Craniotomy improves outcomes for cranial subdural empyemas: Computed tomography-era experience with 699 patients

OBJECTIVE: Uncertainty regarding the best surgical management for subdural empyemas (SDEs) continues. Our unit has considered craniotomy the preferred method of surgical drainage for all cranial SDEs since 1988. We performed an analysis of our previously published, computed tomography-era, experienc e with 699 patients. METHODS: Two analyses of the database (1983-1997) were performed. First, an alysis of the periods from 1983 to 1987 and from 1988 to 1997 was performed . Second, analysis of the composite database was performed. Outcomes were c ompared for possible outcome predictors by univariate analysis. Multivariat e analysis was used to identify variables that contributed independently to outcomes, using stepwise discriminant analysis. RESULTS: Significant correlations between the analyzed periods with respect to outcome and type of surgery (P = 0.001) were noted. Analysis of the ent ire database (1983-1997) revealed a significant relationship between outcom e and surgery type (P = 0.05). Pairwise comparison of limited procedures su ch as burr holes or craniectomies with wide-exposure surgical procedures su ch as primary craniotomies or procedures proceeding to full craniotomies in dicated significant correlation with outcomes (P = 0.027). Reoperation and morbidity rates were increased with limited procedures. Stepwise discrimina nt analyses revealed that the type of surgery was correlated with outcomes (P = 0.0008, partial r(2) = 0.034). CONCLUSION: Craniotomy was determined to be the surgical procedure of choic e for treatment of cranial SDEs, allowing complete evacuation of the pus an d, more importantly, decompressing the underlying cerebral hemisphere. Limi ted procedures such as burr holes or craniectomies may be performed for pat ients in septic shock, for patients with parafalcine empyemas, or for child ren with SDEs secondary to meningitis.