Drains result in greater reduction of subdural width and midline shift in burr hole evacuation of chronic subdural haematoma.

BACKGROUND: Drain insertion following chronic subdural haematoma (CSDH) evacuation reduces recurrence and improves outcomes. The mechanism of this improvement is uncertain. We assessed whether drains result in improved postoperative imaging, and which radiological factors are associated with recurrence and functional outcome. METHODS: A multi-centre, prospective cohort study of CSDH patients was performed between May 2013 and January 2014. Patients aged > 16 years undergoing burr hole evacuation of primary CSDH with pre- and postoperative imaging were included in this subgroup analysis. Baseline and clinical details were collected. Pre- and postoperative maximal subdural width and midline shift (MLS) along with clot density were recorded. Primary outcomes comprised mRS at discharge and symptomatic recurrence requiring re-drainage. Comparisons were made using multiple logistic regression. RESULTS: Three hundred nineteen patients were identified for inclusion. Two hundred seventy-two of 319 (85%) patients underwent drain insertion at the time of surgery versus 45/319 (14%) who did not. Twenty-nine of 272 patients who underwent drain insertion experienced recurrence (10.9%) versus 9 of 45 patients without drain insertion (20.5%; p = 0.07). Overall change in median subdural width was significantly greater in the drain versus 'no drain' groups (11 mm versus 6 mm, p < 0.01). Overall change in median midline shift (MLS) was also significantly greater in the drain group (4 mm versus 3 mm, p < 0.01). On multivariate analysis, change in maximal width and MLS were significant predictors of recurrence, although only the former remained a significant predictor for functional outcome. CONCLUSIONS: The use of subdural drains results in significantly improved postoperative imaging in burr hole evacuation of CSDH, thus providing radiological corroboration for their recommended use.

Does Drain Position and Duration Influence Outcomes in Patients Undergoing Burr-Hole Evacuation of Chronic Subdural Hematoma? Lessons from a UK Multicenter Prospective Cohort Study.

BACKGROUND: Drain insertion following chronic subdural hematoma (CSDH) evacuation improves patient outcomes. OBJECTIVE: To examine whether this is influenced by variation in drain location, positioning or duration of placement. METHODS: We performed a subgroup analysis of a previously reported multicenter, prospective cohort study of CSDH patients performed between May 2013 and January 2014. Data were analyzed relating drain location (subdural or subgaleal), position (through a frontal or parietal burr hole), and duration of insertion, to outcomes in patients aged >16 yr undergoing burr-hole drainage of primary CSDH. Primary outcomes comprised modified Rankin scale (mRS) at discharge and symptomatic recurrence requiring redrainage within 60 d. RESULTS: A total of 577 patients were analyzed. The recurrence rate of 6.7% (12/160) in the frontal subdural drain group was comparable to 8.8% (30/343) in the parietal subdural drain group. Only 44/577 (7.6%) patients underwent subgaleal drain insertion. Recurrence rates were comparable between subdural (7.7%; 41/533) and subgaleal (9.1%; 4/44) groups (P = .95). We found no significant differences in discharge mRS between these groups. Recurrence rates were comparable between patients with postoperative drainage for 1 or 2 d, 6.4% and 8.4%, respectively (P = .44). There was no significant difference in mRS scores between these 2 groups (P = .56). CONCLUSION: Drain insertion after CSDH drainage is important, but position (subgaleal or subdural) and duration did not appear to influence recurrence rate or clinical outcomes. Similarly, drain location did not influence recurrence rate nor outcomes where both parietal and frontal burr holes were made. Further prospective cohort studies or randomized controlled trials could provide further clarification.

Validating the use of smartphone-based accelerometers for performance assessment in a simulated neurosurgical task.

BACKGROUND: Reductions in working hours affect training opportunities for surgeons. Surgical simulation is increasingly proposed to help bridge the resultant training gap. For simulation training to translate effectively into the operating theater, acquisition of technical proficiency must be objectively assessed. Evaluating "economy of movement" is one way to achieve this. OBJECTIVE: We sought to validate a practical and economical method of assessing economy of movement during a simulated task. We hypothesized that accelerometers, found in smartphones, provide quantitative, objective feedback when attached to a neurosurgeon's wrists. METHODS: Subjects (n = 25) included consultants, senior registrars, junior registrars, junior doctors, and medical students. Total resultant acceleration (TRA), average resultant acceleration, and movements with acceleration >0.6g (suprathreshold acceleration events) were recorded while subjects performed a simulated dural closure task. RESULTS: Students recorded an average TRA 97.0 ± 31.2 ms higher than senior registrars (P = .03) and 103 ± 31.2 ms higher than consultants (P = .02). Similarly, junior doctors accrued an average TRA 181 ± 31.2 ms higher than senior registrars (P < .001) and 187 ± 31.2 ms higher than consultants (P < .001). Significant correlations were observed between surgical outcome (as measured by quality of dural closure) and both TRA (r = .44, P < .001) and number of suprathreshold acceleration events (r = .33, P < .001). TRA (219 ± 66.6 ms; P = .01) and number of suprathreshold acceleration events (127 ± 42.5; P = .02) dropped between the first and fourth trials for junior doctors, suggesting procedural learning. TRA was 45.4 ± 17.1 ms higher in the dominant hand for students (P = .04) and 57.2 ± 17.1 ms for junior doctors (P = .005), contrasting with even TRA distribution between hands (acquired ambidexterity) in senior groups. CONCLUSION: Data from smartphone-based accelerometers show construct validity as an adjunct for assessing technical performance during simulation training.