The identification of gyri and sulci before, can help us delimitate the intracraneal lesions and preserve as much as possible the neurofunctional and eloquent areas.

Craniotomies are often a critical operation performed on patients suffering from brain lesions or traumatic brain injury (TBI), and can also allow doctors to surgically implant deep brain stimulators for the treatment of Parkinson's disease, epilepsy and cerebellar tremor. The procedure is also widely used in neuroscience for extracellular recording, brain imaging, and for neurological manipulations such as Electrostimulation and chemical titration.

Craniotomy is distinguished from craniectomy (in which the skull flap is not immediately replaced, allowing the brain to swell, thus reducing intracranial pressure) and from trepanation, the creation of a burr hole through the cranium in to the dura mater.

One of the problems in neurosurgery is how to perform rapid and effective craniotomies that minimize the risk of injury to underlying eloquent structures. The traditional high-powered pneumatic tools and saws are efficient in terms of speed and penetration, but they can provoke bone necrosis and sometimes damage neurovascular structures.

As an alternative, the piezoelectric bone scalpel (piezosurgery), a device that potentially allows thinner and more precise bone cutting without lesioning neighboring delicate structures, even in the case of accidental contact.

From January 2009 to December 2011, 20 patients (8 men and 12 women), 19 to 72 years of age (mean: 49.3 years) were treated using piezosurgery. Surgery was performed for the removal of anterior cranial fossa meningiomas, orbital tumors, and sinonasal lesions with intracranial extension. Results The time required to perform craniotomy using piezosurgery is a few minutes longer than with traditional drills. No damage was observed using the piezoelectric device. Follow-up clinical and neuroradiologic evaluation showed a faster and better ossification of the bone flap with good esthetic results. Conclusions Piezosurgery is a new promising technique for selective bone cutting with soft tissue preservation. This instrument seems suitable to perform precise thin osteotomies while limiting damage to the bone itself and to the underlying delicate structures even in the case of unintentional contact. These advantages make the piezoelectric bone scalpel a particularly attractive instrument in neurosurgery 1).

All procedures except awake craniotomy are performed under general anesthesia. Indwelling Foley catheters, arterial lines, and peripheral intravenous lines.

Multiple craniotomy have been performed for resection of multiple brain metastases in the same surgical session with satisfactory outcomes, but the role of this procedure in the management of multifocal and multicentric glioblastomas is undetermined, although it is not the standard approach at most centers.

Iacoangeli M, Rienzo AD, Nocchi N, Balercia P, Lupi E, Regnicolo L, Somma LG, Alvaro L, Scerrati M. Piezosurgery as a Further Technical Adjunct in Minimally Invasive Supraorbital Keyhole Approach and Lateral Orbitotomy. J Neurol Surg A Cent Eur Neurosurg. 2014 Feb 19. [Epub ahead of print] PubMed PMID: 24554609.
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