterile dressing
  4. Alternative (Experimental, case reports only from low resource centers)
    1. Case report of successful trephination with EZ-IO (Intraosseous Cathether Placement)
    2. Case report used the same landmarks as Burr Tool (see above)
    3. Use standard adult EZ-IO (25 mm, blue intraosseous needle) and hubbed the catheter
    4. No cut-down to skull was performed (EZ-IO inserted directly through skin, as done with standard IO)
    5. References
      1. Durnford (2018) J Intensive Care Soc 19(1):76-9 +PMID: 29456607 [PubMed]
  • Efficacy
  1. Non-neurosurgeon performed emergency trephination is associated with improved outcomes (when neurosurgery not available)
    1. Nelson (2011) Acad Emerg Med 18(1): 78-85 [PubMed]
    2. Smith (2010) J Emerg Med 39(3):377-83 [PubMed]
  • References
  1. (2021) EM:Rap 21(1): 2-3