Forensic Imaging 40 (2025) 200616

Contents lists available at ScienceDirect

Forensic Imaging
journal homepage: www.sciencedirect.com/journal/forensic-imaging

Cranial surgical approaches in the 21st Century Identified

Skeletal Collection
Maria Teresa Ferreira a,*, Catarina Coelho a , Rosa Ramos Gaspar b,c , Daniela P. de Matos d,e,
Ricardo Pereira d,e, Eugénia Cunha a,f, Inês Oliveira-Santos a
a
Centre for Functional Ecology, Laboratory of Forensic Anthropology, Department of Life Sciences, University of Coimbra, Calçada Martim de Freitas, Coimbra 3000-
456, Portugal
b
School of Health Sciences, University of Aveiro, Aveiro, Portugal
c
Medical Imaging Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
d
Faculty of Medicine, University of Coimbra, Coimbra, Portugal
e
Neurosurgery Service, Centro Hospitalar e Universitário de Coimbra, Portugal
f
Institute of Legal Medicine and Forensic Sciences I. P. (INMLCF, I. P.), Lisboa, Portugal

A R T I C L E I N F O A B S T R A C T

Keywords: In Forensic Anthropology, identification is comparing information from a person whose fate and whereabouts are
Cranium unknown with data from a person who is present but whose identity is unknown. The rarer and more distinctive
Neurosurgery the characteristics observed during the anthropological investigation, the greater the probability of reaching an
Identification
identification. Taking this into account, cranial surgeries can be considered good individualization factors. The
Skeletal collections
Forensic Anthropology
cases of skulls with lesions compatible with surgical procedures from the 21st Century Identified Skeletal
Collection are presented, and their identification potential is discussed. This collection comprises 302 adult
individuals, of which four females (aged 55 to 94 years) and four males (aged 67 to 92 years) present cranial
lesions of surgical origin. The results of the macroscopic and imaging analyses (conventional x-rays and CTs) are
presented, along with a detailed description and location of each lesion. In five cases there is clear evidence of
bone remodelling. This research, which combines anthropological analysis with imaging and neurosurgical in­
sights, demonstrates the importance of correctly interpreting these lesions, illustrating how important is a
complete and interdisciplinary analysis for forensic expertise.

Introduction identify is to compare the information of a person whose fate and

whereabouts are unknown with the data of a person who is present, but
The forensic anthropologist’s work should begin upstream of the whose identity is unknown [1–5]. In forensic anthropology expertise
laboratory analysis. From the beginning, in a criminal investigation, there are two major phases for identification: the reconstructive and the
alongside other experts, such as forensic archaeologists and police comparative. The first, where the characteristics of the unidentified
forces, the forensic anthropologist can participate in the location, person (body without identity) are inferred through a scientifically
excavation and recovery of human remains and contribute to under­ based analysis, and the second, where these data are compared with
standing their context. The skills of these experts include, among others, those of the missing person (identity without body). The first step in the
taphonomic and trauma analyses, which contribute to reconstituting the reconstructive phase is to assess the biological profile (generic identity
scene, understanding the postmortem processes, and making a para­ factors: sex, population affinities, age, and stature) which, by itself, does
mount contribution in determining the mechanism, the cause and the not allow an identification, only exclusions. Then, in the second step of
circumstances of death. Notwithstanding, of course, that identification, the reconstructive phase, the individualizing factors are sought. With
both of the living and the dead, is one of the main objectives of Forensic the most common Forensic Anthropology casework being decedents in
Anthropology expertise. various degrees of skeletonization, the individualizing characteristics of
The identification process is necessarily comparative. That is, to interest are skeletal variants of anatomical or pathological aetiology that

* Corresponding author.
E-mail address: [email protected] (M.T. Ferreira).

