Improving the aesthetic outcome with burr hole cover placement in chronic subdural hematoma evacuation-a retrospective pilot study

Abstract

Background: The aesthetic outcome after burr hole trepanation for the evacuation of chronic subdural hematomas (cSDH) is often unsatisfactory, as the bony skull defects may cause visible skin depressions. The purpose of this study was to evaluate the efficacy of burr hole cover placement to improve the aesthetic outcome.

Methods: We reviewed consecutive patients treated by burr hole trepanation for cSDH with or without placement of burr hole covers by a single surgeon between October 2016 and May 2018. The clinical data, including complications, were derived from the institution's prospective patient registry. The primary endpoint was the aesthetic outcome, as perceived by patients on the aesthetic numeric analog (ANA) scale, assessed by means of a standardized telephone interview. Secondary endpoints were skin depression rates and wound pain, as well as complications.

Results: From n = 33, outcome evaluation was possible in n = 28 patients (n = 24 male; mean age of 70.4 ± 16.1 years) with uni- (n = 20) or bilateral cSDH (n = 8). A total of 14 burr hole covers were placed in 11 patients and compared to 50 burr holes that were not covered. Patient satisfaction with the aesthetic outcome was significantly better for covered burr holes (mean ANA 9.3 ± 0.74 vs. 7.9 ± 1.0; p < 0.001). Skin depressions occurred over 7% (n = 1/14) of covered and over 92% (n = 46/50) of uncovered burr holes (p < 0.001). There was no difference in wound pain (p = 0.903) between covered and uncovered sites. No surgical site infection, cSDH recurrence, or material failure was encountered in patients who had received a burr hole plate.

Conclusions: In this retrospective series, placement of burr hole covers was associated with improved aesthetic outcome, likely due to reduction of skin depressions. A randomized controlled trial is developed to investigate whether adding burr hole covers results in superior aesthetic outcomes, without increasing the risk for complications.

Keywords: Aesthetic outcome; Burr hole cover; Burr hole plate; Chronic subdural hematoma; Complications; Patient satisfaction; Scar; Trepanation.

Conflict of interest statement

Conflict of interest

All the authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

The local ethics committee (Kantonale Ethikkommission KEK-ZH 2012–0244) approved the prospective collection and analysis of data in the patient registry. The study was registered at

Figures

Fig. 1

Illustrative picture of a 76-year-old male patient, seen in outpatient clinics about 12 weeks after right-sided frontal and parietal burr hole trepanation for a cSDH, with the trepanation site not covered by a burr hole plate

Fig. 2

Study algorithm demonstrating how the intervention and control groups were arrived at

Fig. 3

Box plot (25th to 75th percentile and mean) with whiskers (5th–95th percentile) and outliers (points). The mean aesthetic satisfaction (ANA) score in the intervention group was 9.3 (SD 0.74) and 7.9 in the control group (SD 1.0, ***p < 0.001)

Fig. 4

The rate of skin depressions over covered burr holes was 7% (1/14) and 92% (46/50) over burr holes that are not covered (***p < 0.001)

Fig. 5

Illustrative picture of an 91-year-old male patient, seen in outpatient clinics about 16 weeks after right-sided frontal and parietal burr hole trepanation for a cSDH, with the trepanation site covered by a burr hole plate