*Mohamed Lotfy 1, Ashraf El desoukey Zaghloul



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The Effect of Postoperative Supine Position versus 30 Degree Head Elevation on Clinical Outcome and Recurrence Rate in Chronic Subdural Hematomas Treated by Burr Hole Drainage
*Mohamed Lotfy 1, Ashraf El desoukey Zaghloul 2, Moataz A. Elawady 3

Departments of Neurosurgery, *professor of neurosurgery- Cairo University1, Benha University2, 3; Egypt

ABSTRACT

Background: chronic subdural hematoma (CSDH) occurs most frequently in the elderly population. Treatment options for this entity have remained controversial. The recurrence rate for CSDHs ranges from 5% to 33%. Objective: to compare the effect of postoperative head position (supine position vs. 30o head elevation position) on clinical outcome and recurrence rate in CSDH treated by burr hole drainage. Patients and Methods: This prospective study included all the patients admitted to Benha University Hospital from December 2010 to December 2014 with CSDHs and they were randomly assigned into 2 groups, group (A) and (B). These patients were operated upon by two burr holes irrigation and subgleal drainage, and for 3 days after surgery patients of group (A) were kept in a supine position while the patients of group (B) their heads kept elevated by 30o and no restriction in patients' activities after that. Clinical follow-up and post-operative CT brain was done at discharge, 1 month, and 6 months postoperatively to evaluate the clinical outcome measured by improvement in Glasgow coma score (GCS) and the complications rate including the recurrence of CSDH and need for reoperation and death rate Results: our study included 56 patients, all the patients showed improved postoperative GCS except 8 patients. In group A 3 patients had recurrent CSDH and one died of acute myocardial infarction. While 4 patients in group B had recurrent CSDH. The differences between both groups found insignificant regarding the improvement in postoperative GCS, the recurrence rate and need for reoperation, the complications and death rates.Conclusion: according to the results, we think that the two studied postoperative head positions could be effective comparable options with insignificant difference in treating CSDHs by two burr holes irrigation and subgleal drainage.
Key words: Chronic subdural hematoma, burr hole drainage, supine position

Correspondence to Ashraf EL-Desouky. Department of Neurosurgery, Benha University; Egypt Tel.: 01151241615 Email: ashraf.altantawy@fmed.bu.edu.eg

INTRODUCTION

Chronic subdural hematoma (CSDH) is an encapsulated collection of old blood, mostly or totally liquefied and located between the dura mater and arachnoid. CSDH occurs most frequently in the elderly population. An estimated incidence of 1.72/100000 per year, this is expected to rise further due to the continuing growth of the older population. (5) Trauma is an important factor in the development of CSDH. However, a history of head injury (direct trauma) is absent in about 30%–50% of the cases. (4, 11) Other predisposing factors include anticoagulation, alcoholism, epilepsy, bleeding diathesis, low intracranial pressure secondary to dehydration or after the removal of cerebrospinal fluid, and receiving renal dialysis, presumably due to platelet dysfunction.(16)

The common manifestations of CSDH are altered mental state and focal neurological deficit. Diagnosis can readily be facilitated by brain computed tomography (CT) and magnetic resonance imaging (MRI).Neurological state at the time of diagnosis is the most important prognostic factor. Morbidity and mortality is higher in the elderly but outcome is good in patients who undergo neurosurgical intervention. (5)

Treatment options for this entity have remained controversial ranging from craniotomy, twist drill drainage to burr-hole drainage, with or without intraoperative irrigation, with or without postoperative closed system drainage.(8,7,12,14,17,19) .Despite these treatment possibilities, the recurrence rate for CSDHs ranges from 5% to 33% (8,7,17, 19) .Previous studies identified several risk factors for the recurrence of CSDH, such as advanced age, bleeding tendency, brain atrophy, alcohol abuse, as well as bilateral CSDH, hematoma density, diabetes mellitus, arachnoid cyst, postoperative posture, postoperative subdural air accumulation, and some technical aspects of surgery. However, the crucial risk factors are debatable until now (5, 9, 3, and 20).

