Drains result in greater reduction of subdural width and midline shift in burr hole evacuation of chronic subdural haematoma

Laurence Johann Glancz,On Behalf Of The British Neurosurgical Trainee Research Collaborative (Bntrc) ,Peter John Hutchinson,Paul Martin Brennan,Michael Tin Chung Poon,Angelos Georgiou Kolias

doi:10.1007/s00701-020-04356-z

Abstract

BackgroundDrain insertion following chronic subdural haematoma (CSDH) evacuation reduces recurrence and improves outcomes. The mechanism of this improvement is uncertain. We assessed whether drains result in improved postoperative imaging, and which radiological factors are associated with recurrence and functional outcome.MethodsA multi-centre, prospective cohort study of CSDH patients was performed between May 2013 and January 2014. Patients aged > 16 years undergoing burr hole evacuation of primary CSDH with pre- and postoperative imaging were included in this subgroup analysis. Baseline and clinical details were collected. Pre- and postoperative maximal subdural width and midline shift (MLS) along with clot density were recorded. Primary outcomes comprised mRS at discharge and symptomatic recurrence requiring re-drainage. Comparisons were made using multiple logistic regression.ResultsThree hundred nineteen patients were identified for inclusion. Two hundred seventy-two of 319 (85%) patients underwent drain insertion at the time of surgery versus 45/319 (14%) who did not. Twenty-nine of 272 patients who underwent drain insertion experienced recurrence (10.9%) versus 9 of 45 patients without drain insertion (20.5%; p = 0.07). Overall change in median subdural width was significantly greater in the drain versus ‘no drain’ groups (11 mm versus 6 mm, p < 0.01). Overall change in median midline shift (MLS) was also significantly greater in the drain group (4 mm versus 3 mm, p < 0.01). On multivariate analysis, change in maximal width and MLS were significant predictors of recurrence, although only the former remained a significant predictor for functional outcome.ConclusionsThe use of subdural drains results in significantly improved postoperative imaging in burr hole evacuation of CSDH, thus providing radiological corroboration for their recommended use.

Highlights

Chronic subdural haematoma (CSDH) is increasingly common in neurosurgical practice, especially with our ageing population; the incidence has been estimated to be 8.2 to 14.0 per 100,000 person-years [17]
Significant differences were observed in bed rest prescribed, and number of burr holes used between groups; the ‘no drain’ group underwent single burr hole evacuation more frequently in comparison to the drain group (22.2% versus 4.4%, p < 0.01)
Change in maximal width and midline shift (MLS) remained significant predictors of recurrence (Table 5), only the former remained a significant predictor for functional outcome (Table 6)

Summary

Introduction

Chronic subdural haematoma (CSDH) is increasingly common in neurosurgical practice, especially with our ageing population; the incidence has been estimated to be 8.2 to 14.0 per 100,000 person-years [17]. Level 1 evidence suggests the placement of a closed subdural drainage system at the time of burr hole evacuation maintained for 48 h postoperatively reduces symptomatic recurrence [23]; it improves long-term outcomes [13]. We have reported in a large prospective national UK audit that drains are associated with a significantly lower recurrence rate and better early functional outcome [3]. Drain insertion following chronic subdural haematoma (CSDH) evacuation reduces recurrence and improves outcomes. The mechanism of this improvement is uncertain. We assessed whether drains result in improved postoperative imaging, and which radiological factors are associated with recurrence and functional outcome. Patients aged > 16 years undergoing burr hole evacuation of primary CSDH with pre- and postoperative imaging were included in this subgroup analysis.

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Conclusion