https://doi.org/10.1016/j.fri.2024.200616

Available online 20 November 2024

2666-2256/© 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
M.T. Ferreira et al. Forensic Imaging 40 (2025) 200616

constitute unique and exclusive conditions for each individual. These years old (mean: 81.22 y.o.; S.D.: 12.85). There are 140 males (46.36%)
include the frontal sinuses, trabecular bone patterns, anatomical vari­ aged between 25 and 96 years old (mean: 73.29 y.o.; S.D.: 15.60). It is
ants, developmental anomalies, pathological changes due to disease or important to highlight that this collection consists mostly of elderly in­
antemortem trauma, and medical interventions [1,3,4,6]. dividuals (87.75% are older than 60 years old), which mimics the cur­
The work of forensic anthropologists is not limited to forensic rent demographic profile of the Portuguese population deaths. Research
expertise, it must also involve multidisciplinary scientific research, in this collection has a positive legal appraisal from the Ethics Com­
encompassing a continuous search for new and better diagnostic mittee of the Faculty of Medicine of the University of Coimbra
methods. In addition to the study of real forensic cases already solved, (CE_026.2016). It is also noteworthy, that due to the Portuguese data
forensic anthropologists often resort to identified osteological collec­ protection law, the medical data of these individuals cannot be accessed
tions to develop new methods, test/validate the existing ones, and for the purposes of this investigation, thus no comparison between ante
establish their accuracy [7]. In fact, the importance of this type of and postmortem data was made in this study [13]. These type of ana­
osteological collection has been internationally recognized for a long lyses are still relevant to better understand cranial lesions from an
time [7–10]. anthropological perspective, contributing a documented corpus of sur­
The 21st Century Identified Skeletal Collection, housed in the Lab­ gical descriptions of the lesions on dry bone. This allows for a more
oratory of Forensic Anthropology, Department of Life Sciences, Uni­ targeted, efficient and faster search for medical records in forensic cases.
versity of Coimbra, embraces this long tradition of the assemblage of The skulls of the 302 individuals, including those fragmented and/or
identified human skeletons for use in research and teaching, with the poorly preserved, were analysed macroscopically (a magnifying glass
advantage of being a recent collection, whose individuals died, mostly, was used whenever needed) to scrutinize for lesions compatible with
in the 21st century [9]. One of the benefits of resorting to recent col­ surgical procedures: evidence of cuts, with or without remodelling, were
lections for research in Forensic Anthropology is the availability of cases searched on all cranial surfaces. Cutting marks compatible with an au­
with current medical treatments. Thus, the experts can train in the topsy procedure were excluded from this study. Subsequently, the post-
identification of lesion patterns, both in bone and teeth, implant­ cranial skeleton of the selected individuals was macroscopically ana­
s/prostheses, and surgical procedures of various types. Some informa­ lysed, and the respective skulls were subjected to imaging analysis. For
tion is known about the individuals of the 21st Century Identified the conventional radiology approach, a Philips Digital Diagnost equip­
Skeletal Collection, including the name (not available for all in­ ment was used and orthogonal projections were made in the ante­
vestigations due to it being sensitive information), age-at-death, sex, roposterior and lateral planes. In computed tomography, the volumetric
date of death, and year of exhumation. For some individuals, other in­ acquisition was performed, with reconstruction in the axial plane and
formation is known, such as cause of death, antemortem traumas, and subsequent additional 2D and 3D multiplanar reformatting in Siemens
pathologies, but these are limited to a minority. However, none of these Somatom Go All equipment. The skulls under study were positioned at
individuals will be analysed within the scope of the present the isocenter. In the CT exposure parameters, the Care Dose 4D systems
investigation. (perform automatic tube-current modulation in the angular and longi­
This article will focus on the analysis of cranial surgical lesions. Head tudinal directions [mA]) were used, with 100KV, a minimum collima­
