An article in this week’s Surgery Special Issue of The Lancet reports that the use of a drain following surgery to drain a chronic subdural haematoma significantly reduces both mortality and haematoma recurrence. The article is the work of Dr Peter Hutchinson, Thomas Santarius and colleagues from the Academic Department of Neurosurgery, Addenbrooke’s Hospital, Cambridge, UK.
A subdural haematoma (SDH) is a form of traumatic brain injury in which blood gathers under the dura which is the outer protective membrane covering of the brain. Chronic SDH develops over days or weeks, frequently after minor head injuries. Sometimes, they may not be discovered until weeks or even months after the initial injury. Chronic SDH particularly affects the elderly. In 100,000 patients 58 are over 70 years old. With an ageing population, the prevalence of chronic SDH is anticipated to increase.
In around 5 to 30 percent of patients, chronic SDH recurs after surgery. In some cases, a plastic drain is placed a few centimeters into the subdural space and left for a few days after the operation. It can be useful in reducing recurrence but it is not used routinely by all surgeons. Moreover, drain use is controversial. The authors studied the effect of drains on recurrence and clinical outcomes.
This randomised controlled trial took place at the Addenbrooke’s Hospital, UK between November 2004 and 2007. Researchers evaluated 215 patients aged 18 years and older. They all had chronic SDH and were having it removed using the burr-hole surgery technique. 108 of them were randomised to receive a drain inserted into the subdural space and 107 to no drain after evacuation. The primary endpoint was recurrence needing re-drainage. Because of a significant benefit in reduction of recurrence in the drain group, the trial was stopped early.
Findings indicated that recurrence rates occurred in 9.3 percent (10 of 108) people with a drain and 24 percent (26 of 107) without. After six months, mortality was 8.6 percent (9 of 105) and 18.1 percent (19 of 105), respectively. Medical and surgical complications were very similar between the study groups.
The authors explain: “Use of a drain after burr-hole drainage of chronic subdural haematoma is safe and associated with reduced recurrence and mortality at 6 months…concern about heightened operative risk was the main reason why most neurosurgeons in the UK and Ireland preferred to avoid use of drains.”
They write in conclusion: “We could not identify any difference in frequency of medical or surgical complications between drain and no drain groups…Results of our study lend support to use of drains after burr-hole evacuation of chronic subdural haematoma.”
In an associated note, Dr Timo Koivisto and Dr Juha Jääskeläinen, of the Department of Neurosurgery, Kuopio University Hospital, Finland, remark: “Drain or no drain has called for a randomised clinical trial for decades – and here it is, impeccably done. The use of a drain statistically reduced recurrences, management, and mortality. Hutchinson and colleagues study should be circulated to every neurosurgical department.”
“Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial”
Thomas Santarius, Peter J Kirkpatrick, Dharmendra Ganesan, Hui Ling Chia, Ibrahim Jalloh, Peter Smielewski, Hugh K Richards, Hani Marcus, Richard A Parker, Stephen J Price, Ramez W Kirollos, John D Pickard, Peter J Hutchinson
Lancet 2009; 374: 1067-73
The Lancet
Written by Stephanie Brunner (B.A.)