Minicraniotomy versus bur holes for evacuation of chronic subdural collections in infants-a preliminary single-institution experience

Le Bonheur Children's Hospital, Memphis, Tennessee, USA.
Journal of Neurosurgery Pediatrics (Impact Factor: 1.63). 11/2011; 8(5):423-9. DOI: 10.3171/2011.8.PEDS1131
Source: PubMed

ABSTRACT Various surgical interventions have been described to evacuate chronic subdural collections (CSCs) of infancy. These include transfontanel percutaneous aspiration, subdural drains, placement of bur hole(s) with or without a subdural drain, and shunting. Shunt placement typically provides good long-term success (resolution of the subdural fluid), but comes with well-known early and late complications. Recently, the authors have used a mini-osteoplastic craniotomy technique with the goal of definitively treating these children with a single surgery while avoiding the many issues associated with a shunt. They describe their procedure and compare it with the traditional bur hole technique.
In this single-institution retrospective study, the authors evaluated 26 cases involving patients who underwent treatment for CSC. Preoperative, intraoperative, and postoperative data were reviewed, including radiographic findings (density of the subdural fluid and ventricular and subarachnoid space size), neurological examination findings, and intraoperative fluid description. The primary outcome was treatment failure, defined as the patient requiring any subsequent surgical intervention after the index procedure (minicraniotomy or bur hole placement).
Fifteen patients (10 male and 5 female; median age 5.1 months) collectively underwent 27 minicraniotomy procedures (each procedure representing a hemisphere that was treated). In the bur hole group, there were 11 patients (6 male and 5 female; median age 4.6 months) with 18 hemispheres treated. Both groups had subdural drains placed. The average follow-up for each treatment group was just over 7 months. Treatment failure occurred in 2 patients (13%) in the minicraniotomy group compared with 5 patients (45%) in the bur hole group (p = 0.09). Furthermore, the 2 patients who had treatment failure in the minicraniotomy group required 1 subsequent surgery each, whereas the 5 in the bur hole group needed a total of 9 subsequent surgeries. Eventually, 80% of the patients in the minicraniotomy group and 70% of those in the bur hole group had resolution of the subdural collections on the last imaging study.
The minicraniotomy technique may be a superior technique for the treatment of CSCs in infants compared with bur hole evacuation. The minicraniotomy provides greater visualization of the subdural space and allows more aggressive evacuation of the fluid, better irrigation of the space, the ability to fenestrate any accessible membranes safely, and continued egress of fluid into the subgaleal space. Although this preliminary report has obvious limitations, evaluation of this technique may be worthy of a prospective, multiinstitutional collaborative effort.

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    ABSTRACT: Chronic subdural hematomas (CSDH), which are frequently encountered in neurosurgical practice, are, in the majority of cases, ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care. A retrospective chart review of 119 patients requiring surgical drainage of CSDH was conducted at a large tertiary care center over a three-year period. Of the cases reviewed, 58 patients underwent craniotomy, while 61 patients underwent burr hole washout. The study focused on re-operation rates, mortality, and morbidity, as measured by Glasgow coma scores (GCS), discharge Rankin disability scores, and discharge disposition. Secondary endpoints included length of stay and cost of procedure. Burr hole washout was superior to craniotomy with respect to patient outcome, length of stay and recurrence rates. In both study groups, patients required additional surgical procedures (6.6% of burr hole patients and 24.1% of craniotomy patients) (P = 0.0156). Of the patients treated with craniotomy, 51.7% were discharged home, whereas 65.6% of the burr hole patients were discharged home. Patients who underwent burr hole washout spent a mean of 78.8 minutes in the operating suite while the patients undergoing craniotomy spent 129.4 minutes (P < 0.001). The difference in mean cost per patient, based solely on operating time, was $2,828 (P < 0.001). This does not include the further cost due to additional procedures and hospital stay. The mean length of stay after surgical intervention was 3 days longer for the craniotomy group (P = 0.0465). Based on this retrospective study, burr hole washout is superior for both patients' clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings.
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