The evolution of craniotomies, from the ancient civilizations to modern warfare: a historical review

Background Craniotomies represent one of the oldest surgical procedures in human history and have evolved significantly through centuries of medical innovation and wartime necessity. From prehistoric trepanation practices to modern neurosurgical interventions, military conflicts have repeatedly accelerated advances in cranial surgery. Methods This historical review examines the evolution of craniotomies across major historical periods, including prehistoric civilizations, the Renaissance, and modern warfare. Emphasis was placed on the influence of battlefield medicine, technological innovation, and ethical considerations in shaping contemporary neurosurgical practice. Results Early civilizations such as the Egyptians, Greeks, and Incas performed trepanation for therapeutic, traumatic, and ritualistic purposes, demonstrating surprising procedural sophistication and postoperative survival. During the Renaissance and subsequent military conflicts, including World Wars I and II, the Korean War, Vietnam War, and recent Middle Eastern conflicts, craniotomy techniques rapidly advanced due to the urgent demands of combat-related neurotrauma. Innovations including standardized debridement techniques, mobile neurosurgical units, rapid evacuation systems, neuroimaging, minimally invasive procedures, and robotic-assisted surgery significantly improved survival and neurological outcomes. Modern military neurosurgery additionally recognizes the importance of integrating psychological and rehabilitative care alongside surgical intervention. Conclusions The evolution of craniotomies reflects the continuous interaction between warfare, technological progress, and medical innovation. Although modern neurosurgery has achieved remarkable precision and improved outcomes, ongoing ethical and logistical challenges remain, particularly in military settings. Understanding the historical development of craniotomies highlights both the resilience of surgical innovation and the enduring pursuit of improved care for patients with traumatic brain injury.