|Year : 2016 | Volume
| Issue : 2 | Page : 103-105
Endoscope-assisted single burr hole drainage and irrigation of chronic subdural hematoma (SDH): A retrospective analysis
Vyas Khongbantabam1, Khaidem Mani Singh2, Supriya Laifangbam3, Takhellambam Arun Singh1
1 Department of Surgery, Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Imphal, Manipur, India
2 Department of Radiodiagnosis, Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Imphal, Manipur, India
3 Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Imphal, Manipur, India
|Date of Web Publication||24-May-2016|
Department of Surgery, Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Imphal - 795 005, Manipur
Source of Support: None, Conflict of Interest: None
Background: Chronic subdural hematoma (SDH) is usually associated with mild trivial head trauma in the elderly population. Its treatment varies from multiple burr hole, irrigation, twist drill, and craniotomy for membranectomy. Objectives: 1) To describe the operative procedure of single burr hole, drainage, and irrigation assisted by an endoscope in the management of patients with chronic SDH and 2) to present its favorable outcome. Materials and Methods: Seventy-two patients were managed by endoscope-assisted single burr hole, drainage, and irrigation during the period from July 2008 to August 2013. All patients were given local anesthesia. Retrospective data at the times of admission, discharge, and at follow-up at 3 weeks and 6 weeks were analyzed. Results: The mean age of the patients was 65 years and males outnumbered females. Average operation time was 30 min. All patients were discharged at Markwalder's grade 0 within 3-4 days of admission. There were 1.38% cases of seizures but no cases with recurrences or mortality. On follow-up, 86.11% and 100% cases of full brain expansion were achieved at 3 and 6 weeks, respectively. Conclusion: Endoscope-assisted single burr hole drainage and irrigation of chronic SDH is simple, safe, and patient friendly. The short duration of this surgery performed in the elderly patients under local anesthesia is its biggest advantage.
Keywords: Chronic subdural hematoma (SDH), endoscope, burr hole
|How to cite this article:|
Khongbantabam V, Singh KM, Laifangbam S, Singh TA. Endoscope-assisted single burr hole drainage and irrigation of chronic subdural hematoma (SDH): A retrospective analysis. J Med Soc 2016;30:103-5
|How to cite this URL:|
Khongbantabam V, Singh KM, Laifangbam S, Singh TA. Endoscope-assisted single burr hole drainage and irrigation of chronic subdural hematoma (SDH): A retrospective analysis. J Med Soc [serial online] 2016 [cited 2021 Apr 17];30:103-5. Available from: https://www.jmedsoc.org/text.asp?2016/30/2/103/182910
| Introduction|| |
Chronic subdural hematoma (SDH) is a condition commonly seen in neurosurgical practice, usually among elderly patients with or without a history of head injury.  Its treatment varies from multiple burr hole drainage and irrigation, twist drill, and craniotomy for membranectomy. ,,,,,, The objectives of this article are as follows:
- To describe the operative procedure of single burr hole, drainage and irrigation assisted by an endoscope in the management of patients with chronic SDH and
- To present its favorable outcome.
| Materials and Methods|| |
This is a retrospective analysis of 72 patients, who underwent single burr hole drainage and irrigation, assisted with an endoscope under local anesthesia with or without sedation at a tertiary-care center in eastern India during the period from July 2008 to August 2013. An approval from the Institutional Ethics Committee was obtained before conducting the study.
The recruitment of the cases was done by the principal investigator from the hospital records such as case sheets, discharge summaries, and follow-up sheets. All consecutive patients admitted and operated for chronic SDH were included while the patients having other concomitant head injury were excluded from the study. Informed consent for the operation should be obtained from the patient (if conscious) or the closest relative of the patient on a prescribed consent form before every operation. At the time of admission, the clinical status was measured using Markwalder grading scale [Table 1]. Computed tomography (CT) scan of the head was done to confirm the diagnosis.
All the patients were operated under local anesthesia with or without intravenous sedation. The burr hole was placed at the parietal eminence or posterior frontal region of the skull. Care was taken to release the chronic SDH slowly to prevent jet-like escape of liquefied hematoma under pressure, by using cotton patties. Irrigation was done using normal saline to wash the cortical surface of the brain till the effluent ran clear.  Around 500 mL to 1 L normal saline was required for irrigation. After completion of the irrigation through the burr hole, a 30° endoscope is inserted to inspect the subdural space. If clots are still present, irrigation is continued and further escape of hematoma is facilitated by making the burr hole dependent. In some of the cases, expansion of the brain could be appreciated during the process of irrigation. Once it is that no clots are left inside, a drain is placed in the burr hole to allow drainage. A single layered skin closure is done using 2/0 silk suture. A single intravenous injection each of third generation cephalosporin and of levetiracetam was used during the procedure. In the postoperative phase, the patients were advised absolute bed rest for 24 h. The drain was removed after 24 h. The patients were discharged only after they had no neurological complaints or deficits by the third or fourth postoperative day. CT scans of brain were done postoperatively at 48 h, at 3 weeks, and at 6 weeks until the patients achieved full expansion of the brain.