This clinical study was done aiming to compare the effect of two postoperative head positions (supine position vs. 30o head elevation position) on clinical outcome and recurrence rate in CSDHs treated by two burr holes irrigation and subgleal drainage.Burr hole craniotomy is the most common form of treatment for chronic subdural hematoma. However, there have been very few studies to see the postoperative influence of head position (head low/supine) on recurrence of chronic subdural hematoma

PATIENTS AND METHODS

This prospective study included all the patients that were admitted to Benha University Hospital from December 2010 to December 2014 with diagnosis of chronic subdural hematomas (CSDHs) based on plain CT brain. These patients were randomly assigned into 2 groups, group (A) and (B). They operated upon by two burr holes irrigation and subgleal drainage and for 3 days after surgery patients of group (A) were kept in a supine (flat) position while the patients of group (B) their heads kept elevated by 30o and there was no restriction in patients' activities after that. Recurrent chronic subdural hematomas, chronic subdural hematoma drained by single burr hole and the cases of CSDH after two burr hole irrigation that drained with subdural drain were excluded from the study.

At the time of admission, the Patients were evaluated based on history, general examination, neurological examination, blood investigation and plain CT brain. CSDH was seen in plain CT brain as hypodense or mixed density on the basis of the density of hematoma relative to brain tissue. Coagulation parameters - Prothrombin time (PT), partial thromboplastin time (PTT) and international normalization ratio (INR) were checked and ECG was done for all patients. Written informed consent was obtained from the patient or from the relatives if the patient was unable to give consent before surgery.

Surgical procedure

The procedures performed under general anesthesia. Prophylactic antibiotics given with the induction of anesthesia. In the operating theatre the patient was positioned supine on headrest. Head slightly elevated and tilted to opposite side. After the sterilization of operative site with antiseptic solution, two burr holes (approx. 12–15 mm size) about 5-6 cm apart were made over the maximum width of the hematoma detected on CT brain. Care must be taken to secure any dural bleeding. The dura was opened in a cruciate manner and coagulated with bipolar diathermy. The subdural collection was washed out with warm (as body temperature) isotonic saline very gently and slowly until the effluents were clear, one subgleal drain draining both burr holes tunneled for a minimum of 5 cm away from the scalp incision then the subdural space was filled with warm isotonic saline and the scalp was closed in two layers then the drain connected to a closed collection bag that was kept in a dependent position for 48-72 hours then removed. In cases of bilateral chronic subdural hematomas both sides received the same treatment starting with larger one first. For 3 days after the operation, the patients of group (A) were kept in a supine (flat) position while the patients of group (B) their heads kept elevated by 30o. After 3 days; there was no restriction in patients' activities. Antibiotics were given for 7 days after surgery. Patients were discharged home when they no longer need specialized neurosurgical care.

The patients were under clinical evaluation for 6 months postoperatively to evaluate the results of the 2 groups in term of clinical outcome measured by improvement in Glasgow coma score, the volume of post-operative fluid drained /day, complications rate including the recurrence rate of CSDH and need for reoperation and death rates.

Routine follow up CT brain was done at discharge, and 6 months after surgery and also repeated in case of unsatisfactory course of recovery.

The recurrence was defined as reappearance of clinical symptoms or neurological deterioration within 3 months of initial surgery when associated with re-accumulation of CSDH or with increase in the size and mass effect of residual CSDH on the same site on follow up CT brain.

Statistical analysis:

The collected data were summarized in terms of mean ±SD and range for quantitative data and frequency and percentage for qualitative data. Comparisons between the study groups were carried out using the test of proportion (Z-test) to compare two proportions and the Chi-square test (χ2) to compare more than two proportions. The Student t-test (t) was used to detect differences in the means of the two groups regarding parametric data, while the Mann-Whitney test was used to compare two non-parametric data. Statistical significance was accepted at P value <0.05. All statistical analyses were carried out in STATA/SE version 11.2 for Windows (STATA Corporation, College Station, Texas).



