A randomized study of twist drill versus burr hole craniostomy for treatment of chronic subdural hematomas in 100 patients

Abstract

Chronic subdural hematoma (CSDH) has been treated by a variety of surgical approaches like twist drill craniostomy (TDC), burr hole craniostomy (BHC), craniotomy, etc. There are large variations in cure rates and recurrence rates among the surgical options in literature and like all surgical techniques, there is a paucity of well-designed trials to sort out the issue. It is an accepted fact of surgery that the least invasive approach will often be the best approach. We set out with the hypothesis that TDC is as safe and as effective as BHC for CSDH treatment. A prospective randomized controlled trial for 100 patients was done to compare the results of TDC and BHC (both with drain) in patients of unilateral CSDH. Recurrence rate was the primary outcome variable evaluated. A strict clinic-radiological criteria was used to avoid ambiguity in the study. Forty-eight patients underwent TDC and 52 patients underwent BHC. Mortality was 2% (patients in low GCS), and 2% unexpected mortality occurred (unrelated causes). Complication rate was 14% overall and was similar in both groups. Overall outcome (primary and secondary) was comparable across both groups with no significant difference. Cost, invasiveness and duration of surgery was significantly less in the TDC group. The cure rate, recurrence rate, mortality and morbidity of TDC with drain is significantly similar to that of BHC with drain for treatment of defined patients of unilateral sub-acute and chronic subdural hematoma. The cost, duration and invasiveness of TDC surgery is significantly less than that for BHC surgery.

Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures

“…Drainage time was also dif ferent: Gökmen et al 7 removed the catheter on the 2nd day after surgery, while Muzii et al 24 and Horn et al 11 re moved the catheter when draining stopped. Singh et al 32 did not report on drainage time. The study by Horn et al 11 did not meet our predefined criteria for a clear definition of recurrence of hematoma.…”

Management of subdural chronic hematoma in Colombia: national survey

“…Regarding the procedure of choice in cases of recurrence, the most used was the craniotomy, followed by the 1 Burr Hole, 2 Burr Hole, and TDC, which contrasts with other studies where BHC occupies the first place, followed by the TDC, The latter considered advantageous because it can be performed at the patient's bedside with the use of local anesthesia, together with cost and time saving (8). This difference could be given by the population studied, places of training and access to certain materials and procedures.…”

“…65 years (5,6), being more frequent in the male sex, (7) people with risks of falls, convulsions, alcohol abuse, coagulation disorders (2,8) and associated medicines (9). Its origin begins from the formation of acute hematomas, which may resolve spontaneously or increase in size and continue to enlarge, generating rupture of small veins as it expands, further increasing the amount of blood and thus becoming a HSC8, (10).…”

“…(12) The treatment options include craniotomy, Burr Hole craniostomy (BHC), Twist drill craniostomy (TDC), endoscopic management and Medical management; however, there is still no consensus on the technique of choice. (8) On the other hand, the use of preventive measures to reduce recurrence has been implemented, including: Use of corticosteroids, angiotensin receptor antagonists, correct positioning of the head postoperatively, continuous subdural irrigation, among others (13). Despite this, recurrence rates have been reported from 6.6 to 38% and mortality rates of 3.8% (8).…”

“…(8) On the other hand, the use of preventive measures to reduce recurrence has been implemented, including: Use of corticosteroids, angiotensin receptor antagonists, correct positioning of the head postoperatively, continuous subdural irrigation, among others (13). Despite this, recurrence rates have been reported from 6.6 to 38% and mortality rates of 3.8% (8). This high recurrence rate, coupled with the prevalence of this condition, raises the need to know how this pathology is approached in Colombia, the conditions that could be influencing this method and, at the same time, to evaluate the implications that this may have on the patient.…”