Is There Still a Role for Twist Drill Craniostomy in Contemporary Management of Chronic Subdural Hematoma?

Background/Objectives: Chronic subdural hematoma (cSDH) is an increasingly prevalent neurosurgical condition in the aging population. Burr hole craniotomy (BHC) with irrigation and postoperative drainage represents the evidence-based standard of care, yet recurrence rates remain substantial. Twist drill craniostomy (TDC), a minimally invasive bedside procedure performed under local anesthesia, offers theoretical advantages for frail patients but has been largely abandoned due to concerns regarding incomplete evacuation and recurrence. This study aimed to identify the predictors of a successful TDC outcome and to compare the recurrence rates between TDC and BHC. Methods: We performed a retrospective cohort study of consecutive patients undergoing surgical treatment for radiologically confirmed cSDH at RWTH Aachen University Hospital between 2015 and 2023. Hematoma morphology was classified using an extended CT-based architecture system and grouped into homogeneous, organized, sedimented, or subacute categories. The primary endpoint was recurrence requiring surgical reintervention. Multivariable logistic regression was used to identify independent predictors of recurrence among patients discharged after definitive TDC. Propensity score matching was performed to compare recurrence rates between TDC and BHC while adjusting for baseline demographic, clinical, and radiographic differences. Results: Among 178 patients initially treated with TDC, 56 (31.5%) were discharged without conversion to BHC. Late recurrence occurred in 26 of 56 patients (46.4%) treated definitively with TDC. In multivariable analysis, homogeneous hematoma architecture was the only independent predictor of recurrence (adjusted OR 4.48, 95% CI 1.10-22.07, p = 0.037). Propensity score matching yielded 48 well-balanced pairs of TDC and BHC patients. Recurrence rates remained significantly higher after TDC compared with BHC (42.6% vs. 17.0%, p = 0.012), as confirmed by conditional logistic regression (adjusted OR 3.20, 95% CI 1.17-8.73). Conclusions: Twist drill craniostomy may provide definitive treatment in carefully selected patients but is associated with substantially higher recurrence rates than burr hole craniotomy, particularly in homogeneous hematomas. Burr hole evacuation remains the preferred standard approach, while optimized drainage protocols and architecture-guided selection may define a limited role for TDC in high-risk patients.