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