RESULTS

Our prospective study included 56 patients .These patients were randomly assigned into 2 groups A and B (28 patients each group) and were operated upon by two burr holes irrigation and subgleal drainage. For 3 days after surgery the patients of group (A) were kept in a supine (flat) position while the patients of group (B) their heads kept elevated by 30o and there were no restriction in patients' activities after that. The age of these 56 patients ranged from 23 years to 72 years with mean age of 55. 07 ± 7.86 years and 39 patients (69.64%) of them are males while 17 patients (30.36%) are females

In group (A) the age of the patients ranged from 27- 72 years (Mean ± SD = 55.53± 7.58 years ) ,while in group (B) the age of the patients ranged from 23-69 years (Mean ± SD = 54.61 ± 8.24 years ).

In group (A) 19 cases are males (67.85%) and 9 cases are females (32.14%) while in group (B) 20 cases are males (71.42%) and 8 cases are females (28.57%) (table1).


Table Age and sex differences between the study groups

Variable

Group A

(No.=28)

Group B

(No.=28)

Total

(No.=56)

Test

P

No.

%

No.

%

No.

%







Sex

Females

9

32.14

8

28.57

17

30.36

χ2= 0.08

0.77

Males

19

67.86

20

71.43

39

69.64

Age (years

Mean ±SD; (range)

55.53±7.58; (27-72)

54.61±8.24; (23-69)

55.07±7.86; (23-72)



z*= 0.71

0.47

* Obtained using the Mann-Whitney test

There were no significant differences between the two groups regarding sex and age.


Headache, limb weakness, gait disturbance, speech impairment, were the most common presentations in both groups (table 2).Past history of head trauma in 67.8% of patients of group A and 71.4 % of patients of group B (table 3). Preoperative level of consciousness was assessed using Glasgow coma score (GCS) in patients of both groups (table 4).Five patients of group (A) and four patients of group (B) had bilateral CSDHs while CSDH was unilateral in the rest (table 5).
Table 2 Clinical presentation of patients of both groups

Clinical presentation

Group A

(No.=28)

Group B

(No.=28)

Z

P

No.

%

No.

%







Headache

19

67.8

17

60.7

0.55

0.58

Limb weakness

18

64.3

16

57.1

0.55

0.58

Gait disturbance

13

46.4

12

42.9

0.26

0.79

Speech impairment

8

28.6

9

32.1

0.28

0.77

Nausea and/ or vomiting

8

28.6

7

25.0

0.30

0.76

Seizures

3

10.7

2

7.1

0.47

0.64

There were no significant differences in the proportions of patients who were presented with headache, limb weakness, gait disturbance, speech impairment, nausea and/or vomiting and seizures between Group A and Group B.


Table 3 Factors associated with the development of chronic SDH in the study groups

Past history

Group A

(No.=28)

Group B

(No.=28)

Z

P

No.

%

No.

%







Head trauma

19

67.8

20

71.4

0.29

0.77

Hypertension

12

42.8

10

35.7

0.54

0.59

Diabetes Mellitus

8

28.6

9

32.1

0.28

0.77

Anticoagulant

3

10.7

2

7.1

0.47

0.64

Antiplatelet

5

17.8

3

10.7

0.76

0.45

There were no significant differences in the proportions of patients with past history of head trauma, hypertension, diabetes mellitus, anticoagulant and antiplatelet between Group A and Group B.


Table 4 Preoperative Glasgow coma score (GCS) in both groups

GCS

Group A

(No.=28)

Group B

(No.=28)

Z

P

No.

%

No.

