Drilling [Neurosurgery Wiki]

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====== Drilling ======

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Drilling is a cutting process that uses a [[drill]] bit to cut or enlarge a hole of circular cross-section in solid materials. The drill bit is a rotary cutting tool, often multipoint. The bit is pressed against the workpiece and rotated at rates from hundreds to thousands of revolutions per minute. This forces the cutting edge against the workpiece, cutting off chips (swarf) from the hole as it is drilled.

Drilling of the [[clinoid process]] and [[tuberculum sellae]], and [[optic canal]] unroofing are important surgical techniques, which may be performed relatively safely by a skilled neurosurgeon. 

Skull base drilling is a necessary and important element of [[skull base surgery]]; however, drilling around vulnerable neurovascular structures has certain risks.
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In a simulated surgical setting using human [[cadaver]]s, a [[trial]] was conducted with 5 expert [[skull base]] surgeons from 3 different [[hospital]]s. They performed 10 AP approaches, using either the feedback method or standard image guidance. Damage to critical structures was assessed. [[Operative time]], [[drill]] cavity sizes, and proximity of postoperative drill cavities to the cochlea and the [[internal acoustic meatus]], were measured. [[Questionnaire]]s were obtained postoperatively. Errors in the virtual [[drill]] cavities as compared with actual postoperative cavities were calculated. In a clinical setup, the method was used during AP.

Surgeons rated their intraoperative orientation significantly better with the feedback method compared with standard image guidance. During the cadaver trial, the [[cochlea]] was harmed on 1 occasion in the control group, while surgeons drilled closer to the cochlea and meatus without injuring them in the group using feedback. Virtual [[drilling]] under- and overestimation errors were 2.2 ± 0.2 and -3.0 ± 0.6 mm on average. The method functioned properly during the clinical setup.

The proposed feedback method improves orientation and surgical performance in an experimental setting. Errors in virtual drilling reflect spatial errors of the [[image guidance]] [[system]]. The feedback method is clinically practicable during [[anterior petrosectomy]]
((Voormolen EH, Diederen S, Cebula H, Woerdeman PA, Noordmans HJ, Viergever MA, 
Robe PA, Froelich S, Regli L, Berkelbach van der Sprenkel JW. Distance Control
and Virtual Drilling Improves Anatomical Orientation During Anterior
Petrosectomy. Oper Neurosurg (Hagerstown). 2019 Apr 24. pii: opz064. doi:
10.1093/ons/opz064. [Epub ahead of print] PubMed PMID: 31323686.
)).
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Manual [[cranial drill]]ing is an old but in modern [[neurosurgery]] still established [[procedure]] which can be applied quickly and universally in [[emergency]] situations. Electrical [[drilling]] requires more complex equipment and is usually reserved to the [[Operating Room]] (OR). It also seems desirable to apply an electrical drill for bedside usage but a suitable [[product]] does not exist so far.

An [[experimental]] study using a manually and an electrically driven skull drill included a total of 40 holes drilled into synthetic biomechanical sheets. Half of the holes were produced with a prototype electrical drilling machine of the company [[Kaiser Medical Technology]] and half of them with a traditional manual drill. Different drilling parameters such as the geometry of the borehole, the drilling forces and the drilling vibrations were captured during all experiments.

The electrical drilling needed higher vertical force by the operators and a longer time to penetrate the sheet. A reason was the relatively lower rotational speed provided by this particular drill. When drilling electrically the vibrations were substantially less which in turn led to a more precise shape of the holes (revealed by observation via a microscope).

The electrification of bedside drilling can in principle enable emergency craniostomies to be performed with greater ease and accuracy. The power of the electric drive, however, must be at least equivalent to the power of the traditional manual drill. Otherwise, the vertical forces exerted on the scull by the operator become inhibitive. The challenge is to combine cost-efficiency and re-sterilizability of an electrically driven drilling machine which at the same time is small and simple enough to qualify for emergency applications
((Carolus A, Richter W, Fritzen CP, Schmieder K, Brenke C. Experimental
investigations of a manually versus an electrically driven skull drill for
bedside usage. PLoS One. 2019 Apr 18;14(4):e0215171. doi:
10.1371/journal.pone.0215171. eCollection 2019. PubMed PMID: 30998712.
)).
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see [[Transmeatal drilling]]

===== References =====