injuries of various aetiologies (e.g., infectious, circulatory, traumatic, tion of 0.6 mm, a rotation time of 0.8s, and a pitch of 0.5. Regarding the
oncological) may be at the origin of surgical procedures that require the reconstruction, reformatting, and visualization parameters, we estab­
opening of the skull. Since every surgery is unique, its potential for lished an effective slice thickness of 1.0 mm in all planes (axial, coronal,
identification requires further research. In any scenario, to make an and sagittal); the Field of View (FOV) limited to the area of interest; with
appropriate diagnosis, the anthropologist must know the characteristics an Hr60 kernel; a window with a level of 400 UH and a width of 4000
of this type of intervention. This becomes a pressing issue, considering HU, thus allowing for proper differentiation of the studied bone tissue. A
that the discovery of skulls with this type of evidence is not rare, either second reconstruction was performed with an effective thickness of
in archaeological or forensic contexts. Cranial surgery (irrespective of its 0.6mm, with 50% overlap, and an Hr36 kernel, aiming to carry out a 3D
motivations, beliefs, or treatments) is not a modern procedure but rather volume rendering.
has a long history that dates back to the distant past. In fact, references Metric analyses of the lesions were made both macroscopic and
to cranial surgery are abundant in archaeological literature. For through CTs.
example, in the Portuguese context, considering the current national The observations obtained by the two methodological approaches
territory, the first case of probable trepanation was identified in the were compared and complemented. After this, a comparison was made
Moita do Sebastião shell midden (Muge shell midden complex, on the between standard neurosurgical procedures and findings in the skulls in
Tagus River), dating back to the Mesolithic period [14]. Already in the order to be able to list the most probable causes for the observed pro­
Late Neolithic, several cases were identified in different regions of the cedures. The macroscopic analysis was carried out by four of the au­
territory, and many of these cases were associated with blunt trauma thors, three anthropologists and an imaging specialist with training in
[15,16]. Outside of Portugal, there are records of these procedures in biological anthropology. The image capture and processing was carried
different regions and at different times, namely in classical antiquity. out by one of the authors who is a specialist in imaging with training in
The history of these interventions on the skull is outside the scope of this biological anthropology. The interpretation of the images was done
paper, for a more comprehensive knowledge of the history of cranial jointly by all authors. The neurosurgical analysis was carried out by two
surgery the reader can consult (among others) [11,17–24]. of the authors who are neurosurgeons.
The present research article aims to explore the eight cases of skulls To facilitate the reading flow of this paper, here follows a brief
with lesions compatible with surgical procedures from the 21st Century explanation of some of the most common nomenclature in skull surgery:
Identified Skeletal Collection and discuss its potential for identification Craniotomy (the piece of bone that is removed from the skull during the
in Forensic Anthropology casework. procedure is put back in place after the surgery is complete) is distin­
guished from craniectomy (where the bony flap of the skull is not
Sample and methods replaced immediately, allowing the brain to swell, thus reducing intra­
cranial pressure) and from trepanation (the opening of one or more holes
The creation of the 21st Century Identified Skeletal Collection began in the skull). For trepanning, a trephine is used (a surgical instrument
in 2009 and, currently, comprises 302 individuals of Portuguese na­ with a cylindrical blade). Burr holes are small holes in the skull that can
tionality, who died between 1982 and 2012, and were exhumed be­ be used to relieve pressure to avoid compressing the brain tissue. It is
tween 1999 and 2016 [9,12]. Female individuals comprise more than also important to mention that trepanning is also known as trepanation,
half of the collection (162; 53.64%), with ages ranging from 28 to 101 trephination, trephining or making a burr hole. In Bioarchaeology, the

