Journal Club: Randomized Trial Comparing Burr Hole Craniostomy, Minicraniotomy, and Twist Drill Craniostomy for Treatment of Chronic Subdural Hematoma

Title and Citation

Randomized Trial Comparing Burr Hole Craniostomy, Minicraniotomy, and Twist Drill Craniostomy for Treatment of Chronic Subdural Hematoma

Neurosurgery 2022

Background and importance

Unknown best surgical technique for chronic subdural hematoma

Recurrence of SDH despite evacuation can occur in up to 30% of patients

Trial design

Multicenter prospective randomized trial

Drainage system for all left for 48 hours

Duration

2012-2019 across 4 hospitals in Belgium

Objectives

Determine which surgical technique for drainage of chronic subdural hematoma offers best results (burr hole craniostomy (BC), mini craniotomy (MC), twist drill craniostomy(TDC))

Inclusion Criteria

18 years of age or older

Deemed surgical candidate

Equipoise among all types of intervention (no contraindication for a particular technique)

Eligible for inclusion

Primary endpoint

Reoperation rate

Complication rate (secondary)

Statistical Analysis

Chi squared test

Results

N = 245 (79 burr hole craniostomy, 84 mini craniotomy, 82 twist drill craniostomy)

(P=0.07)	Burr hole craniostomy	Mini craniotomy	Twist drill craniostomy
Reoperation rate	7.6% (6 of 79)	13.1% (11 of 84)	19.5% (16 of 82)

29 of 33 reoperations occurred within the 30 day post operative period

Drain misplacement in 6.1% of twist drill craniostomy

Acute subdural 2.5% in burr hole craniostomy and 2.4% in mini craniotomy

Limitations

Underpowered to demonstrate statistical significance

No control over surgical technique

Decision to reoperate not based on a centralized assessment therefore possibly different thresholds for reoperation

Author’s Conclusion

“Although not reaching statistical significance in our study, [burr hole craniostomy] offers the lowest recurrence rate”

Applicability

Twist drill craniostomy is an option especially in those who may not tolerate general anesthesia well

With 29 of 33 reoperations occurring within 30 days it may be worth having a follow up image within this time to determine trajectory of recovery or reaccumulation