- Division of Neurological Surgery, Department of Surgery, LAUTECH Teaching Hospital, Osogbo, Nigeria
Taopheeq B. Rabiu
Division of Neurological Surgery, Department of Surgery, LAUTECH Teaching Hospital, Osogbo, Nigeria
DOI:10.4103/2152-7806.110657Copyright: © 2013 Rabiu TB. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Rabiu TB. Chronic subdural hematoma: A survey of neurosurgeons’ practices in Nigeria. Surg Neurol Int 18-Apr-2013;4:58
How to cite this URL: Rabiu TB. Chronic subdural hematoma: A survey of neurosurgeons’ practices in Nigeria. Surg Neurol Int 18-Apr-2013;4:58. Available from: http://sni.wpengine.com/surgicalint_articles/chronic-subdural-hematoma-a-survey-of-neurosurgeons-practices-in-nigeria/
Background:Chronic subdural hematoma (CSDH) is a commonly encountered condition in neurosurgical practice. In Nigeria, a developing country, patients with CSDH are less likely to be diagnosed and treated by surgical drainage early. Aware of the reported variations in neurosurgeons’ practices regarding CSDH in many parts of the world, we sought to determine the current practices of Nigerian neurosurgeons in managing CSDH.
Methods:An Internet-based survey was carried out in which all Nigerian neurosurgeons listed in the Nigerian Academy of Neurological Surgeons directory during the July–December 2012 time period were asked to participate. Questions asked in the survey were: (1) Type of treatment used in patients with CSDH, (2) Use of drains postoperatively, (3) Postoperative patient positioning, (4) Postoperative mobilization, (5) Postoperative complications, and (6) Postoperative computed tomography (CT) scan monitoring.
Results:Survey information was sent to the 25 practicing neurosurgeons in Nigeria who met the criteria listed above for being included in this study. Each of the 14 neurosurgeons who responded reported that CSDH is often misdiagnosed initially, usually as a stroke having occurred. Once a diagnosis of CSDH was made, the most common method of treatment reported was placement of one or two burr-holes for drainage of the hematoma. Reported, but used in only a few cases, were twist drill craniostomy, craniectomy, and craniotomy. Each neurosurgeon who responded reported irrigation of the subdural space with sterile saline, and in some cases an antibiotic had been added to the irrigation solution. Six of the 14 neurosurgeons left drains in the subdural space for 24-72 hours. Seven neurosurgeons reported positioning patients with their heads elevated 30° during the immediate postoperative period. No neurosurgeon responding reported use of steroids, and only one acknowledged routine use of anticonvulsive medication for patients with CSDH. Only 3 of the 14 neurosurgeons taking part in the study said they routinely order CT scans postoperatively.
Conclusion:There are several differences in the ways Nigerian neurosurgeons manage CSDH. Future studies may help to streamline the approaches to managing CSDH.
Keywords: Burr-hole drainage, chronic subdural hematoma, hematoma recurrence, Nigerian neurosurgeons, survey of practices
Although it has been recognized by neurosurgeons for about 16 decades since it was first described by Virchow,[
At the November 2010 meeting of the Nigerian Academy of Neurological Surgeons (NANS) discussions of CSDH suggested wide variations in the management of the condition among the Nigerian Neurosurgeons in attendance in line with reported variations in neurosurgeons’ practices in other regions of the world.[
An internet-based survey of Nigerian neurosurgeons was conducted between July and Decembe 2012 using a Google document survey questionnaire, which may be accessed at
Questions on postoperative care of the CSDH patients were designed to address the following: (1) Positioning of patients in the immediate postoperative period (height of bed: Flat vs. 30° head-up vs. trendelenburg), (2) Timing of postoperative mobilization of the patients, and (3) Whether or not the surgeons obtained routine postdrainage computed tomography (CT). The next set of questions assessed recurrence rate of hematomas and the occurrence of other complications as experienced by the surgeons.
Participants were identified through the NANS directory used for the November 2010 and February 2012 meetings of the association, which is a complete listing of all neurosurgeons in Nigeria. Neurosurgeons who are retired or who are less than 1 year postcertification were excluded. E-mails soliciting for participation in the study were sent to all the 25 eligible neurosurgeons and contained a link to the online survey. Internet-based health care surveys have been validated by previous studies.[
An introductory cover letter in the e-mails as well as in the online questionnaire noted the apparent differences in care of CSDH in Nigeria and the need to objectively document the current practices. It also indicated the estimated time-burden for completing the questionnaire of 10 minutes and assured that participation was entirely voluntary and guaranteed confidentiality in the data collection and dissemination of results.
An initial study was conducted from February to July 2011. Only eight responses (representing about one-third of the survey population) were received. A preliminary presentation of the findings was made at the 2012 meeting of NANS in Enugu, Nigeria and members were called upon to participate in the survey to validate the findings. Consequently, a second survey (being reported here) was carried out from July to December 2012. The new survey included questions on the case load of CSDH, symptomatology and diagnosis of CSDH, use of steroids and anticonvulsants, as well as the diagnosis of recurrence. Reminders were sent on two occasions during the study period and telephone contacts also made with the neurosurgeons urging for participation in the study. Some respondents (when contacted by phone) had stated that poor access to the internet and their busy schedules delayed their participation.
The responses were recorded anonymously. Responses were recorded on the Google-based Microsoft-Excel database. Simple descriptive statistics of proportions was done using SPSS Version 15 (SPSS Inc., Chicago, IL). Differences in response rates were evaluated using Chi-square statistics (Epi info version 6). A P < 0.05 was considered statistically significant.
