Early insertion of the subdural drain during chronic subdural hematoma surgery
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LETTER TO THE EDITOR - BRAIN TRAUMA
Early insertion of the subdural drain during chronic subdural hematoma surgery In response to “Drain type and technique for subdural insertion after burr hole evacuation of chronic subdural hematoma” by TSR Jensen et al., Acta Neurochirurgica (Wien), 25 June 2020 N. Beucler 1
&
A. Sellier 1 & C. Joubert 1 & N. Desse 1 & A. Dagain 1,2
Received: 19 August 2020 / Accepted: 7 September 2020 # Springer-Verlag GmbH Austria, part of Springer Nature 2020
Dear Editor, We read with great interest the recent article by TSR Jensen and colleagues regarding a surgical tip for the safe insertion of the subdural drain in chronic subdural hematoma (CSH) surgery [2]. Insertion of the subdural drain is a fundamental [5] but delicate surgical sequence, as there is still a significant rate of misplaced drains [3, 8] with sometimes serious neurological consequences [4]. In order to reduce this iatrogenic complication, the authors use a 3.2-mm diameter soft silicone drain inserted through a single burr hole [2]. The extremity of the drain is recurved on itself and caught with anatomy forceps, and then it is released once appropriately placed in the subdural space. The extremity of the drain naturally unfolds itself on the surface of the inner membrane of the subdural hematoma. We salute the authors’ ingenuity as they free themselves from finding the appropriate angle for the insertion of the subdural drain. However, we feel that the timing of insertion of the subdural drain is of potential importance and was not addressed here. In our institution, we perform a brief but copious subdural irrigation using a silicone urinary catheter, which is long and smooth enough to perform atraumatic washing of the whole subdural space [9]. The subdural drain is inserted right afterwards, when there is still liquid under tension in the subdural
space and the hypotonic brain is far below the surface. It is our opinion that this detail improves the safety of drain insertion, because the subdural space is widely opened. We are used to insert a 7-mm diameter Jackson-Pratt flat silicone drain (Biometrix®), but sometimes we can only insert a 4-mm Jackson-Pratt drain if the subdural space quickly becomes narrow. This is particularly relevant in young patients. Because of the brain trophicity, the CSH becomes symptomatic earlier with predominant symptoms of intracranial hypertension [1]. This is correlated with cerebral imaging findings: the CSH is generally thinner (10 mm) with a greater midline shift (11 mm) [1, 6]. Consequently, there is not much time until brain expansion which is sometimes a reason not to place a subdural drain [7]; in such case, we insert the drain right after the opening of the dura mater. The early presence of the drain is not an obstacle to copious irrigation of the subdural space through the burr hole. We use a bulb irrigation syringe which provides a broad water spout to reduce the risk of water jet-related cerebral contusion.
Compliance with ethical standards Conflict of interest The author
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