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Surgery for chronic subdural haematoma: is there an evidence base?
  1. L T Dunn
  1. Department of Neurosurgery, Glasgow University, Southern General Hospital, Glasgow G51 4TF, UK; ltd1x{at}udcf.gla.ac.uk

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    It is time for a well designed and adequately sized clinical trial of the treatment of chronic subdural haematoma

    In their paper on pp 937–943 (this issue),1 Weigel et al have assessed in a systematic way the published studies on outcome following different surgical treatments for chronic subdural haematoma. They suggest that burr hole evacuation has the best cure/complication ratio and that postoperative closed system drainage reduces the risk of recurrence. One of their striking findings is the small number of good quality studies published on this topic. There are no randomised controlled trials to provide class I evidence, and only six studies that provide class II evidence. This limits the strength of the recommendations that can be made and precludes application of the statistical techniques of meta-analysis. Given that chronic subdural haematoma is a common condition in routine neurosurgical practice, this paucity of good quality clinical studies seems surprising. There are real and recognised, but not insurmountable, difficulties in conducting randomised controlled trials in surgery.2,3 They are expensive, difficult to set up, and difficult to conduct. Surgeons often have strongly held opinions about the “best” treatment in a given situation and it can be difficult to convince them of the need for or value of clinical trials of established treatments. On the other hand the mortality and morbidity reported in the various studies cited in Weigel’s paper vary widely—mortality between 0% and 11%, morbidity between 0% and 25%, and recurrence between 0% and 76%. Much of this variability almost certainly relates to baseline differences in the various patient groups but some is likely to relate to the different treatment methods. The best way to resolve these issues would be with a well designed and adequately sized clinical trial and perhaps the time has come to consider doing this, so that we can provide our patients with a rational basis for the treatment(s) we offer for this common condition.

    It is time for a well designed and adequately sized clinical trial of the treatment of chronic subdural haematoma

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