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M.T. Ferreira et al. Forensic Imaging 40 (2025) 200616

term trepanation is generally used to describe any surgical procedure to also be noted that this surgical technique continues to be employed in
the skull, regardless of the object used, the type of procedure and Portugal to this day.
whether it occurred ante or postmortem.
Individual CEI/XXI_156, male, 67 years old, year of death: 1998
Results
The skull of this individual shows a hole in the right posterior region
Four female (aged 55 to 94 years) and four male individuals (aged 67 of the frontal bone. This orifice is round (approximately 12 mm in
to 92 years), who died between 1998 and 2010, present cranial lesions diameter) and has a regular margin. In the macroscopic analysis, doubt
compatible with surgical procedures (please refer supplementary ma­ arose as to whether or not it has (some) signs of bone remodelling. The
terial). Table 1 presents the sex, age-at-death and year of death of the frontal bone, especially in its medial region, shows porosity with signs of
individuals, as well as the location of the lesions and whether or not they remodelling, a lesion compatible with cribra cranii. On the other hand,
have signs of remodelling. The post-cranial skeletons were also analysed the CT scan shows a right frontal trephine without signs of remodelling,
macroscopically and no lesions compatible with tumours or metastases, which means that if there was a survival period, it was short.
perimortem trauma, prostheses and/or other medical devices were This surgical technique can be used to place a drainage tube to
found. A detailed description of the skull of each individual is presented decrease intracranial pressure, e.g. acute cerebrospinal fluid pathology,
next. In the supplementary material, photographs and CT-scan images in due to hydrocephalus or intraventricular haemorrhages. It is a technique
different planes can be consulted. frequently used in emergency cases, although it can also be employed
when treating tumours. Analysis of the post-cranial skeleton showed no
Individual CEI/XXI_88, female, 80 years old, year of death: 2001 bone pathology or trauma that could contribute to elucidating the need
for this neurosurgical intervention.
Macroscopically, it is possible to observe a hole measuring about
42x51mm in the left portion of the occipital bone, with rounded edges Individual CEI/XXI_176, male, 71 years old, year of death: 2007
and no porous lesions on the bone surfaces, i.e., completely remodelled.
The lesion encompasses the occipito-mastoid junction to the midline and In this case, the individual exhibits a hole (88x79mm) in the right
from the superior nuchal line next to the foramen magnum. CT analysis side of the skull that affects several bones (frontal, sphenoid, right pa­
shows a left occipital craniectomy with a corticalized bony ridge. From rietal and temporal). Inside this hole and joined by a small metallic
what was observed through both approaches, there is no doubt that this device (there is another similar device, but it is not fixed to the skull) is
woman survived the surgical procedure and lived for some years. the bone fragment (72x59mm) that was cut. The metallic devices (about
From a neurosurgery standpoint, it is most likely that this was an 19mm in length) are attached to the bone by small screws. The edges of
emergency surgery, which would justify the non-replacement of the the skull lesion are sharp, with no signs of bone remodelling. These
bone plate removed during the craniotomy. The extension of the cra­ edges are irregular, and in three zones (one in the parietal, another in the
niectomy suggests an approach to the cerebellar hemisphere or the lower part of the temporal, and another in the frontal region immedi­
treatment of extra-axial pathology of the left posterior hemifossa (such ately above the frontosphenoid suture) where the cut has a different
as a tumour, or a haemorrhage, among others). It is much less likely to rounded shape, namely burr holes. It is evident, to the naked eye, that
be a cerebellopontine angle approach. There are no changes in the rest of the removed bone portion is smaller than the cut margin, which is
the skull and skeleton that could give indications about the injury/pa­ confirmed by its measurements. Moreover, the antero-inferior portion of
thology that motivated the intervention. the bone flap has an irregular form.
Concerning the postcranial skeleton, besides the general degenera­
Individual CEI/XXI_99, female, 55 years old, year of death: 2001 tive lesions compatible with an age-at-death of 71 years old, it should be
mentioned an old fracture on the right ulna, identifiable by the visible
In the skull of this individual are present two circular metallic de­ remodelled bone callus, in the proximal third of the diaphysis. There­
vices (approximately 12mm in diameter), five orifices of different sizes fore, this lesion is not contemporary to the skull intervention.
with round borders (the largest measuring 13x13mm and the smaller The imaging analyses show a right fronto-parieto-temporal crani­
measuring 12x18mm) and regions of bone depression, arranged in a otomy started from at least two burr holes (one frontal and one parietal).
circular fashion (with about 72x62mm) in the area of the left parietal The remaining bone flap has been fixed with microplates and screws.
and occipital bones. CT analysis corroborates these findings, a left The lesion shows no signs of bone remodelling.
parieto-occipital craniotomy with rounded margins and corticalization. From a neurosurgical point of view, it is an atypical format crani­
Moreover, the bone was replaced by resorting to CranioFix®, still dis­ otomy, with a craniectomy component, which suggests unplanned sur­
playing two devices. There is no doubt that the edges of the lesion show gery, potentially for the treatment of traumatic pathology (intra- or
bone remodelling, indicating an antemortem lesion. extra-cerebral haemorrhage) or, eventually, spontaneous cerebral hae­
Compared to the neurosurgical practice, the most likely cause for this morrhage or decompensated neoplastic pathology. The fact that the
procedure is a tumour, perhaps a meningioma. However, the hypothesis antero-inferior limit of the bone flap is irregular means that it was not
of a vascular lesion cannot be excluded. Once again, the analysis of the performed with a craniotome, which may indicate the presence of some
post-cranial skeleton did not contribute to a possible diagnosis. It should previous anomaly, more likely of a traumatic nature. There is also severe