%







13-15

20

71.4

21

75.0

0.30

0.76

9-12

6

21.4

5

17.8

0.34

0.73

3-8

2

7.1

2

7.1

0.00

1.00

There were no significant differences between both groups regarding the Glasgow coma scores


Table Laterality of Chronic Subdural Hematoma (CSDH) in the study groups

Side of CSDH

Group A

(No.=28)

Group B

(No.=28)

Z

P

No.

%

No.

%

Right sided

12

42.8

14

50.0

0.54

0.59

Left sided

11

39.3

10

35.7

0.28

0.78

Bilateral

5

17.8

4

14.3

0.36

0.72

There were no significant differences between Group A and Group B regarding the side of CSDH





A

B B

C

Fig.1 CT brain ( A ) axial , (B) coronal views of a female patient 25 years old presented with severe headache, repeated vomiting , GCS 14 showing acute on top of bilateral chronic subdural hematoma.

(c) Axial view of the same patient was done 6 months postoperative showing complete disappearance of the subdural hematoma


The volume of post-operative fluid drained ml/day was higher among Group A patients (180.15±15.23 ml) compared to Group B patients (171.87±10.06 ml). The difference between the two groups was statistically significant (P=0.01).

At the end of our study, all the patients showed improved postoperative GCS except 8 patients. In group A, 3 patients had recurrent subdural hematomas and one patient died 10 days after surgery because of acute myocardial infarction. While in group B, 4 patients had recurrent subdural hematomas. All recurrent CSDHs underwent reoperation with burr hole irrigation and a new drain insertion in the 2nd and 3rd months after surgery. Newly developed seizures occurred in 2 patients of group A and 3 of group B. One patients of group A and 2 in group B developed wound infection postoperatively, which were successfully treated with antibiotics.
There were no significant differences between both groups regarding the post-operative results except for the volume of post-operative fluid drained ml/day was statistically significant (table 6).


Table Comparison between the study groups regarding post-operative results

Post-operative results

Group A

(No.=28)

Group B

(No.=28)

Test

P

No.

%

No.

%







Volume of fluid drained ml/day

Mean ±SD; (range) n



180.15±15.23; (150-210) 33*

171.87±10.06; (150-190) 32*

t= 2.58

0.01

Improvement in GCS

24

85.71

24

85.71

Z= 0.00

1.00

Complications

Total post-operative complications

6

21.43

9

32.14

Z= 0.90

0.36

Newly developed seizures
Wound infection
Recurrence and need for reoperation

2

7.14

3

10.71

Z= 0.47

0.64

1

3.6

2

7.1

Z= 0.59

0.55

3

10.7

4

14.3

Z= 0.40

0.69

Deaths

1

3.57

0

0.0

Z= 1.01

0.31

* Five patients of group (A) and four patients of group (B) had bilateral CSDHs and every side operated upon by two burr holes irrigation and subgleal drainage.
DISSCUSSION

Although chronic subdural hematoma (CSDH) is a well-known entity, the best means of its management remains controversial .Treatment options for this entity ranging from craniotomy, twist drill drainage to burr-hole drainage, with or without intraoperative irrigation, with or without postoperative closed system drainage. (8, 7, 12, 14, 17 and 19). Despite these treatment possibilities, the recurrence rate for CSDHs ranges from 5% to 33 % (8, 7, 17, 19).Previous studies identified several risk factors for the recurrence of CSDH, such as advanced age, bleeding tendency, brain atrophy, alcohol abuse, as well as bilateral CSDH, hematoma density, diabetes mellitus, arachnoid cyst, postoperative posture, postoperative subdural air accumulation, and some technical aspects of surgery. However, the crucial risk factors are debatable until now (5, 9, 3, and 20).

CSDHs are commonly associated with cerebral atrophy and the associated increase in potential space in the subdural area. Some neurosurgeons place the patient's head and the head end of bed flat during treatment in an attempt to decrease this potential space and encourage drainage.

In contrast, a second group of neurosurgeons prefers to elevate the patient's head end of bed during treatment in an attempt to decrease intracranial pressure.

