Acta Neurochirurgica

, Volume 160, Issue 5, pp 901–911 | Cite as

Burr hole trepanation for chronic subdural hematomas: is surgical education safe?

  • Nicolai Maldaner
  • Marketa Sosnova
  • Johannes Sarnthein
  • Oliver Bozinov
  • Luca Regli
  • Martin N. Stienen
Original Article - Neurosurgery Training
  • 103 Downloads

Abstract

Background

There is a paucity of data concerning the safety and efficacy of surgical education for neurosurgical residents in the evacuation of chronic subdural hematomas (cSDH) by burr hole trepanation.

Methods

This is a retrospective analysis of prospectively collected data on consecutive patients receiving burr hole trepanation for uni- or bilateral cSDH. Patients operated by a supervised neurosurgery resident (teaching cases) were compared to patients operated by a board-certified faculty neurosurgeon (BCFN; non-teaching cases). The primary endpoint was surgical revision for any reason until the last follow-up. The secondary endpoint was occurrence of any complication until the last follow-up. Clinical status, type of complications, mortality, length of surgery (LOS), and hospitalization (LOH) were tertiary endpoints.

Results

A total of n = 253 cases were analyzed, of which n = 217 (85.8%) were teaching and n = 36 (14.2%) non-teaching cases. The study groups were balanced in terms of age, sex, surgical risk (ASA score), and preoperative status (Karnofsky Performance Scale (KPS), modified Rankin Scale (mRS), National Institute of Health Stroke Scale (NIHSS)). The cohort was followed for a mean of 242 days (standard deviation 302). In multivariate analysis, teaching cases were as likely as non-teaching cases to require revision surgery (OR 0.65, 95% CI 0.27–1.59; p = 0.348) as well as to experience any complication until the last follow-up (OR 0.79, 95% CI 0.37–1.67; p = 0.532). Mean LOS was about 10 min longer in teaching cases (53.0 ± 26.1 min vs. 43.5 ± 17.8 min; p = 0.036), but LOH was similar. There were no group differences in clinical status, mortality and type of complication at discharge, and the last follow-up.

Conclusions

Burr hole trepanation for cSDH can be safely performed by supervised neurosurgical residents enrolled in a structured training program, without increasing the risk for revision surgery, perioperative complications, or worse outcome.

Keywords

Burr hole trepanation Chronic subdural hematoma Surgical education Outcome Safety Training Complications 

Abbreviations

ASA

American Society of Anesthesiology grading scale

BCFN

Board-certified faculty neurosurgeon

CDG

Clavien-Dindo grade

cSDH

Chronic subdural hematoma

CT

Computed tomography

IQR

Interquartile range

LOH

Length of hospitalization

LOS

Length of surgery

KPS

Karnofsky Performance Scale

mRS

Modified Rankin scale

NIHSS

National Institute of Health Stroke Scale

MLS

Midline shift

PGY

Postgraduate year

SD

Standard deviation

Notes

Acknowledgements

The authors thank all resident and staff physicians of the department, who prospectively collected and verified the data that is the basis of the current analysis.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The local ethics committee (Kantonale Ethikkommission KEK-ZH 2012–0244) approved the prospective data collection in the patient registry. The study was registered at clinicaltrials.gov (NCT01628406) and follows the STROBE recommendation for observational studies.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

701_2017_3458_Fig3_ESM.gif (29 kb)
Supplementary Figure 1

Kaplan-Meier time-to-event estimates with time censored at 365 days postoperative. The endpoint is death in patients operated on by supervised neurosurgery residents (Teaching procedure) or experienced board-certified faculty neurosurgeons (No teaching procedure). There was no significant difference in the endpoint (Log-rank test: p = 0.322). (GIF 28 kb)

701_2017_3458_MOESM1_ESM.eps (1.8 mb)
High resolution image (EPS 1805 kb)

