Title : Chronic subdural hematoma drainage under local vs. General anesthesia: Systematic review and meta-analysis
Introduction Chronic subdural hematoma (cSDH) is one of the most encountered conditions seen in neurosurgery. Although mainstay treatment of cSDH has been burr hole drainage, no consensus yet exists on optimal anesthesia technique for surgical treatment. Currently, the decision to use either local anesthesia (LA) or general anesthesia (GA) depends on the protocol of the hospital or the preference of the individual surgeon. The primary objective of this study is to determine whether GA or LA causes the least complications peri and postoperatively. To do this, we undertook a systematic review and meta-analysis to examine the efficacy of both anesthesia types. Method A search was conducted in MEDLINE (1946 to November 11, 2022), Embase (1974 to November 11, 2022), and PubMed (up to November 11, 2022). The inclusion criteria were 1) Studies reporting clinical outcome after chronic subdural hematoma burr-hole drainage under local anesthesia, 2) Studies published in English, 3) Studies in humans. Studies were excluded if they were 1) Non-surgical studies (review articles, technique articles, commentary) and case reports, 2) Studies without separate outcomes for chronic subdural hematoma drainage under local anesthesia. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to systematically screen studies. Two reviewers independently screened abstracts of the studies identified through the literature search. Relevant articles were retrieved and rescreened for eligibility based on the full-text articles. Any disagreements were resolved through discussion with a third reviewer. Data was extracted in duplicate by two reviewers. Disagreements were resolved through a third reviewer. Results Our literature search identified 521 studies, out of which 20 were included. There were a total of 1750 patients who underwent chronic subdural hematoma drainage under LA. The weighted mean age of the patient was 71.0 years, and 449 (27.1%) of the patients were female. The overall complication rate was significantly lower in the LA group (odds ratio 0.44, 95% CI = 0.26 to 0.77, p = 0.004). The revision rate (odds ratio 2.71, 95% CI 0.89 to 8.25, p = 0.08) and mortality rate were not significantly different between groups (odds ratio 1.23, 95% CI 0.63 to 2.43, p = 0.55). The mean operative time was significantly shorter in the LA group (mean difference -29.28 minutes, 95% CI = -41.43 to -17.13 minutes, p <0.0001). The length of admission was also shorter in the LA group (mean difference -1.58 days, 95% CI = -2.40 to -0.76 days, p = 0.0002). Sample Abstract Template Discussion In the present meta-analysis, it is clearly shown that LA does show benefits in lower operative time, shorter admission length, and fewer postoperative complications. This makes local anesthesia a less invasive and potentially superior alternative to general anesthesia as cSDH affects mainly the elderly, a more vulnerable population, in whom the risk of general anesthesia is not insignificant.
Audience Take Away
• Guide for anesthesiologists and surgeons on cSDH burr-hole drainage anesthetics
• The evaluation of LA versus GA for neurosurgical procedures
• Aiding the physician in deciding what is best for their patient