Table 1
Summary description of individuals.
No. Sex Age-at-death Year of death Signs of remodelling Location of lesions

CEI/XXI_88 Female 80 2001 Yes Occipital

CEI/XXI_99 Female 55 2001 Yes Left parietal and occipital
CEI/XXI_156 Male 67 1998 No Frontal
CEI/XXI_176 Male 71 2007 No Right parietal and temporal, frontal, sphenoid
CEI/XXI_230 Male 92 2008 Yes Frontal
CEI/XXI_231 Female 92 2009 Yes Frontal, sphenoid (?)
CEI/XXI_251 Female 94 2010 Yes Frontal
CEI/XXI_259 Male 81 2010 No Frontal, right parietal

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M.T. Ferreira et al. Forensic Imaging 40 (2025) 200616

bilateral sclerosis in the inner ears (cochlea, vestibule, semicircular ca­ and skull occurred in a single event.
nals), a fact that does not seem to be associated with the surgery. The
type of fixation device found in this skull is still used in surgeries per­ Individual CEI/XXI_259, male, 81 years old, year of death: 2010
formed in Portugal today.
The skull of this individual shows two round holes with regular
Individual CEI/XXI_230, male, 92 years old, year of death: 2008 margins in the right side (both, approximately, 14 mm in diameter): one
in the coronal suture, affecting the frontal and the right parietal, and the
Two small holes were observed in the frontal bone of this individual other in the right parietal, spaced 39 mm apart. These orifices are very
(12x2mm and 11x5mm) with clear signs of bone remodelling since the similar to the one presented by Individual CEI/XXI_156, and, as in that
borders are rounded and smooth. There are no signs of porous lesions. case, there were doubts in the anthropological analysis as to whether or
From the analysis of the radiological projections, only the profile image not it presents (some) signs of bone remodelling.
shows a change in continuity of the frontal sinuses. However, in the CT The CT scan images display two trephines located on the right side,
images of the axial plane, the absence of bone continuity at the level of one on the coronal suture and one on the parietal. These two burr holes
the frontal sinuses, right lateral and left lateral is evident. On sagittal do not show any signs of bone remodelling, which are indicative that the
plane images, it can be observed bone discontinuity with evidence of individual did not survive.
bone remodelling process, rounded edges with increased bone density. This intervention may have been performed with the intent of
These findings are more evident in the sagittal planes of the left maxil­ draining a subdural fluid collection, such as a chronic subdural hema­
lary sinus. From a surgical point of view, the observed lesion may have toma, or due to a traumatic accident that occurred weeks before. It may
been originated by a frontal sinus drainage procedure. also have been employed with the intent of draining an empyema (i.e., a
collection of pus within a natural cavity). Like the case of individual
Individual CEI/XXI_231, female, 92 years old, year of death: 2009 CEI/XXI_156, presented before, the type of cutting instrument
commonly utilized in these situations has been used in Portugal since the
In this case, the skull presents a lesion on the right frontal with a 1950s.
sulcus and, approximately, rounded shape (with an area of 53x65mm)
and three small depressions, without continuity. Laterally, following the Discussion
sulcus, a small cavity (4x21mm) exists in the region of the right fron­
tosphenoid suture. Anteriorly, the sulcus converges with another orifice The 21st Century Identified Skeletal Collection skulls were analysed
(28x21mm), with rounded edges, which extends to the upper rim of the and eight (2.7%) presented signs of cranial lesions compatible with a
right orbit. The smooth and rounded edges and the absence of porosities surgical origin. In these eight cases (4 females aged 55 to 94 years, and 4
are indicative of an old lesion, which suggests survival after the inter­ males aged 67 to 92 years), five show clear evidence of healed bone,
vention. Imaging results are consistent with macroscopic observations. pointing to surgical intervention several years before death. The frontal
It is a right frontal craniectomy, with a right supra-orbital bone defect, bone was the most affected, having been intervened in 6 cases (75%).
