Elsevier

The Lancet

Volume 374, Issue 9695, 26 September–2 October 2009, Pages 1067-1073
The Lancet

Articles
Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial

https://doi.org/10.1016/S0140-6736(09)61115-6Get rights and content

Summary

Background

Chronic subdural haematoma causes serious morbidity and mortality. It recurs after surgical evacuation in 5–30% of patients. Drains might reduce recurrence but are not used routinely. Our aim was to investigate the effect of drains on recurrence rates and clinical outcomes.

Methods

We did a randomised controlled trial at one UK centre between November, 2004, and November, 2007. 269 patients aged 18 years and older with a chronic subdural haematoma for burr-hole drainage were assessed for eligibility. 108 were randomly assigned by block randomisation to receive a drain inserted into the subdural space and 107 to no drain after evacuation. The primary endpoint was recurrence needing redrainage. The trial was stopped early because of a significant benefit in reduction of recurrence. Analyses were done on an intention-to-treat basis. This study is registered with the International Standard Randomised Controlled Trial Register (ISRCTN 97314294).

Findings

Recurrence occurred in ten of 108 (9·3%) people with a drain, and 26 of 107 (24%) without (p=0·003; 95% CI 0·14–0·70). At 6 months mortality was nine of 105 (8·6%) and 19 of 105 (18·1%), respectively (p=0·042; 95% CI 0·1–0·99). Medical and surgical complications were much the same between the study groups.

Interpretation

Use of a drain after burr-hole drainage of chronic subdural haematoma is safe and associated with reduced recurrence and mortality at 6 months.

Funding

Academy of Medical Sciences, Health Foundation, and NIHR Biomedical Research Centre (Neurosciences Theme).

Introduction

Chronic subdural haematoma, a common disorder mainly affecting elderly people, is associated with substantial morbidity and mortality.1, 2 Its incidence is about five per 100 000 per year in the general population,3 but is higher for those aged 70 years and older (58 per 100 000 per year).4 Because the proportion of people aged 65 years and older is expected to double worldwide between 2000 and 2030,5 a large rise in incidence is expected.

Treatment for this disorder is generally surgical evacuation, usually resulting in great improvement in neurological condition. Three techniques are most often used—twist-drill craniostomy (diameter less than 5 mm), burr-hole craniostomy (5–30 mm), and craniotomy.2 In a meta-analysis, Weigel and co-workers2 showed that all three techniques have about the same mortality (2–4%). Craniotomy is associated with a much higher morbidity than is craniostomy (12·3% vs 3–4%), and recurrence with twist-drill craniostomy is much higher than with burr-hole craniostomy (33% vs 12·1%) and craniotomy (33% vs 10·8%). Burr-hole craniostomy, an evacuation via one or two burr holes drilled over the site of the haematoma, is the most popular surgical technique worldwide.6, 7, 8, 9

Recurrence rates after the initial drainage procedure range from roughly 5% to 30%, and is a focus of research.2, 3 A recurring theme in this debate is whether postoperative drainage should be used in conjunction with burr-hole craniostomy.3 After Laumer and co-workers'10 prospective study, in which no difference was reported between recurrences in patients with and without drainage, emerging evidence suggests that such drainage of the subdural space lowers recurrence rates6, 8, 11, 12, 13 However, further evidence from randomised controlled trials is needed to guide treatment.2, 3, 14

Most surgeons remain unconvinced about the role of drains in burr-hole evacuation. Results of a survey9 commissioned by the Society of British Neurological Surgeons in 2006, showed that most neurosurgeons do not use drains most of the time. Perceived risk, surgeons' experience of a patient with a complication, and insufficient or a perception of insufficient evidence might play a part in their decision.2, 3 Our aim was to analyse the effect of postoperative drainage in management of chronic subdural haematoma after burr-hole evacuation.

Section snippets

Patients

In this single-centre block-randomised controlled trial recruitment began in November, 2004, and was stopped by the Data Monitoring Committee in accordance with the protocol in November, 2007. Patients aged 18 years or older who presented to the department of neurosurgery at Addenbrooke's Hospital in Cambridge, UK, with symptomatic chronic subdural haematoma proven by CT scan for burr-hole drainage were eligible for inclusion. We excluded patients with ipsilateral haematomas who had been

Results

The trial profile is shown in the figure. The primary outcome and duration of neurosurgical hospital admission was measured for all participants. Mortality at 30 days and 6 months was recorded in all but three patients with drains and two without drains. MRS scores at follow-up were available for 161 participants (76 treated with and 85 without drain). Completeness of other secondary outcome data varied.

Table 1 shows baseline characteristics. The groups were well matched. Mean age of the

Discussion

We have shown that patients with chronic subdural haematoma treated with burr-hole evacuation and postoperative drainage had a recurrence rate roughly half that of those without drainage. Mortality was lower at 6 months' follow-up for those with drains. At discharge, patients with drains had better functional status, more had favourable MRS scores and a GCS of 15, and fewer had neurological deficits than those without drains. Surgical complications were not increased in those with drains.

Our

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