OT notes · Neurosurgery

Burr-hole evacuation of chronic subdural haematoma

Usual anaesthesia
General anaesthesia, or local anaesthesia with conscious sedation
Position
Supine, head turned about 30 degrees to the opposite side on a horseshoe or ring, shoulder roll under the same side
Setting
emergency

Operative note template for burr-hole drainage of a chronic subdural haematoma with a subdural drain, with a filled example for a right-sided chronic SDH in an elderly man on aspirin.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • recurrence needing repeat surgery
  • fresh bleeding (subdural, extradural or into the brain)
  • seizures
  • air in the head after surgery (pneumocephalus)
  • wound or drain site infection, CSF leak
  • conversion to a craniotomy
  • neurological worsening or death
  • brain injury from the drain or catheter

Pre-operative details for this operation

  1. SideRightLeftBilateral
  2. GCS before surgeryE, V, M and total, with time
  3. Pupils before surgerysize in mm and reaction, right and left
  4. Focal deficitlimb power, speech
  5. CT findingsdate, density (hypo / iso / mixed), maximum thickness in mm, midline shift in mm, membranes or septations
  6. Anticoagulant / antiplateletdrug, last dose, reversal or platelet transfusion if given
  7. Coagulation and plateletsPT/INR, platelet count
  8. Consentby patient, or by relative if the patient lacks capacity: name, relation, language
  9. Side markedYes

Anaesthesia and position

  1. AnaesthesiaGeneralLocal with conscious sedationlocal: lignocaine 1% with adrenaline 1:100000, volume
  2. Positionsupine, head turned to the opposite side, horseshoe / ring, shoulder roll; neutral head for bilateral
  3. Hairclipped over the affected side

Operative findings

  1. DuraBluish, tenseNormal
  2. Outer membraneNonePresent, opened with bipolar and blade
  3. Haematomacolour, liquid / partly clotted, under pressure or not, estimated volume
  4. SeptationsNonePresent, broken
  5. Communication between burr holesFreeBlocked by membrane
  6. Fresh bleedingNonePresent: source
  7. Brain expansion at the endGoodPartialPoor

Procedure (steps)

  1. Painting and drapingantiseptic used; question-mark incision outlined in case a craniotomy is needed
  2. Incisionsnumber and length; frontal just in front of the coronal suture, parietal over the parietal eminence, midway between midline and superior temporal line
  3. Burr holesnumber, site, diameter, drill used; bone wax
  4. Dura openedbipolar, cruciate with No. 11 blade; which hole first (parietal)
  5. Membrane openedif present: coagulated and incised
  6. Specimen collectedfluid (and membrane) in a trap for pathology or culture
  7. Irrigationlukewarm saline, how (soft rubber catheter / flushing between holes), volume, until clear in all directions
  8. Conversion to craniotomyNot neededDone: reason
  9. Subdural drainPlacedNot placed: brain filled the spacetype and size, entry hole, direction, length in the subdural space
  10. Air removedholes filled with saline, gelatin sponge over the dural openings

Closure, drains and dressing

  1. Galea and subcutaneous layerinverted interrupted braided absorbable, size
  2. SkinStaplesNylon vertical mattress
  3. Drain fixationpurse-string at the exit site, suture size; drain tunnelled or not
  4. Dressingsterile dressing, head wrap

Specimens and implants

  1. Subdural fluid / membraneSent for HPESent for cultureNot sent
  2. ImplantsNone

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Neuro-observationGCS, pupils, limb power; hourly in ICU / HDU while the drain is in
  2. Head positionflat or up to 20 degrees until the drain is out
  3. Drainto gravity, bag level (at or below ear), record output; do not clamp without instruction
  4. Drain removalplanned day (usually within 48 hours); close the site tightly with nylon
  5. Antiepilepticdrug, dose, for 7 days in total
  6. Antibioticcontinue for 24 hours after surgery
  7. Anticoagulant / antiplateletstay off until the residual collection has resolved
  8. CT headafter surgery; repeat about 3 days after drain removal; then at 2-4 weeks and 2-3 months
  9. Sutures or staplesremove at 1-2 weeks

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.P., 72 years, fell at home 5 weeks ago, on aspirin 75 mg daily, now 10 days of headache, confusion and left-sided weakness.

Case details

Date: 18/08/2026. Emergency. OT 3. Start 14:05, end 15:00.

Surgeon: Dr A. (2nd-year resident, MCh Neurosurgery). Assistant: Dr B. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Right frontoparietal chronic subdural haematoma. CT 18/08/2026: hypodense with a few septations, maximum thickness 19 mm, midline shift 9 mm to the left.

GCS at 13:00: E3 V4 M6 = 13. Pupils 3 mm, equal, reacting. Left upper and lower limb power 4/5.

Aspirin last taken 17/08/2026 morning, stopped. INR 1.0, platelets 2.1 lakh/cumm.

