Weigel Ralf, Schlickum Linda, Weisser Gerald, Krauss Joachim K
a Department of Neurosurgery , Medical School Hannover , Hannover , Germany.
Br J Neurosurg. 2015;29(4):538-43. doi: 10.3109/02688697.2015.1015101. Epub 2015 Mar 31.
Surgical treatment for chronic subdural haematoma (CSH) has been analysed by applying evidence-based medicine (EBM) criteria earlier. Whether implementation of EBM-derived key factors into an optimised treatment algorithm would improve outcome, however, needs to be clarified.
Symptomatic patients with CSH who fulfilled the inclusion criteria were either assigned to an optimised treatment algorithm (OA-EBM group) or to a control group treated by the standard departmental surgical technique (SDST group) in a prospective design. For the OA-EBM algorithm only one burr hole, extensive intraoperative irrigation and a closed system drainage with meticulous avoidance of entry of air was mandatory. A two-catheter technique was used to reduce intracavital air. Final endpoints were neurological outcome (Markwalder Score), recurrence and the amount of intracranial air.
A total of 93 out of 117 patients were evaluated accounting for 113 cases because 20 patients had bilateral haematomas. Demographic data of 68 cases in the SDST group did not differ from 45 cases in the OA-EBM group. The Markwalder Score showed greater improvement in the OA-EBM group (0.5 ± 0.6 vs. 1.0 ± 1.0, p = 0.003). The recurrence rate was 18% (12 patients) in the SDST group versus 2% (1 patient) in the OA-EBM group (p < 0.05). The amount of intracranial air was significantly lower in the OA-EBM group (3.3 ± 5.0 cm(3) vs. 5.2 ± 7.7 cm(3)) with p = 0.04. In the standard group computerised tomography scanning was performed slightly earlier (3 ± 1.7 days vs. 3.6 ± 1.4 days). When comparing only non-recurrent cases in both groups no significant difference was apparent.
Implementation of EBM key factors into a treatment algorithm for CSH can improve neurological outcome in a typical neurosurgical department, reduce recurrence and minimise the amount of postoperative air within the haematoma cavity.
早期已运用循证医学（EBM）标准对慢性硬膜下血肿（CSH）的外科治疗进行了分析。然而，将循证医学得出的关键因素纳入优化治疗方案是否能改善治疗效果，仍有待明确。
符合纳入标准的有症状CSH患者，以前瞻性设计被分配至优化治疗方案组（OA-EBM组）或采用科室标准手术技术治疗的对照组（SDST组）。对于OA-EBM方案，仅需一个骨孔、术中广泛冲洗以及采用封闭系统引流并严格避免空气进入。采用双导管技术减少腔内空气。最终终点为神经功能结局（马克瓦尔德评分）、复发情况及颅内空气量。
117例患者中共有93例接受评估，计113例病例，因为20例患者为双侧血肿。SDST组68例的人口统计学数据与OA-EBM组45例无差异。马克瓦尔德评分显示OA-EBM组改善更明显（0.5±0.6对1.0±1.0，p = 0.003）。SDST组复发率为18%（12例患者），而OA-EBM组为2%（1例患者）（p < 0.05）。OA-EBM组颅内空气量显著更低（3.3±5.0 cm³对5.2±7.7 cm³），p = 0.04。标准组的计算机断层扫描稍早进行（3±1.7天对3.6±1.4天）。仅比较两组未复发病例时，无明显差异。
将循证医学关键因素纳入CSH治疗方案可改善典型神经外科科室的神经功能结局，降低复发率并使血肿腔内术后空气量最小化。