A hypothesis suggests that recurrent bleeding accounts for the expansion of CSDH and it appears to originate from dilated, abnormal vessels contained in the outer membrane of the haematoma. (13)Exudation from macro capillaries in the outer membrane of CSDH probably plays an important role in the pathophysiology and the growth of CSDH. (15) If this is the case, elevation of the head end of bed could decrease this source of hemorrhage.

The role of postoperative patient posture in the recurrence of CSDH has not been studied sufficiently and this clinical study was done aiming to compare the effect of two postoperative head positions (supine position vs. 30o head elevation position) on clinical outcome and recurrence rate in CSDHs treated by two burr holes irrigation and subgleal drainage.

CSDH is generally considered a disease of elderly population. The mean age in our study was 55.07 years while mean age in Asim Ishfaq et al study was 59.98 years(2) and in Gelabert et al. study, it was older ( 72.7 years) (6).

In our study, mean ± SD of the volume of postoperative fluid drained per day in group A = 180.15±15.23 ml while it was 171.87±10.06 ml in group B and this difference between the 2 groups was statistically significant (P= 0.01). Asim Ishfaq et al. (2009), found also that patients with postoperative flat position in bed had higher amounts of drainage than patients kept with head end of bed elevated by 30 0 i.e. reverse Trendelenburg position. (Average daily output of 152 ml vs. 142 ml), but this figure did not reach statistical significance (p > 0.05).

While Vincent J. Miele et al. found that the patients with elevated head of bed (HOB) to 30 0 had higher amounts of drainage than flat HOB (239 vs. 166 mL), this figure did not reach statistical significance (P = .23) (18).

At the end of our study, all the patients showed improved postoperative GCS except 8 patients. In group A, 3 patients had recurrent subdural hematomas and one patient died 10 days after surgery because of acute myocardial infarction. While in group B, 4 patients had recurrent subdural hematomas. All recurrent CSDHs underwent reoperation with burr hole irrigation and a new drain insertion in the 2nd and 3rd months after surgery.

We found the difference between both groups insignificant regarding the improvement in postoperative GCS, the recurrence rate and need for reoperation, the complications and death rates.

These results match those of Asim Ishfaq et al.(2009) , who studied the effect of two post- operative positions (flat vs. head elevation by 30 0 ) and found no difference in postoperative complications and recurrence rate amongst the two groups and also those of Nakajima et al. (2002) , who studied the role of postoperative patient posture in the recurrence of chronic subdural hematoma and they found their patients when nursed in sitting position after the operation had no significant increase in recurrence rate.(10) However Abouzari et al.(2007),studied the role of postoperative patient posture in the recurrence of traumatic chronic subdural hematoma after burr hole surgery and found that assuming an upright posture soon after burr hole surgery was associated with increased incidence of recurrence but not other postsurgical complications.(1).



Conclusion according to the results, we think that the two studied postoperative head positions could be effective comparable options with insignificant difference in treating CSDHs by two burr holes irrigation and subgleal drainage.

Acknowledgement

www.bu.edu.eg www.fac.bu.edu.eg


REFERENCES

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  2. Asim Ishfaq, Ishfaq Ahmed and Sabir Hussain Bhatti .Effect of Head Positioning on Outcome after Burr Hole Craniostomy for Chronic Subdural HaematomaJournal of the College of Physicians and Surgeons Pakistan Vol. 19 (8): 492-495, 2009

  3. El-Kadi H, Miele VJ, Kaufman HH. Prognosis of chronic subdural hematomas. Neurosurg Clin N Am 11:553–567, 2000

  4. Feldman RG, Pincus JH, McEntee WJ. Cerebrovascular accident or subdural fluid collection? Arch Intern Med 112:966–76,1963

  5. Fogelholm R, Waltimo O. Epidemiology of chronic subdural haematoma. Acta Neurochir(Wien) 32:247–250, 1975

  6. Gelabert Gonzalez M, Iglesias Pais M, Garcia Allut A, Martinez Rumbo R. Chronic subdural haematoma: surgical treatment and outcome in 1000 cases. Clin Neurol Neurosurg 107:223-9,2005