Consent: patient confused, so procedure-specific consent taken from the son, Mr. S.P., in Hindi, including recurrence, seizures, bleeding and conversion to craniotomy. Right side marked.

WHO checklist sign in and time out done. IV antibiotic given within 1 hour before incision (drug and dose on the anaesthesia chart). Antiepileptic prophylaxis started (drug and dose on the drug chart).

Anaesthesia and position

General anaesthesia. Supine on a horseshoe, head turned 30 degrees to the left, roll under the right shoulder, back of the table raised slightly.

Right side hair clipped. Painted with povidone-iodine. Reverse question-mark incision outlined. Incision sites infiltrated with lignocaine 1% with adrenaline 1:100000.

Procedure

Two 3 cm incisions midway between the midline and the superior temporal line: frontal just in front of the coronal suture, parietal over the parietal eminence. Pericranium pushed aside.

One burr hole at each site, about 1.5 cm, with a perforator. Bone wax to edges.

Parietal hole opened first. Dura bluish and tense, coagulated with bipolar and opened in a cruciate way with a No. 11 blade.

Findings: dark brown liquid haematoma under pressure, about 120 ml drained. Thin outer membrane at the frontal hole, coagulated and cut. A few septations. Fluid collected in a trap.

Soft rubber catheter passed under vision. Irrigated with lukewarm saline by gravity between the two holes, about 1 L, free communication, until the return was clear in all directions. No fresh bleeding.

Brain expanded partly. Small ventricular-type catheter passed as a subdural drain from the frontal hole towards the parietal hole, seen at the parietal hole.

Holes filled with saline to push out air. Gelatin sponge placed over both dural openings.

Closure

Galea closed with inverted interrupted polyglactin 910 (Vicryl) 3-0. Skin with staples.

Drain exit site closed around the drain with a 2-0 braided purse-string, which also anchors it. Sterile dressing and head wrap.

End of procedure

Blood loss about 50 ml. No complications.

Mop, needle and instrument count correct.

Specimen: subdural fluid sent for culture. No implants.

Extubated in OT. GCS E4 V4 M6 = 14, pupils 3 mm equal reacting. Shifted to neuro-ICU.

Post-op orders

Hourly GCS, pupils and limb power while the drain is in.

Keep flat (0 to 20 degrees) until the drain is out. Drain to gravity at ear level. Record hourly output. Do not clamp.

Antibiotic for 24 hours. Antiepileptic to continue for 7 days in total.

Aspirin to stay stopped until the residual collection has resolved on CT.

CT head tomorrow morning. Plan drain removal within 48 hours, site to be closed tightly with 3-0 nylon.

Repeat CT about 3 days after drain removal. Staples out at 10 days.

Signature

Dr A., MCh resident (year 2), Neurosurgery. Reg. no. ________. 18/08/2026, 15:15.

Must document for this operation

  • Side of the haematoma and the side operated. Operating on the wrong side is wrong-site surgery, and bilateral collections make the side easy to mix up.
  • GCS (Glasgow Coma Scale) and pupils just before surgery, with the time. They are the baseline for judging improvement or a new bleed after surgery, and for audit.
  • Anticoagulant or antiplatelet drug, last dose and any reversal. Anticoagulant use is linked to recurrence, and the ward needs to know that it stays stopped.
  • Character of the fluid and presence of membranes or fresh blood. Thick membranes and septations limit burr-hole drainage, and fresh blood that does not clear is a reason to convert to craniotomy.
  • Whether the holes communicated and the irrigation ran clear. It shows the collection was drained fully, not just tapped at one point.
  • Drain type, route, and how far it lies in the subdural space. The team removing it, and the radiologist reading the CT, need to know what is in the head.
  • Brain expansion and steps to remove air. A large amount of air after evacuation is linked to recurrence, and it explains what the post-op CT shows.

Common mistakes in these notes

  • Not writing the side, or writing only 'CSDH evacuated'.
  • No pre-op GCS and pupil record, or a GCS without the E, V and M parts.
  • Leaving out the anticoagulant or antiplatelet status.
  • Not recording the drain type and where it lies, or leaving out the removal plan.
  • Writing 'irrigated' without saying until clear.
  • Not noting who gave consent when the patient was confused.

Indian practice and paperwork

  • Consent must be in a language the patient or relative understands and taken by the person who will do the operation. The anaesthesia consent is taken by the anaesthetist. (NABH 5th ed., PRE.4(c) and (e), COP.13(d))
  • Write the name of every anaesthetist in the note. A hospital was held negligent when the operation notes did not name the anaesthetist. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • The operative note must be written before the patient leaves recovery, and post-op care follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Ullman JS, Raksin PB, eds. Atlas of Emergency Neurosurgery. Thieme; 2015, Ch 2, Chronic subdural hematomas (Skovrlj B, Rasouli J, Levy AS, Raksin PB, Ullman JS), pp. 16-30.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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