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A 4-Year Multi-Centre Observational Study of 302 Cases

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A 4-Year Multi-Centre Observational Study of 302 Cases Journal of Clinical Neuroscience 36 (2017) 27–30 Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Original paper Use of subdural drain for chronic subdural haematoma? A 4-year multi-centre observational study of 302 cases David Yuen Chung Chan a, Peter Yat Ming Woo b, Calvin Hoi Kwan Mak c, Alberto Chi Ho Chu b, Charles Churk Hang Li d, Natalie Man Wai Ko b, Stephanie Chi Ping Ng a, Tin Fung David Sun a, ⇑ Wai Sang Poon a, a Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong b Department of Neurosurgery, Kwong Wah Hospital, Hong Kong c Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong d Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong article info abstract Article history: Chronic subdural haematoma (CSDH) is a common neurosurgical condition and is more prevalent in the Received 18 August 2016 ageing population. Studies have suggested that placement of subdural drains after burr-hole drainage Accepted 29 October 2016 was associated with lower recurrence rates. However, a considerable proportion of surgeons remained unconvinced of the effectiveness of drain placement and concerns exist with the potential complications this additional manoeuvre entails such as infection or bleeding. The aim of the present study is to eval- Keywords: uate the impact of subdural drain on CSDH recurrence and its safety. This is a multicentre observational Burr hole study. Data of consecutive patients with burr-hole drainage performed for CSDH in three hospitals in Chronic subdural haematoma Hong Kong during a four-year period from January 2008 to December 2011 were prospectively collected Elderly trauma Head injury and retrospectively analysed. The primary outcome was symptomatic recurrence requiring re-operation. Recurrence Secondary outcomes included the modified Rankin scales (mRS), morbidity and mortality at six months. Subdural drain A total of 302 patients were identified. The recurrence rate was 8.72% (13/149) with drain placement ver- sus 16.3% (25/153) with no drain (Odds Ratio = 0.489, 95%CI 0.240–0.998; p = 0.0463). Local wound infec- tion, subdural empyema, acute subdural haematoma and other complications had no significant difference. Six-month mRS, 30-day mortality and six-month mortality were comparable in both groups. In conclusion, the use of subdural drain significantly reduced recurrence with no significant increase in complications. Ó 2016 Published by Elsevier Ltd. 1. Introduction per 100,000 persons and for those aged 65 years or older, it is 58.1 per 100,000 persons [1]. Burr-hole drainage is an effective sur- Chronic subdural haematoma (CSDH) is a common neurosurgi- gical procedure but recurrence can be up to 8–22% [2]. Previous cal condition and is more prevalent in the ageing population. The prospective studies as early as in 1989 have shown that placement estimated incidence of CSDH in the general population is 13.5 of subdural drains after burr-hole drainage was associated with lower recurrence [3,4]. However a considerable proportion of neu- rosurgeons within our locality remain unconvinced of the effec- tiveness of drain placement and concerns exist regarding the ⇑ Corresponding author at: Division of Neurosurgery, Department of Surgery, The potential complications this additional manoeuvre entails such as Chinese University of Hong Kong, 4/F Lui Che Woo Clinical Sciences Building, Prince infection or bleeding. A survey on the practice of British neurosur- of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong. Fax: +852 2637 7974. geons showed that only 11% routinely placed subdural drains and E-mail addresses: [email protected] (D.Y.C. Chan), peterymwoo@ 58% used them in fewer than or equal to one-quarter of their cases gmail.com (P.Y.M. Woo), [email protected] (C.H.K. Mak), albertochu@ [5]. Meta-analyses have shown that only two out of six studies hotmail.com (A.C.H. Chu), [email protected] (C.C.H. Li), [email protected] favoured subdural drain placement [6]. The aim of the present (N.M.W. Ko), [email protected] (S.C.P. Ng), [email protected]. edu.hk (T.F.D. Sun), [email protected] (W.S. Poon), wpoon@surgery. study is to evaluate the impact of subdural drain on CSDH cuhk.edu.hk (W.S. Poon). recurrence. http://dx.doi.org/10.1016/j.jocn.2016.10.039 0967-5868/Ó 2016 Published by Elsevier Ltd. 28 D.Y.C. Chan et al. / Journal of Clinical Neuroscience 36 (2017) 27–30 2. Material and methods statistical analyses were done with the SPSS software version 22.0. This study and the research protocol had received ethic The study design was a multi-centre retrospective observa- approval by the Institutional Review Board of the Joint Chinese