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Postural stability in patients with chronic subdural hematoma

  • Clinical Article - Brain Injury
  • Published:
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Abstract

Background

Gait disturbances and falls are common in patients with chronic subdural hematoma (cSDH). Postural stability is mainly visually assessed and has not been described using an objective and quantitative measurement tool. The objective of this prospective study was to evaluate postural stability in cSDH patients by measuring trunk sway during stance and gait compared to healthy elderly (HE). It was also to evaluate the relationships among postural stability and age, hematoma size, brain midline shift and hematoma location.

Methods

Using a gyroscopic method, trunk sway was measured in 22 cSDH patients preoperatively, 5 postoperatively and 58 HE during seven standing and walking tasks. Trunk sway amplitude and velocity in the anterior-posterior and medial-lateral directions were assessed.

Results

Postural stability was reduced in the cSDH group compared to HE for all standing tasks. During gait, the sway angle was increased while velocity was decreased in the cSDH group. Only 18 % of the patients could perform all tasks without losing their balance. Postoperatively, postural stability was normalized in the medial-lateral direction during standing. There were no correlations among age, hematoma size, brain midline shift or location of the hematoma and trunk sway.

Conclusions

The majority of cSDH patients had reduced postural stability that was partly reversed soon after surgery. It was not correlated to hematoma characteristics, indicating that an increased risk to fall is present regardless of hematoma size and midline shift. This must be accounted for when handling these patients and measures taken to prevent further fall accidents during hospital stays.

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Acknowledgments

We thank Dr. Izabella Rusnak for help with the study. The financial support from the Faculty of Medicine, Umeå University, and the Västerbotten County Council (ALF) is acknowledged.

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Authors and Affiliations

  1. Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden

    Nina Sundström

  2. Department of Neurosurgery, Division of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden

    Linda Djerf, Zandra Olivecrona & Lars-Owe D. Koskinen

Authors
  1. Nina Sundström
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  2. Linda Djerf
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  3. Zandra Olivecrona
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  4. Lars-Owe D. Koskinen
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Corresponding author

Correspondence to Nina Sundström.

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Conflict of interest

None

Funding

This study was not sponsored by any corporate or governmental funding.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All aspects of the study were approved by the internal review board at Umeå University (dnr 2010-377-31 M, 2013-44-32 M). After receiving written as well as oral information, all participants provided signed consent prior to testing.

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Comments

An interesting and concise study that uses a gyroscopic method to assess for poor stability as per seven parameters in a cohort of patients with chronic subdural hematoma (CSDH) vs. a normal group.

It is not necessarily surprising that the CSDH cohort had poor stability, yet this method could provide a quantifiable means of assessment. While well written, the manuscript’s main weakness is the fact that only 5 out of the 22 CSDH patients were assessed postoperatively.

Andreas K. Demetriades

Edinburgh, UK

Sundström et al. report the occurrence of postural instability in up to 82 % of patients in a case series of 22 patients with a chronic subdural hematoma (cSDH). A novel feature of this study is that postural instability was objectively evaluated and quantified using the commercially available Sway Star™ system. The degree of trunk sway and sway velocity was quantified. Measurements were performed during walking and on standing with feet together and eyes closed, both on a hard floor and on foam rubber. This combination of tests ensured capture of both more severe and milder forms of postural instability.

Although the case series is limited in number, this study is important in raising awareness for the high occurrence of postural instability and consequent risk for falls in patients with a cSDH.

A major question is whether this objective assessment permits detection of subclinical forms of postural instability not detected on routine clinical examination. This issue is not specifically addressed by the authors, but they do report clinical evidence of postural instability in 32 % of patients and a hemiparesis in 36 %. It would seem that subclinical occurrence of postural instability is not uncommon. A second issue is whether the postural instability improves after treatment. The results reported do not permit any definitive answer to this question. Postoperative testing was only performed in five patients, but a clear selection bias in this small cohort exists as patients discharged early from surgery to referring hospitals (e.g., still requiring clinical care) were excluded. Despite these limitations, this study provides a strong incentive for clinicians and nursing staff to implement fall prevention program measures in patients with a cSDH.

Andrew Maas

Antwerp, Belgium

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Sundström, N., Djerf, L., Olivecrona, Z. et al. Postural stability in patients with chronic subdural hematoma. Acta Neurochir 158, 1479–1485 (2016). https://doi.org/10.1007/s00701-016-2862-9

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  • DOI: https://doi.org/10.1007/s00701-016-2862-9

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