Department of Neurosurgery, Weill Cornell Medical College, New York, New York.
Department of Neurology, Weill Cornell Medical College, New York, New York.
JAMA Netw Open. 2018 Oct 5;1(6):e183737. doi: 10.1001/jamanetworkopen.2018.3737.
Elderly patients who undergo surgery for an isolated nontraumatic subdural hematoma (SDH) are at major risk for SDH reaccumulation, which can cause further injury and disability. Few population-based studies have examined how often nontraumatic SDH reaccumulates and necessitates repeated operation.
To determine the rate of repeated operation after evacuation of nontraumatic SDH.
DESIGN, SETTING, AND PARTICIPANTS: In a cohort study, 2 parallel analyses were performed using data from the National Surgical Quality Improvement Project (NSQIP) from January 1, 2012, through December 31, 2015, and inpatient and outpatient claims data from a 5% nationally representative sample of Medicare beneficiaries from January 1, 2009, to September 30, 2015. In both samples, our cohort comprised patients 65 years or older who underwent surgical evacuation of nontraumatic SDH. Data were analyzed from March 28 to April 13, 2018.
The outcome variable was repeated operation for SDH after the index operation. Survival analysis and Kaplan-Meier statistics were used to calculate cumulative rates.
Among 2 831 274 cases submitted to the NSQIP registry, 515 patients 65 years or older (mean [SD] age, 76.9 [7.4] years; 177 [34.4%] women; 367 [71.3%] white) who underwent craniotomy or craniectomy for nontraumatic SDH were identified. Within 30 days after the index surgery, 37 patients underwent a repeated operation for SDH. The cumulative 30-day mortality rate was 13.8% (95% CI, 11.0%-17.1%), and the repeated operation rate was 7.8% (95% CI, 5.7%-10.7%). Among a cohort of 1 952 305 Medicare beneficiaries, 1534 patients (mean [SD] age, 77.7 [7.0] years; 498 [32.5%] women; 1244 [81.1%] white) who underwent evacuation of nontraumatic SDH were identified. A total of 103 patients underwent a repeated operation within 90 days. The cumulative 30-day mortality rate was 11.6% (95% CI, 10.1%-13.3%), and the repeated operation rate was 4.9% (95% CI, 3.9%-6.2%); the cumulative 90-day mortality rate was 17.6% (95% CI, 15.7%-19.6%), and the repeated operation rate was 7.5% (95% CI, 6.2%-9.0%). The study found no evidence of a significant difference in cumulative repeated operation rates at 90 days between patients whose index surgery was a burr-hole procedure for chronic SDH (11.7%; 95% CI, 6.3%-21.3%) vs a craniotomy or craniectomy (7.2%; 95% CI, 6.0%-8.8%) (P = .14 by the log-rank test).
In 2 large cohorts of US patients, approximately 5% to 10% of patients who underwent surgery for nontraumatic SDH were required to undergo repeated operation within 30 to 90 days. These results may inform the design of future prospective studies and trials and help practitioners calibrate their index of suspicion to ensure that patients are referred for timely surgical care.
因孤立性非创伤性硬脑膜下血肿（SDH）而接受手术的老年患者存在 SDH 再次积聚的主要风险，这可能导致进一步的损伤和残疾。很少有基于人群的研究调查过非创伤性 SDH 再次积聚并需要重复手术的频率。
确定非创伤性 SDH 引流后再次手术的发生率。
设计、地点和参与者：在一项队列研究中，使用国家手术质量改进计划（NSQIP）从 2012 年 1 月 1 日至 2015 年 12 月 31 日的数据和从 2009 年 1 月 1 日至 2015 年 9 月 30 日 Medicare 受益人的全国 5%代表性样本的住院和门诊索赔数据进行了 2 项平行分析。在这两个样本中，我们的队列包括 65 岁或以上接受非创伤性 SDH 手术清除的患者。数据于 2018 年 3 月 28 日至 4 月 13 日进行分析。
主要结局变量为索引手术后再次发生 SDH 的手术。生存分析和 Kaplan-Meier 统计用于计算累积率。
在提交给 NSQIP 登记处的 2831274 例病例中，确定了 515 名年龄在 65 岁或以上（平均[标准差]年龄，76.9[7.4]岁；177[34.4%]女性；367[71.3%]白人）接受颅骨切开术或颅骨切除术治疗非创伤性 SDH 的患者。在索引手术后 30 天内，有 37 名患者因 SDH 接受了重复手术。30 天内的累积死亡率为 13.8%（95%CI，11.0%-17.1%），重复手术率为 7.8%（95%CI，5.7%-10.7%）。在 1952305 名 Medicare 受益人的队列中，确定了 1534 名（平均[标准差]年龄，77.7[7.0]岁；498[32.5%]女性；1244[81.1%]白人）接受非创伤性 SDH 清除术的患者。共有 103 名患者在 90 天内接受了重复手术。30 天内的累积死亡率为 11.6%（95%CI，10.1%-13.3%），重复手术率为 4.9%（95%CI，3.9%-6.2%）；90 天内的累积死亡率为 17.6%（95%CI，15.7%-19.6%），重复手术率为 7.5%（95%CI，6.2%-9.0%）。研究未发现指数手术为慢性 SDH 颅骨钻孔术与颅骨切开术或颅骨切除术之间 90 天累积重复手术率存在显著差异（颅骨钻孔术 11.7%[95%CI，6.3%-21.3%]与颅骨切开术或颅骨切除术 7.2%[95%CI，6.0%-8.8%]）（对数秩检验 P=0.14）。
在 2 个美国患者大队列中，约 5%至 10%接受非创伤性 SDH 手术的患者在 30 至 90 天内需要再次手术。这些结果可能为未来前瞻性研究和试验的设计提供信息，并帮助从业者校准其怀疑指数，以确保患者及时接受手术治疗。