The following data were collected for each patient and were analyzed collectively:
- History of head injury,
- Grading according to the Markwalder grading scale at the time of admission and discharge,
- Site of burr hole,
- Operation time duration,
- Incidence of recurrence,
- Incidence of redo operation,
- Any other complications,
- Duration of hospital stay,
- Follow-up findings of CT scan at 3 weeks and 6 weeks.
| Result|| |
The age of patients ranged from 50 years to 81 years with a mean age of 65 years. Maximum number 48/72 (66.67%) of cases were observed in the age group of 60-69 years. Out of 72 patients studied, 57 (79.17%) were males and 15 (20.83%) were females. History of trivial trauma, ranging from 3 weeks to 6 weeks, could be found in all the patients. Clinical examination revealed that 12 (16.67%) patients were in grade 0, 48 (66.67%) were in grade I, and 21 (29.17%) were in grade II of the Markwalder grading scale. CT scan showed that 45 (62.5%) were left sided, 24 (33.33%) were right sided, and 3 (4.17%) were bilateral. The site of burr holes in 65 (90%) patients were in the parietal region, while 7 (10%) were in the posterior frontal region of the skull. Operation time duration ranged from 25 min to 40 min with a mean of 30 min. There was 1 (1.38%) case of seizure but no cases of recurrence of SDH or reoperation. No mortality was seen. All the patients were discharged in satisfactory condition with Markwalder's grade 0 within 3-4 days of admission. On follow-up CT scan, 62 (86.11%) patients at 3 weeks and 72 (100%) patients at 6 weeks were found to have full brain expansion.
| Discussion|| |
Several surgical procedures have been described for the treatment of chronic SDH. ,,,,,, The more commonly adopted ones are either drainage procedures, such as the burr hole drainage and twist drill drainage, or craniotomy with membranectomy. Weigel et al. pointed out that there was no statistically significant difference in the mortality of these three commonly used procedures.  Craniotomy showed higher morbidity than the drainage procedures.  Among the drainage procedures, recurrence rate was higher than that in the twist drill type and the burr hole type. This is because irrigation is not possible through the small opening of the twist drill drainage procedures, and residual hematoma are common complications.
Burr hole drainage has been the most favored technique in the treatment of chronic SDH. The rationale behind the placement of two burr holes is to facilitate for irrigation of the subdural space so that evacuation of the hematoma along with the membrane shreds could be complete. In this study, patients were treated using the single burr hole technique unlike the more practiced two burr hole technique. No significant difference in the complication rates were seen between the single burr hole and two burr hole techniques in a study by Joon et al.  Another study published a series of 307 patients treated for chronic SDH using single burr hole drainage under local anesthesia.  It was proven that a single burr hole reduces the operation time and it is sufficient for the drainage of a hematoma in the subdural space.
Irrigation of the subdural space using normal saline is for dilution of profibrinolytic compounds and elimination of air in the subdural space. As was earlier believed, two burr holes are not necessary for complete drainage and irrigation of SDH. A soft jet of saline through a single burr hole for a few minutes until the effluents ran clear is sufficient to achieve the same effect.
At this stage of the operation, a 30° endoscope was inserted to inspect the just washed cortical surface of the brain and the subdural space. In almost about half the cases, 34/72 (47.2%) left over clots were discovered, further normal saline irrigation facilitated escape of the hematoma. Incomplete drainage of clot and membrane or trapped air in the subdural space inhibit reexpansion of the brain. Use of an endoscope can also help the neurosurgeon find out about reexpansion of the brain that is the most important factor regarding satisfactory outcome of operation. Its most crucial added advantage is visual confirmation. Making more than one burr hole will not be able to provide this effect.
In conclusion, endoscope-assisted single burr hole drainage and irrigation of chronic SDH is simple, safe, and patient friendly. The short duration of this surgery under local anesthesia is its biggest advantage in the patients who are mostly over 60 years of age. A comparative prospective analysis using a larger number of patients could be even more conclusive in backing up this finding.
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Conflicts of interest
There are no conflicts of interest.
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