Use of a drain following surgery to drain a chronic subdural haematoma substantially reduces both mortality and haematoma recurrence. This is the conclusion of an Article in this week's Surgery Special Issue of the Lancet, written by 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 (the outer protective membrane covering of the brain). Chronic SDH develops over days or weeks, often after minor head injuries—and they may not be discovered until weeks or even months after the initial injury. Chronic SDH mainly affects the elderly (58 per 100,000 in patients over 70); thus with an ageing population, the prevalence of chronic SDH is expected to increase.
Chronic SDH recurs after surgery in around 5—30% of patients. A plastic drain placed a few centimetres into the subdural space and left for a few days after the operation might reduce recurrence but is not used routinely by all surgeons and drain use is controversial. The authors investigated the effect of drains on recurrence and clinical outcomes.
This randomised controlled trial took place at one UK centre (Addenbrooke's Hospital) between November, 2004, and November, 2007. The study assessed 215 patients aged 18 years and older with a chronic SDH who were having it removed using the burr-hole surgery technique. Of these, 108 were randomised 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 in the drain group.
The researchers found that recurrence rates occurred in ten of 108 (9•3%) people with a drain, and 26 of 107 (24%) without. At 6 months mortality was nine of 105 (8•6%) and 19 of 105 (18•1%), respectively. Medical and surgical complications were much the same between the study groups.
The authors say: "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 conclude: "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 accompanying Comment, Dr Timo Koivisto and Dr Juha Jääskeläinen, Department of Neurosurgery, Kuopio University Hospital, Finland, say: "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."
Dr Peter Hutchinson, Academic Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK. T) +44 (0) 1223 336946 / +44 (0) 1223 596029 E) pjah2@cam.ac.uk
Dr Timo Koivisto and Dr Juha Jääskeläinen, Department of Neurosurgery, Kuopio University Hospital, Finland.T) +358-44 717 2319 E) Timo.Koivisto@kuh.fi
For full Article and Comment, see: http://press.thelancet.com/drains.pdf
Journal
The Lancet