Acta Neurochirurgica

, Volume 160, Issue 5, pp 901–911 | Cite as

Burr hole trepanation for chronic subdural hematomas: is surgical education safe?

  • Nicolai Maldaner
  • Marketa Sosnova
  • Johannes Sarnthein
  • Oliver Bozinov
  • Luca Regli
  • Martin N. Stienen
Original Article - Neurosurgery Training



There is a paucity of data concerning the safety and efficacy of surgical education for neurosurgical residents in the evacuation of chronic subdural hematomas (cSDH) by burr hole trepanation.


This is a retrospective analysis of prospectively collected data on consecutive patients receiving burr hole trepanation for uni- or bilateral cSDH. Patients operated by a supervised neurosurgery resident (teaching cases) were compared to patients operated by a board-certified faculty neurosurgeon (BCFN; non-teaching cases). The primary endpoint was surgical revision for any reason until the last follow-up. The secondary endpoint was occurrence of any complication until the last follow-up. Clinical status, type of complications, mortality, length of surgery (LOS), and hospitalization (LOH) were tertiary endpoints.


A total of n = 253 cases were analyzed, of which n = 217 (85.8%) were teaching and n = 36 (14.2%) non-teaching cases. The study groups were balanced in terms of age, sex, surgical risk (ASA score), and preoperative status (Karnofsky Performance Scale (KPS), modified Rankin Scale (mRS), National Institute of Health Stroke Scale (NIHSS)). The cohort was followed for a mean of 242 days (standard deviation 302). In multivariate analysis, teaching cases were as likely as non-teaching cases to require revision surgery (OR 0.65, 95% CI 0.27–1.59; p = 0.348) as well as to experience any complication until the last follow-up (OR 0.79, 95% CI 0.37–1.67; p = 0.532). Mean LOS was about 10 min longer in teaching cases (53.0 ± 26.1 min vs. 43.5 ± 17.8 min; p = 0.036), but LOH was similar. There were no group differences in clinical status, mortality and type of complication at discharge, and the last follow-up.


Burr hole trepanation for cSDH can be safely performed by supervised neurosurgical residents enrolled in a structured training program, without increasing the risk for revision surgery, perioperative complications, or worse outcome.


Burr hole trepanation Chronic subdural hematoma Surgical education Outcome Safety Training Complications 



American Society of Anesthesiology grading scale


Board-certified faculty neurosurgeon


Clavien-Dindo grade


Chronic subdural hematoma


Computed tomography


Interquartile range


Length of hospitalization


Length of surgery


Karnofsky Performance Scale


Modified Rankin scale


National Institute of Health Stroke Scale


Midline shift


Postgraduate year


Standard deviation



The authors thank all resident and staff physicians of the department, who prospectively collected and verified the data that is the basis of the current analysis.


No funding was received for this research.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The local ethics committee (Kantonale Ethikkommission KEK-ZH 2012–0244) approved the prospective data collection in the patient registry. The study was registered at (NCT01628406) and follows the STROBE recommendation for observational studies.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

701_2017_3458_Fig3_ESM.gif (29 kb)
Supplementary Figure 1

Kaplan-Meier time-to-event estimates with time censored at 365 days postoperative. The endpoint is death in patients operated on by supervised neurosurgery residents (Teaching procedure) or experienced board-certified faculty neurosurgeons (No teaching procedure). There was no significant difference in the endpoint (Log-rank test: p = 0.322). (GIF 28 kb)

701_2017_3458_MOESM1_ESM.eps (1.8 mb)
High resolution image (EPS 1805 kb)


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Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • Nicolai Maldaner
    • 1
  • Marketa Sosnova
    • 1
  • Johannes Sarnthein
    • 1
  • Oliver Bozinov
    • 1
  • Luca Regli
    • 1
  • Martin N. Stienen
    • 1
  1. 1.Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience CenterUniversity of ZurichZurichSwitzerland

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