Subperiosteal versus subdural drainage after burr hole evacuation of chronic subdural hematoma: systematic review and meta-analysis

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The evidence for subperiosteal drainage (SPD) versus subdural drainage (SDD) in chronic subdural hematoma (CSDH) remains controversial, and most surgeons prefer to use SDD over SPD. We aim to assess the latest evidence on the use of SPD compared to SDD in patients with CSDH undergoing burr hole evacuation.


We performed a systematic literature search on topics that assesses the use of SPD compared to SDD in patients with CSDH up until November 2019 from PubMed, EuropePMC, Cochrane Central Database, ScienceDirect, ProQuest, and The primary outcome was recurrent CSDH, and the secondary outcomes were mortality, surgical morbidities, and modified Rankin Score (mRS).


There were a total of 3241 subjects from 10 studies. SPD was shown to reduce recurrent CSDH (OR 0.66 [0.52, 0.84], p < 0.001; I2: 17%, p = 0.30) compared to SDD. Recurrent CSDH was lower in SPD group in subgroup analysis at 3-months (OR 0.63 [0.49, 0.81]; I2: 68%, p = 0.04) and 6-months (OR 0.66 [0.51, 0.85], p = 0.001; I2: 77%, p = 0.01) follow-up. However, there was no difference in CSDH recurrence upon subgroup analysis of RCTs. Similar mortality was demonstrated between SPD and SDD group (p = 0.13). The occurrence of parenchymal injury/new neurological deficit was significantly lower in SPD group (OR 0.26 [0.14, 0.51], p < 0.001; I2: 49%, p = 0.08). The rate of seizure, (p = 0.57), postoperative bleeding (p = 0.29), and infection (p = 0.25) were shown to be similar in both SPD and SDD group. Overall, the rate of surgical morbidity was significantly lower in SPD group (OR 0.61 [0.44, 0.85], p = 0.003; I2: 16%, p = 0.25). mRS at the end of follow-up was similar in SPD and SDD group (p = 0.12).


SPD was associated with less CSDH recurrence, but similar rate of mortality, seizures, postoperative bleeding, and infections compared to SDD. The rate of parenchymal injury/new neurological deficit was lower in the SPD group.

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Author information

R.P proposed and made the design for the study. R. P and H. D acquired the data and drafted the manuscript. R. P and H. D extracted, interpreted the available data, and performed extensive research on the topic. J.J provide critical revision to the manuscript. All aforementioned authors contributed to the writing of this manuscript. R. P performed the statistical analysis.

Correspondence to Raymond Pranata.

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Additional information


The aims of burr hole trepanation for chronic subdural hematoma are to release (most of) the blood which compresses the cerebral hemisphere(s), to allow further hematoma reabsorption by drainage, and to prevent hematoma recurrence. Furthermore, it is of paramount importance to not create any new or additional morbidity to the often elderly and frail patients. I started my training in a department where subdural drain (SDD) placement was standard of care. I then moved on to a department where both subperiosteal drains (SPD) and SDDs were placed for this indication, allowing me to compare complications and results of both techniques. In Zurich we practice SPD placement as standard of care. As this well-conducted systematic review illustrates, the risk of injury to the cerebral cortex is dramatically lower (OR 0.26, 95% CI 0.14–0.51, p < 0.001), no matter how careful one intends to insert the subdural drain. Moreover, the results in terms of hematoma clearance and reoperation are at least as good – if not better – for SPD compared to SDD. The results mirror the clinical experience I made during my training and provide great arguments in the on-going evidence-based discussion on how we should best treat our patients. To me, SPD are clearly preferred over SDD, following the bioethical maxim “primum non nocere.”

Martin N. Stienen

Zurich, Switzerland

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Pranata, R., Deka, H. & July, J. Subperiosteal versus subdural drainage after burr hole evacuation of chronic subdural hematoma: systematic review and meta-analysis. Acta Neurochir (2020) doi:10.1007/s00701-019-04208-5

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  • Subperiosteal
  • Subgaleal
  • Drainage
  • Subdural hematoma
  • Burr hole