Routine placement of subdural drain after burr hole evacuation of chronic and subacute subdural hematoma: a contrarian evidence based approach

Abstract

The objective of this paper was to evaluate whether available evidence supporting placement of subdural drain placement after evacuation of chronic subdural haematoma (CSDH) is applicable to a cohort of patients managed by us. In this observational cohort study, clinical follow-up was obtained in 166 patients who underwent burr hole evacuation of CSDH without placement of subdural drain followed by 3 days of bed rest. The primary outcome studied was recurrence requiring reoperation. Factors predicting recurrence were also analysed. We compared the patient characteristics and management protocols in our cohort with that in reports supporting drain placement to determine whether such evidence is relevant to our patient group. The mean age of our patients was 58 ± 17 years (range, 1 to 89 years). Sixteen of the 166 (9.6%) patients presented with symptomatic recurrence. The median time to reoperation for recurrence (15 of 16 patients) after the primary procedure was 17 days (range, 2 to 68 days). Antiplatelet and anticoagulant therapy was the only factor that was significantly associated with recurrence (p = 0.01). There were no infective or non-infective complications in our patient cohort. Our patient cohort and outcomes differed from those reporting drain placements in the following parameters: they were a decade younger, all patients received bed rest for 3 days after surgery and the recurrence rate was similar to that reported in the drained groups but significantly less than that reported in the non-drained groups. Routine placement of drain following burr hole evacuation of CSDH should only be done after careful comparison of the patient cohort under consideration and those reporting superior outcomes with drains. Evidence-based medicine supports such an approach.

Demonstration of Brain Expansion in Cases of Chronic SDH during Admission Leads to Decreased Rates of Recurrence

“…All publications studied by us have concluded that the use of a closed drainage system gives significantly reduced rates of reaccumulation as opposed to not using drains after surgery. [11][12][13][14] Our operative philosophy is therefor based on the following points drawn from a study of literature (►Fig. 1):…”

Reply

“…We also recognize the great value and contribution of the randomized controlled trial (RCT) performed in 2009 by Santarius et al 4 , in which the use of a drain was effectively associated with a lower rate of recurrence of CSDH and lower rate of patient mortality 4 . The same author has a commendable list of publications in this regard, reinforcing the advantages of using a drain 5 .However, it is almost a decade since the publication of the RCT by Santarius et al, which was the sole RCT discussing this theme at the time, and more recently, some newer, respectable publications have brought to our attention the fact that the same results might not be achieved worldwide.In this regard, Gernsback et al 7 and Sivaraju et al 8 have recently reported, in two different respectable neurosurgical journals, that their results did not match with those found by Santarius et al 4 . In both cases, the use of a drain did not affect recurrence rates 7,8 .…”

“…In this regard, Gernsback et al 7 and Sivaraju et al 8 have recently reported, in two different respectable neurosurgical journals, that their results did not match with those found by Santarius et al 4 . In both cases, the use of a drain did not affect recurrence rates 7,8 . We must highlight that neither of these recent studies were RCTs 7,8 .…”

“…Teles and Kraemer 1 on our article "The number of burr holes and use of a drain do not interfere with surgical results of chronic subdural hematomas (CSDH)". We really appreciated their attention to our study and contribution to current statements on CSDH treatment.We agree that standard management of this condition still remains controversial in its pre-operative, intraoperative and postoperative details 1,2,3,4,5,6,7,8 . This may be due to complex pathophysiological characteristics of this disorder and distinct patient profiles in different health institutions.…”

Frontal placement of subdural drain for subdural hemorrhage: A single center experience

“…CSDH often present weeks or months after the first bleed, as the initial hematoma liquefies, it expands. The increase of volume may result in increased in intracranial pressure and subsequent neurological complications [1][2][3]. CSDH is a profound cause of morbidity and mortality in elderly.…”