Doing More with LessSurgical Drains in Chronic Subdural Hematoma Surgery: From the Cheapest to the Most Expensive Drains
Introduction
Chronic subdural hematoma (CSDH) is a common neurosurgical condition with an incidence of 58 per 100,000 per year in people aged ≥70 years.1 Although it is a common condition, controversies regarding the most optimal neurosurgical technique for the management or treatment of CSDH persist. Worldwide, burr hole craniostomy is the most popularly used neurosurgical technique.2 However, controversies regarding the role of the drains in this technique have only recently been resolved. A meta-analysis by Liu et al3 demonstrated that ensuring drainage after surgical evacuation of a hematoma is superior to nondrainage and that it leads to a better outcome.
Besides the widely and successfully used “burr-hole plus drain” technique,3 other innovative techniques have also been developed with superior outcomes. The subdural evacuating port system (SEPS), which involves a twist-drill craniostomy, subdural drainage using a hollow metal bolt, and closed negative-pressure drainage system, has demonstrated promising results for almost a decade.4 Despite the reported successes and failures of SEPS, it is priced at $300, which is considered expensive in most middle-income countries and is almost impossible to obtain in low-income countries. Therefore until SEPS or newer technique(s) become economical enough to gain widespread usage, the “burr hole plus drain” technique seems to be the most rational choice, especially in middle- or low-income countries.
Despite the various controversies associated with this technique, there is an almost overall consensus on usable drain types. The flexible and pliable natures of the Jackson-Pratt or Blake drains make them the most preferred type. Although it may sound strange to a neurosurgeon who has not worked in economically challenged parts of the world, unavailability of the Jackson-Pratt drains (or any mass-produced preformed drain) is a real issue in these areas because of economic or technical reasons.
Thus we aimed to demonstrate and discuss some postoperative continuous drainage methods that can be used following burr hole subdural hematoma evacuation by presenting a pertinent case.
Section snippets
Materials and Methods
We describe in detail the case of 74-year-old man with CSDH to demonstrate the development of a surgeon-made drain in the operating room when a preformed drain is unavailable. Next, we retrospectively screened for subdural drain usage in consecutive patients undergoing burr hole drainage for CSDH at the Adiyaman University Research and Education Hospital between January 2017 and April 2017, and data from only those patients in whom a surgeon-made drain was used were included for analyses.
Case Presentation
A 74-year-old right-handed male presented with a 3-month history of gradually worsening headaches, left-sided weakness, and drowsiness following a minor head trauma sustained approximately 4 months ago while working at a farm. The symptoms had worsened 2 days before admission. Neurologic examination showed left hemiparesis (4/5 muscle strength), and head computed tomography revealed right-sided isodense CSDH with a mass effect. An emergency evacuation of CSDH was performed using a burr hole
Discussion
A subdural drain should be flexible and pliable to allow easy placement and not harm the cortical surface during removal. A large diameter is also important to prevent obstruction by blood clots, which is a common problem when smaller-diameter “external ventricular drainage” catheters are used.
Jackson-Pratt drains are a suitable choice because they are easily available and affordable, with an average price of $7. One important technical problem that we faced while using these drains was that
Conclusions
In case of unavailability of a preformed drain, a surgeon-made drain can be used during CSDH surgery. Different methods are available and can be further diversified using various combinations of simple medical materials.
References (4)
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Chronic subdural hematoma in elderly people: present status on Awaji Island and epidemiological prospect
Neurol Med Chir
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Management of chronic subdural hematoma: a national survey and literature review
Can J Neurol Sci
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Cited by (4)
Surgical Glove Drain for Chronic Subdural Hematomas: Effective Alternative to Expensive Drains
2018, World NeurosurgerySubdural open drains as an effective and low-cost modality for the treatment of chronic subdural hematomas
2023, British Journal of NeurosurgeryComparison of Two Drainage Systems on Chronic Subdural Hematoma Recurrence
2023, Journal of Neurological Surgery, Part A: Central European Neurosurgery
Note: All prices are approximate and sourced from a simple Google search.
Conflict of interest statement: Preparation for publication of this article is partly supported by the Turkish Neurosurgical Society. On behalf of all authors, the corresponding author states that there is no conflict of interest regarding the manuscript.