tional study. During a four-year period from 1st January 2008 to University of Hong Kong and the New Territories East Cluster Clin- 31st December 2011, data of consecutive CSDH patients with ical Research Ethics Committee and the Kowloon West Cluster burr-hole drainage performed at three hospitals in Hong Kong Research Ethics Committee. were prospectively collected and retrospectively analysed. All patients were followed up for at least six months with clinical Results assessment and interval computed tomography (CT) brain scans according to departmental guidelines. Inclusion criteria for acqui- A total of 302 patients fulfilling the inclusion and exclusion cri- sition of data for analysis in this study were: (1) age of 18 years teria with CSDH treated with burr-hole drainage during the study or older, (2) presence of symptomatic chronic subdural haema- period were identified for analysis. 149 had subdural drains placed toma by imaging (either by CT or magnetic resonance imaging after burr-hole evacuation of the CSDH (SD group) while 153 had (MRI)), and (3) treatment of unilateral CSDH by two-burr-hole no subdural drains inserted (no-drain group). Baseline data includ- drainage. Exclusion criteria for data analysis included (1) previous ing age, gender, admission Glasgow Coma Scale (GCS), smoking history of burr-hole drainage, (2) presence of a cerebrospinal fluid and drinking history were comparable between the two groups diversion device such as a ventriculoperitoneal shunt, (3) bilateral (Table 1). The proportion of patients prescribed with antiplatelet CSDH, (4) alternative surgical drainage techniques other than the and anticoagulant medications were also similar. The SD group two-burr-hole approach e.g. one burr hole or mini-craniotomy, or had more patients with hypertension, but the distribution of (5) use of glucocorticoid medication. Burr-hole drainage was stan- patients with other co-morbidities was not statistically different. dardized in all three hospitals as an operation involving two burr The rate of symptomatic recurrence was 8.7% (13/149) in patients holes with a size at least 14 mm (or greater) in diameter (size of with subdural drains versus 16.3% (25/153) with no drain placed the cranial perforators). The subdural drain (SD) used was a silastic (OR = 0.489, 95%CI 0.240–0.998; p = 0.046) (Table 2). Superficial catheter with an inner diameter of 2 mm and an outer diameter of wound infection rates were 2.6% (4/149) in the SD group versus 3 mm with one to three side holes. The available length of the tub- 1.3% (2/153) in the no-drain group (p = 0.656). Subdural empyema ing was 350 mm and was inserted via the frontal burr hole and was 0.67% (1/149) in the SD group versus 1.3% (2/153) in the no- tunnelled out with an anchoring suture. The silastic catheter was drain group (OR = 0.51, 95%CI 0.046–5.69; p = 0.584). All three connected to a Luer-Lok Connector and three-way connector and patients had reoperation for drainage. The length of stay at the connected to a Drainage Bag. The patient would be instructed to acute hospital was 18 days for the patient with subdural drain lie flat postoperatively and the subdural drainage bag was placed while for the two patients in the no-drain group was 13 days and at bed level for no less than 24 h and no more than 48 h. Due to 34 days respectively. For these three patients complicated with the observational nature of the study, the study protocol did not subdural empyema, there was no mortality at 30 days or six impose any interventions. The decision on whether to insert a sub- months. The mRS at six months was 4 for the SD group while 3 dural drain after burr-hole drainage was based on the operating and 4 respectively for the no-drain group. Two patients, 1.3% surgeon’s judgment. After the operation, computed tomography (2/149), with subdural drain complicated with acute subdural hae- (CT) brain scan was performed at least once before discharge. Fol- matoma (ASDH) and none in the no-drain group. (OR = 5.13, 95%CI low up CT scan was performed at one to four weeks interval till 0.244–107.8; p = 0.292). Both patients with ASDH underwent re- CSDH resolved. Burr-hole drainage would be performed if there operation for clot evacuation. One passed away on postoperative were radiological recurrence and presence of corresponding symp- Day 13 and the other had prolonged hospital stay of 87 days with toms or neurological deficit. The primary outcome was symp- an unfavourable functional outcome (with mRS of 4) at six months. tomatic recurrence rate. Symptomatic recurrence was defined as The average duration of hospital stay was 17 days (4–59 days) for radiological evidence of recurrence with clinical symptoms requir- the SD group versus 11 days (2–50 days) for the no-drain group.
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