which includes the upper edge of the orbit. There is bony fusion over Despite only comprising eight skulls, the cases are very diverse: two
most of the limits of the original craniotomy. The edges of the defect are cases of burr holes (CEI/XXI_156 and CEI/XXI_259); one case of frontal
remodelled, suggestive of an antemortem lesion. Changes are observed sinus drainage (CEI/XXI_230); a case of trephines with closure (CEI/
in the medial portion of the roof of the orbit related to craniectomy. XXI_251); one case of craniectomy (CEI/XXI_88); two cases of crani­
There are several possible causes for this surgical intervention, such otomy (CEI/XXI_99 and CEI/XXI_176); and a more unusual case, with
as haemorrhages, tumours, frontal lobe pathology. This approach can craniotomy and craniectomy (CEI/XXI_231). In two of the cases,
also be used in larger or more complicated pituitary tumours. metallic devices used to fix the bone were identified (CEI/XXI_99 and
CEI/XXI_176). In none of the analysed cases was any evidence of a su­
Individual CEI/XXI_251, female, 94 years old, year of death: 2010 ture thread found.
In a Forensic Anthropology case, the assessment of lesions is
In this skull, two circular and symmetrical lesions can be seen in the extremely relevant. This analysis can help to understand the cause,
frontal bone (on the left side with about 26x27mm and on the right with mechanism and circumstances of death and even, in cases of investiga­
26x26mm), next to the coronal suture. These lesions are sulci with tion of crimes against humanity, make it possible to identify situations of
rounded edges, on the exocranium, more demarked anteriorly than torture. On the other hand, bone lesions that occurred during the in­
posteriorly, not reaching the endocranial surface. The macroscopic dividual’s life, whether traumatic, infectious or of another aetiology, can
analysis leaves doubt as to whether the cut was complete with remod­ be of added value in restoring identity to an unidentified person.
elling or if the cut was just superficial. There are no signs of porous Moreover, the location, type, extent, degree and remodelling of the le­
lesions. sions make each skeleton unique. Thus, one of the tasks of great rele­
The imaging analysis shows two trephine-like orifices, located vance in anthropological expertise is to determine the chronology of the
bilaterally and symmetrically in the frontal and parasagittal regions. The lesions/bone alterations. Nonetheless, this task is not simple, especially
remodelling is visible around the contour of the bone sections. Osteo­ in dry bone, and at times it is not possible to definitively determine the
synthesis material is not present. It should also be noted that there are chronology of the lesion. In these cases, complementary analyses are
some signs of frontal internal hyperostosis. important. Imaging analyses have advantages over histological and
Typically, this type of intervention allows for better access to the chemical approaches, as there is no need to collect bone samples from
removal of hematomas, such as bilateral subdural hematomas. The ob­ the lesion area, thus maintaining the integrity of the bone piece. The
servations indicate that this must have been a surgery performed a long interpretation of images obtained from dry bone is also not without
time before the death of the individual, considering that the year of challenges, hence the advantage of working in teams with members
death was 2010, there was time for bone healing, and this technique has from different disciplines. The cases here described demonstrate the
rarely been applied in Portugal since the end of the 20th century. potential of a double methodological approach when analysing human
In the post-cranial skeleton, the following were also observed: partial osteological remains, which can be beneficial both for forensic cases and
hip prosthesis and osteosynthesis plate in the lower third of the diaph­ for past populations contexts.
ysis, both in the left femur. A poly-traumatic event could have caused a In a medico-legal context, the identification of a body is of para­
cerebral hematoma, therefore, given the pattern of injuries and the fact mount importance for ethical, juridical and civil motives and is per­
that they all healed, it cannot be excluded that the injuries to the femur formed through a comparison between biological data obtained from the