  7. Markwalder TM, Seiler RW: Chronic subdural hematomas: To drain or not to drain? Neurosurgery 16:185-188, 1985

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  9. Mellergrad P, Wisten O: Operations and re-operations for chronic subdural haematomas during a 25-year period in a well-defined population. Acta Neurochir 138; 708-713, 1996

  10. Nakajima H, Yasui T, Nishikawa M, Kishi H, Kan M. The role of postoperative patient posture in the recurrence of chronic subdural haematoma: a prospective randomized trial. Surg Neurol 58:385-7, 2002

  11. Rozzelle CJ, Wofford JL, Branch CL. Predictors of hospital mortality in older patients with subdural haematoma. J Am Geriatr Soc 43:240–4, 1995

  12. Sambasivan M: An overview of chronic subdural hematoma: Experience with 2300 cases. Surg Neurol 47:418-422, 1997

  13. Stoodley M, Weir B. Contents of chronic subdural haematoma. Neurosurg Clin N Am 11:425-34,2000

  14. Tabaddor K, Shulman K: Definitive treatment of chronic subdural hematoma by twist-drill craniostomy and closed-system drainage. J Neurosurg 46:220-226, 1977.

  15. Tokmak M, Iplikcioglu AC, Bek S, Gokduman CA, Erdal M. The role of exudation in chronic subdural haematomas. J Neurosurg 107:290-5, 2007

  16. Traynelis VC. Chronic subdural haematoma in the elderly. Clin Geriatr Med 7:583–98, 1991

  17. Tsutsumi K, Maeda K, Iijima A, Usui M, Okada Y, Kirino T: The relationship of preoperative magnetic resonance imaging findings and closed system drainage in the recurrence of chronic subdural hematoma. J Neurosurg 87:870-875, 1997.

  18. Vincent J. Miele, Ali Sadrolhefazi, Julian E. Bailes. Influence of head position on the effectiveness of twist drill craniostomy for chronic subdural hematoma. Volume 63, Issue 5, 420–423,2005

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  20. Yamamoto H, Hirashima Y, Hamada H, Hayashi N, Origasa H, Endo S. Independent predictors of recurrence of chronic subdural hematoma : results of multivariate analysis performed using a logistic regression model. J Neurosurg.98:1217–1221, 2003


الملخص العربي

تاثير وضع الاستلقاء مقابل ارتفاع راس المريض 30 درجه بعد الجراحه علي النتائج السريريه و معدل الارتجاع في علاج النزيف المزمن تحت الام الجافيه بالصرف خلال ثقب الجمجمه
المقدمه : خيارات العلاج في هذه الحالات متعدده ولا تزال مثيره للجدل

هدف الدراسه :دراسه تاثير وضع الاستلقاء مقابل وضع ارتفاع راس المريض 30 درجه بعد الجراحه علي النتائج السريريه و معدل الارتجاع في علاج النزيف المزمن تحت الام الجافيه بالصرف خلال ثقب الجمجمه



اساليب الدراسه : البحث تضمن 56 حاله جراحيه مقسمه عشوائيا علي مجموعتين أ و ب في وضعين مختلفين بعد الجراحه اجريت ما بين ديسمبر 2010 الي ديسمبر 2014 في مستشفي بنها الجامعي مع متابعه النتائج لمده سته شهورلتقييم النتائج السريريه و معدلات الارتجاع.

النتائج :اظهرت النتائج ان الفارق بين مرضي المجموعتين غير ذي دلاله احصائيه في ما يخص تحسن حالات المرضي بعد الجراحه و معدلات الارتجاع و المضاعفات و الوفيات

الخلاصه : نعتقد ان كلا الوضعين يمكن ان يمثل خيار فعال بفروق غير ذي دلاله احصائيه في علاج هذه الحالات

ا




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