References

  1. 1.
    Babu R, Thomas S, Hazzard MA et al (2014) Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions. J Neurosurg 121(2):262–276CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Babu R, Thomas S, Hazzard MA et al (2014) Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform: clinical article. J Neurosurg Spine 21(4):502–515CrossRefPubMedGoogle Scholar
  3. 3.
    Bartek J, Sjåvik K, Kristiansson H, Ståhl F, Fornebo I, Förander P, Jakola AS (2017) Predictors of recurrence and complications after chronic subdural hematoma surgery: a population-based study. World Neurosurg 106:609–614CrossRefPubMedGoogle Scholar
  4. 4.
    Bellut D, Woernle CM, Burkhardt J-K, Kockro RA, Bertalanffy H, Krayenbühl N (2012) Subdural drainage versus subperiosteal drainage in burr-hole trepanation for symptomatic chronic subdural hematomas. World Neurosurg 77(1):111–118CrossRefPubMedGoogle Scholar
  5. 5.
    Bina RW, Lemole GM, Dumont TM (2016) On resident duty hour restrictions and neurosurgical training: review of the literature. J Neurosurg 124(3):842–848CrossRefPubMedGoogle Scholar
  6. 6.
    Borger V, Vatter H, Oszvald Á, Marquardt G, Seifert V, Güresir E (2012) Chronic subdural haematoma in elderly patients: a retrospective analysis of 322 patients between the ages of 65-94 years. Acta Neurochir 154(9):1549–1554CrossRefPubMedGoogle Scholar
  7. 7.
    Brennan PM, Kolias AG, Joannides AJ et al (2016) The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom. J Neurosurg:1–8Google Scholar
  8. 8.
    Coulter IC, Kolias AG, Marcus HJ et al (2014) Proposal for a prospective multi-centre audit of chronic subdural haematoma management in the United Kingdom and Ireland. Br J Neurosurg 28(2):199–203CrossRefPubMedGoogle Scholar
  9. 9.
    Gastone P, Fabrizia C, Homere M, Cacciola F, Francesco C, Alberto M, Nicola DL (2004) Chronic subdural hematoma: results of a homogeneous series of 159 patients operated on by residents. Neurol India 52(4):475–477PubMedGoogle Scholar
  10. 10.
    Han M-H, Ryu, JIL, Kim CH, Kim JM, Cheong JH, Yi H-J (2016) Predictive factors for recurrence and clinical outcomes in patients with chronic subdural hematoma. J Neurosurg 1–9Google Scholar
  11. 11.
    Ivamoto HS, Lemos HP, Atallah AN (2016) Surgical treatments for chronic subdural hematomas: a comprehensive systematic review. World Neurosurg 86:399–418CrossRefPubMedGoogle Scholar
  12. 12.
    Joswig H, Gautschi OP, El Rahal A, Sveikata L, Bartoli A, Hildebrandt G, Schaller K, Stienen MN (2016) Cranioplasty: is surgical education safe? World Neurosurg 91:81–88CrossRefPubMedGoogle Scholar
  13. 13.
    Joswig H, Haile SR, Hildebrandt G, Stienen MN (2017) Residents’ learning curve of lumbar transforaminal epidural steroid injections. J Neurol Surg A Cent Eur Neurosurg 78(5):460–466CrossRefPubMedGoogle Scholar
  14. 14.
    Joswig H, Hock C, Hildebrandt G, Schaller K, Stienen MN (2016) Microscopic lumbar spinal stenosis decompression: is surgical education safe? Acta Neurochir 158(2):357–366CrossRefPubMedGoogle Scholar
  15. 15.
    Joswig H, Jucker D, Lavalley A, Sprenger L, Gautschi OP, Hildebrandt G, Schaller K, Stienen MN (2017) Shunts: is surgical education safe? World Neurosurg 102:117–122CrossRefPubMedGoogle Scholar
  16. 16.
    Kaliaperumal C, Khalil A, Fenton E, Okafo U, Kaar G, O’Sullivan M, Marks C (2012) A prospective randomised study to compare the utility and outcomes of subdural and subperiosteal drains for the treatment of chronic subdural haematoma. Acta Neurochir (Wien) 154(11):2083-8-9Google Scholar
  17. 17.
    Leroy H-A, Aboukaïs R, Reyns N, Bourgeois P, Labreuche J, Duhamel A, Lejeune J-P (2015) Predictors of functional outcomes and recurrence of chronic subdural hematomas. J Clin Neurosci 22(12):1895–1900CrossRefPubMedGoogle Scholar
  18. 18.
    Liu W, Bakker NA, Groen RJM (2014) Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. J Neurosurg 121(3):665–673CrossRefPubMedGoogle Scholar
  19. 19.
    Mellergård P, Wisten O (1996) Operations and re-operations for chronic subdural haematomas during a 25-year period in a well defined population. Acta Neurochir 138(6):708–713CrossRefPubMedGoogle Scholar
  20. 20.
    Nathan S, Goodarzi Z, Jette N, Gallagher C, Holroyd-Leduc J (2017) Anticoagulant and antiplatelet use in seniors with chronic subdural hematoma: systematic review. Neurology 88(20):1889–1893CrossRefPubMedGoogle Scholar
