Neurosurgery papers

Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial. Santarius T, Kirkpatrick P J, Ganesan D et al. Lancet 2009; 374: 1067-1073.

Chronic subdural haematoma causes serious morbidity and mortality. It recurs after surgical evacuation in 5 to 30% of patients. Drains might reduce recurrence but are not used routinely. Our aim was to investigate the effect of drains on recurrence rates and clinical outcomes. A randomised controlled trial was performed at one UK centre between November, 2004 and November, 2007. 269 patients aged 18 years and older with a chronic subdural haematoma for burr-hole drainage were assessed for eligibility. 108 were randomly assigned by block randomisation to receive a drain inserted into the subdural space and 107 to no drain after evacuation. The primary endpoint was recurrence needing re-drainage. The trial was stopped early because of a significant benefit in reduction of recurrence. Analyses were done on an intention-to-treat basis. Recurrence occurred in ten of 108 (9·3%) people with a drain, and 26 of 107 (24%) without (p=0·003; 95% CI 0·14—0·70). At 6 months mortality was nine of 105 (8·6%) and 19 of 105 (18·1%), respectively (p=0·042; 95% CI 0·1—0·99). Medical and surgical complications were much the same between the study groups. It was concluded that the use of a drain after burr-hole drainage of chronic subdural haematoma is safe and associated with reduced recurrence and mortality at 6 months.

Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: A randomized controlled trial. Bernard S A, Vina N, Cameron P et al. Ann Surg 2010; 252: 959-965.

Severe traumatic brain injury (TBI) is associated with a high rate of mortality and long-term morbidity. Comatose patients with TBI routinely undergo endo-tracheal intubation to protect the airway, prevent hypoxia, and control ventilation. In many places, paramedics perform intubation prior to hospital arrival. However, it is unknown whether this approach improves outcomes. The aim of this study was to determine whether paramedic rapid sequence intubation in patients with severe TBI improves neurologic outcomes at 6 months compared with intubation in the hospital. In a prospective, randomized, controlled trial, adults with severe TBI in an urban setting were randomly assigned to either prehospital rapid sequence intubation by paramedics or transport to a hospital emergency department for intubation by physicians. The primary outcome measure was the median extended Glasgow Outcome Scale (GOSe) score at 6 months. Secondary end-points were favourable versus unfavourable outcome at 6 months, length of intensive care and hospital stay, and survival to hospital discharge. A total of 312 patients with severe TBI were randomly assigned to paramedic rapid sequence intubation or hospital intubation. The success rate for paramedic intubation was 97%. At 6 months, the median GOSe score was 5 (interquartile range, 1–6) in patients intubated by paramedics compared with 3 (interquartile range, 1–6) in the patients intubated at hospital (P = 0.28). The proportion of patients with favourable outcome (GOSe, 5–8) was 80 of 157 patients (51%) in the paramedic intubation group compared with 56 of 142 patients (39%) in the hospital intubation group (risk ratio, 1.28; 95% confidence interval, 1.00–1.64; P = 0.046). There were no differences in intensive care or hospital length of stay, or in survival to hospital discharge. It was concluded that in adults with severe TBI, prehospital rapid sequence intubation by paramedics increases the rate of favourable neurologic outcome at 6 months compared with intubation in the hospital.