The respondents and patient population
The response rate was 56% (14 of 25). Most of the respondents were within 10 years of certification (9/14) and worked in government-owned hospitals (12/14) [
The respondents use single burr-hole (7, 50.0%) or double burr-holes (7, 50.0%) as the primary treatment option. Secondary options were twist drill craniostomy, craniectomy, and craniotomy for CSDH management as reported by 4/14, 1/14, and 3/14 of them, respectively [
Adjuvant surgical strategy
All respondents routinely irrigate the subdural space until clean returns are obtained. Saline impregnated with antibiotics is used by 11 while 3 use saline only. Six of the respondents place subdural drains using nasogastric tubes, Foleys catheters, or scalp vein needles [
Postoperative patient care
Most of the respondents (7/14) nurse their patients 30° head-up in the immediate postoperative period. Reported timing of postoperative mobilization of patients varied from within 24 hours to postoperative day 8-10. Most of the respondents do not obtain routine postoperative CT scans due to financial constraints (5/14) and because they do not think it is generally useful (6/14). Only three surgeons do routine postoperative CT and they reported that it influenced the postoperative care of their patients [
None of the respondents routinely use steroids in managing CSDH while only one routinely uses anticonvulsants.
The surgeons assessed the success of the hematoma evacuation using clinical improvement/decline. CT is combined as necessary. The reported approximate hematoma recurrence rates were 0% (5/14), 1-5% (8/14), and 6-10% (1/14). Recurrence was reported by only 3 of those who do not use drains (8) as opposed to 6/6 of those who use drain (P = 0.0309). In addition, recurrence was reported more by those who nurse patients in trendelenburg position (4/14) as opposed to those who nurse them 30° head up and flat (4/7 and 1/3, respectively) in the immediate postoperative period. These differences were not statistically significant (P = 0.1628). Recurrence was also reported more by those who mobilize their patients within 24 hours (4/4) than by 48 hours (3/7) and after 48 hours (1/3) (P = 0.1453). Other reported complications of clinical significance were deep venous thrombosis (1/14), pneumonia (1/14), and wound infection (2/14) [
The management strategies available for CSDH may be as varied as the number of attending neurosurgeons in any particular institution. These variations probably underscore the fact that much is yet unknown about this common condition. Variations in practices among neurosurgeons in different countries regarding CSDH management have been documented.[
The landmark review by Markwalder[
In an evidenced-based review of contemporary surgery for CSDH, Weigel and colleagues did not find any study that provided class I evidence on the efficacy of the various management practices.[
Regarding postoperative positioning of the patients, the various techniques adopted also reveal how so much more needed to be known about CSDH. Tredenlenburg positioning has been practiced with the hope of increasing CSF pressure and aiding brain reexpansion.[
To drain or not to drain used to, and is probably still, an important discourse in CSDH management. Subdural drain when combined with twist drill craniostomy was considered useful as it allows slow, steady and more complete evacuation of the hematoma and gradual reexpansion of the brain.[
Although, the practices of the nonrespondents may be substantial in the overall overview of CSDH management in Nigeria, the findings of this study indicate that:
Nigerian neurosurgeons use burr-hole as their preferred method of surgical treatment of CSDH Subdural space irrigation is generally practiced in Nigeria There is no consensus regarding postoperative positioning of patients among Nigerian Neurosurgeons Routine postoperative CT scanning is not a common practice in Nigeria due to financial constraints Nigerian neurosurgeons do not routinely use steroids in managing CSDH A large majority of Nigerian neurosurgeons do not use prophylactic anticonvulsants in the management of patients with CSDH.
Nigerian neurosurgeons use burr-hole as their preferred method of surgical treatment of CSDH
Subdural space irrigation is generally practiced in Nigeria
There is no consensus regarding postoperative positioning of patients among Nigerian Neurosurgeons
Routine postoperative CT scanning is not a common practice in Nigeria due to financial constraints
Nigerian neurosurgeons do not routinely use steroids in managing CSDH
A large majority of Nigerian neurosurgeons do not use prophylactic anticonvulsants in the management of patients with CSDH.
An equal number of respondents (7 each) use single and double burr-holes in managing CSDH. This lack of uniformity is supported by a recent literature from Nigeria.[
Six of the respondents place subdural drains and all of them reported recurrence rates of 1-5%. Five of the eight who do not employ the use of drains reported no recurrence while the remaining three reported rates of 1-5% (two) and 6-10% (one). These differences were statistically significant (P = 0.0309) in contrast to findings from the United Kingdom and the Republic of Ireland.[
Traditionally, CSDH patients are nursed flat and mobilized late in an effort to reduce hematoma recurrence.[
It is instructive to note that postoperative CT scanning is not routine in Nigeria in contrast with practices in some developed countries.[
One significant limitation of this study is the potential effect of nonresponders on the findings. It is possible that the practices of many of the nonresponders differ from those of the respondents. However, given the close interaction between, and the small number of, Nigerian neurosurgeons as well as the fact that most are trained in or affiliated to the three major local training centers (Ibadan, Lagos, and Sokoto), it is most probable that these findings are representative of the general neurosurgical practice in Nigeria.
This study has shown that there are several differences in the ways Nigerian neurosurgeons manage CSDH. The relatively high cost of CT scanning in Nigeria, its lack of general availability in Nigerian hospitals as well as the high-frequency of malfunctioning of the available CT scanners may contribute to the rarity of postoperative CT monitoring reported in this study. Future studies may help to streamline the approaches to managing CSDH.
The author wishes to thank Dr. Melvin L. Cheatham, Clinical Professor of Neurosurgery at the University of California, Los Angeles, USA for his critical thoughts and comments in shaping this manuscript. The author also appreciates the contributions of all Nigerian neurosurgeons who participated in the study.
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