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M.T. Ferreira et al. Forensic Imaging 40 (2025) 200616

cadaveric remains and antemortem data collected from potential victims Consent to participate
[25–27]. As previously mentioned, forensic anthropologists rely on
skeletal variants of anatomical or pathological aetiology as individual­ Not applicable.
izing factors. It is common knowledge that antemortem trauma and
medical intervention signs observed on skeletal remains can provide Consent for publication
significant information about the identity of a non-identified individual.
Obviously, the more unusual the lesion, the bigger the potential for Not applicable.
identification, as it is easier for it to be remembered by family and
friends, or if it has visible sequelae, such as cosmetic damage or mobility Availability of data and material
difficulties (i.e. someone with a limp). The cases analysed in this
investigation are among those that are most easily remembered by the The 21st Century Identified Skeletal Collection is available for
relatives of the victims (namely, the cases CEI/XXI_230 and research.
CEI/XXI_231 which are located in the facial region). The literature of The data that support the findings of this study are available from the
Forensic Anthropology is poor in the description of these cases. For corresponding author upon reasonable request.
example, in the study of 276 individuals of the Italian CAL Milano
Cemetery Skeletal Collection, Capella and colleagues [28] found no Code availability
cases of cranial surgery.
As it is, this work strives to reinforce the range of knowledge avail­ Not applicable.
able in the field of expertise of the forensic anthropologist, seeing that
recognizing lesions resulting from surgical interventions is imperative to
CRediT authorship contribution statement
a holistic and concise trauma assessment. For example, the work by
Amadasi and collaborators [29] explores two case studies where
Maria Teresa Ferreira: Conceptualization, Data curation, Formal
gun-shot trauma interacts with burr holes present in the skulls,
analysis, Funding acquisition, Investigation, Methodology, Project
demonstrating biomechanical alteration of the formation of fracture
administration, Writing – original draft, Writing – review & editing.
lines in the area where the surgical interventions were evident. Hence,
Catarina Coelho: Conceptualization, Formal analysis, Writing – review
avoiding misinterpretation of lesions (attributing a violent aetiology to
& editing. Rosa Ramos Gaspar: Formal analysis, Methodology, Writing
surgical evidence, or vice versa, for example) and understanding how
– review & editing. Daniela P. de Matos: Formal analysis, Methodol­
these findings may affect typical human anatomy allows for a more
ogy, Writing – review & editing. Ricardo Pereira: Formal analysis,
reliable assessment of cases and, consequently, improves the identifi­
Methodology, Writing – review & editing. Eugénia Cunha: Formal
cation processes.
analysis, Methodology, Writing – original draft, Writing – review &
Despite the impossibility of obtaining antemortem data from the
editing. Inês Oliveira-Santos: Conceptualization, Investigation, Meth­
eight individuals analysed in the present study— making it impossible to
odology, Formal analysis, Writing – original draft, Writing – review &
compare with postmortem findings obtained through the anthropolog­
editing.
ical macroscopic analysis and imaging combined with neurosurgical
interpretation —this type of research remains essential in the field of
Forensic Anthropology. Indeed, this study allows a better understanding Declaration of competing interest
of the lesions observed in dry bone, thus supporting the forensic an­
thropologist’s ability to better evaluate evidence during a forensic ex­ The authors state that they do not have any conflict of interest to
amination. Furthermore, the imaging analysis proved to be particularly declare.
relevant in cases where macroscopic analysis could not determine
whether bone remodelling was present. Acknowledgements
The results of this research show the potential of the combined
application of different disciplines. For what can be observed in these This work was carried out at the Forensic Anthropology Laboratory
skulls through this combined analysis, skeletal findings have the po­ of the University of Coimbra, a research group at the R&D Unit Centre
tential to provide useful postmortem information that can be compared for Functional Ecology – Science for People and the Planet (CFE), with
with antemortem witness statements and clinical imaging. reference UIDB/04004/2020, financed by FCT/MCTES through national
funds (PIDDAC).
Conclusion
Supplementary materials
The combined use of macroscopic anthropological analysis, neuro­
surgical diagnoses, and conventional radiology and computerized axial Supplementary material associated with this article can be found, in
tomography performed for each of the eight skulls of 21st Century the online version, at doi:10.1016/j.fri.2024.200616.
Identified Skeletal Collection with signs of cranial surgery led to a more
comprehensive knowledge of the cranial lesions and their origins. In
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