  21. 21.
    Neidert MC, Schmidt T, Mitova T, Fierstra J, Bellut D, Regli L, Burkhardt J-K, Bozinov O (2016) Preoperative angiotensin converting enzyme inhibitor usage in patients with chronic subdural hematoma: associations with initial presentation and clinical outcome. J Clin Neurosci 28:82–86CrossRefPubMedGoogle Scholar
  22. 22.
    Phang I, Sivakumaran R, Papadopoulos MC (2015) No association between seniority of surgeon and postoperative recurrence of chronic subdural haematoma. Ann R Coll Surg Engl 97(8):584–588CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Santarius T, Kirkpatrick PJ, Ganesan D et al (2009) Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial. Lancet (London, England) 374(9695):1067–1073CrossRefGoogle Scholar
  24. 24.
    Sarnthein J, Stieglitz L, Clavien P-A, Regli L (2016) A patient registry to improve patient safety: recording general neurosurgery complications. PLoS One 11(9):e0163154CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Schaller K (2013) Neurosurgical training under European law. Acta Neurochir 155(3):547CrossRefPubMedGoogle Scholar
  26. 26.
    Schwarz F, Loos F, Dünisch P, Sakr Y, Safatli DAL, Kalff R, Ewald C (2015) Risk factors for reoperation after initial burr hole trephination in chronic subdural hematomas. Clin Neurol Neurosurg 138:66–71CrossRefPubMedGoogle Scholar
  27. 27.
    Soleman J, Lutz K, Schaedelin S, Mariani L, Fandino J (2016) Use of subperiosteal drain versus subdural drain in chronic subdural hematomas treated with burr-hole trepanation: study protocol for a randomized controlled trial. JMIR Res Protoc 5(2):e38CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Stienen MN, Joswig H, Jucker D, Hildebrandt G, Schaller K, Gautschi OP (2015) Anterior cervical discectomy and fusion: is surgical education safe? Acta Neurochir 157(8):1395–1404CrossRefPubMedGoogle Scholar
  29. 29.
    Stienen MN, Netuka D, Demetriades AK, Ringel F, Gautschi OP, Gempt J, Kuhlen D, Schaller K (2016) Working time of neurosurgical residents in Europe—results of a multinational survey. Acta Neurochir 158(1):17–25CrossRefPubMedGoogle Scholar
  30. 30.
    Stienen MN, Netuka D, Demetriades AK, Ringel F, Gautschi OP, Gempt J, Kuhlen D, Schaller K (2016) Neurosurgical resident education in Europe—results of a multinational survey. Acta Neurochir 158(1):3–15CrossRefPubMedGoogle Scholar
  31. 31.
    Stienen MN, Netuka D, Demetriades AK, Ringel F, Gautschi OP, Gempt J, Kuhlen D, Schaller K (2016) Residency program trainee-satisfaction correlate with results of the European board examination in neurosurgery. Acta Neurochir 158(10):1823–1830CrossRefPubMedGoogle Scholar
  32. 32.
    Stienen MN, Smoll NR, Hildebrandt G, Schaller K, Gautschi OP (2014) Early surgical education of residents is safe for microscopic lumbar disc surgery. Acta Neurochir 156(6):1205–1214CrossRefPubMedGoogle Scholar
  33. 33.
    Stienen MN, Smoll NR, Tessitore E, Schaller K, Hildebrandt G, Gautschi OP (2015) Surgical resident education in noninstrumented lumbar spine surgery: a prospective observational study with a 4.5-year follow-up. World Neurosurg 84(6):1589–1597CrossRefPubMedGoogle Scholar
  34. 34.
    Stovell MG, Jenkinson MD (2014) Neurosurgery in octogenarians. Br J Neurosurg 28(5):611–615CrossRefPubMedGoogle Scholar
  35. 35.
    Wada M, Yamakami I, Higuchi Y, Tanaka M, Suda S, Ono J, Saeki N (2014) Influence of antiplatelet therapy on postoperative recurrence of chronic subdural hematoma: a multicenter retrospective study in 719 patients. Clin Neurol Neurosurg 120:49–54CrossRefPubMedGoogle Scholar
  36. 36.
    Wakai S, Hashimoto K, Watanabe N, Inoh S, Ochiai C, Nagai M (1990) Efficacy of closed-system drainage in treating chronic subdural hematoma: a prospective comparative study. Neurosurgery 26(5):771–773CrossRefPubMedGoogle Scholar
  37. 37.
    Zumofen D, Regli L, Levivier M, Krayenbühl N (2009) Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system. Neurosurgery 64(6):1116-21–1116-22CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • Nicolai Maldaner
    • 1
  • Marketa Sosnova
    • 1
  • Johannes Sarnthein
    • 1
  • Oliver Bozinov
    • 1
  • Luca Regli
    • 1
  • Martin N. Stienen
    • 1
  1. 1.Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience CenterUniversity of ZurichZurichSwitzerland

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