Is a Jackson Pratt (JP) drain indicated for managing subdural hematoma?

Jackson Pratt Drain for Subdural Hematoma Management

Jackson Pratt (JP) drains are not specifically indicated as first-line management for subdural hematomas according to current guidelines, with burr hole evacuation with subperiosteal or subgaleal drainage systems being preferred approaches. 1, 2

Recommended Surgical Approaches for Subdural Hematoma

Primary Surgical Options

• Burr hole trepanation with drainage system placement is the standard approach for symptomatic chronic subdural hematomas 2
• Two main drainage placement options:

  1. Subperiosteal drainage system (extracranial) with double burr hole trepanation

     • Shows low recurrence rate (13.1%)
     • Lower risk of postoperative seizures (6.6%)
     • Reduced risk of intracranial infection spread 2

  2. Subgaleal suction drainage (Jackson Pratt drain placed in subgaleal space)

     • Allows continuous drainage through a single burr hole
     • Shows comparable recurrence rates (7.6%)
     • Relatively less invasive 3

Considerations for Drain Selection

The choice between drainage systems should be based on:

• Patient-specific factors:

  • Severity of neurological deficit
  • Risk of recurrence
  • Presence of preoperative risk factors (e.g., coagulopathy)

• Technical considerations:

  • For JP drains specifically, the "curtain-fall" technique can be used to prevent CSF leakage after drain removal 4
  • This technique involves harvesting periosteum during surgery and fixing it with sutures to cover the dural hole upon drain removal

Monitoring Recommendations After Subdural Hematoma Evacuation

For patients with risk factors, ICP monitoring is suggested after evacuation of subdural hematoma if any of these criteria are present 1:

• Preoperative GCS motor response ≤5
• Preoperative anisocoria or bilateral mydriasis
• Preoperative hemodynamic instability
• Severe imaging findings (compressed cisterns, midline shift >5mm)
• Intraoperative cerebral edema
• New postoperative intracranial lesions

Potential Complications of Drainage Systems

Caution with CSF Drainage

• Excessive CSF drainage can lead to serious complications:
  • Subdural hematoma formation (when used for spinal drainage)
  • Significant mortality risk (50% in one study) 5
  • Volume of CSF drained correlates with complication risk

Other Complications

• Infection (1.6% with subperiosteal systems) 2
• Seizures
• Recurrence requiring reoperation (8-13%) 2, 3

Alternative Approaches

For high-risk or emergency cases, minimally invasive options include:

• Subdural evacuating port system (SEPS) which can be performed at bedside in emergency settings 6
• This may be particularly useful in settings with limited neurosurgical coverage

The management of subdural hematomas requires careful consideration of surgical approach and drainage technique based on patient characteristics and clinical presentation, with burr hole evacuation and appropriate drainage being the mainstay of treatment.