Clinical Studies Examining Intrathecal Drainage for Acute Traumatic Spinal Cord Injury: A Living Systematic Review

Traumatic spinal cord injury (TSCI) can cause significant and permanent disability. For over 20 years, lumbar cerebrospinal fluid (CSF) drainage has been routinely performed during the surgical repair of thoracoabdominal aortic aneurysms and descending thoracic aortic aneurysms. However, intrathecal CSF drainage has not been adequately evaluated in the setting of acute TSCI. This living systematic review sought to evaluate whether intrathecal catheter CSF drainage to reduce intrathecal pressure (ITP) in the acute postinjury phase was safe and feasible and could improve clinical indices and neurological recovery in patients with acute TSCI. A literature search of PubMed/MEDLINE, Ovid Medline, CINAHL, and Cochrane Database of Systematic Reviews from database inception to March 2024 yielded 1007 potentially relevant articles, 806 were excluded based on title and abstract search and 147 articles underwent full article review. There were two randomized controlled studies, and one cohort study included in the review. Sample sizes ranged from 11 to 22 patients with an age range of 23-67 years. Drains were placed at different times postinjury in each study, with a range of 10-72 h. In the first study, open CSF drainage was used to decrease ITP to 10 mmHg (limit of 10 mL/h). The second study used periodic drainage with up to 10 mL of CSF drained each time (maximum of 30 mL/day). The third study used an open, less restrictive CSF drainage with a target ITP of <10 mmHg. Mean arterial blood pressure and spinal cord perfusion pressure were measured in all three studies. One study evaluated direct intraspinal pressure monitoring. Despite small sample sizes, the three studies demonstrated that intrathecal CSF drainage through a lumbar catheter was feasible and safe acutely after TSCI. Additionally, the results suggest an overall improvement in spinal cord perfusion acutely and trends toward improvements in neurological recovery. There is an important need for much larger prospective trials to evaluate CSF drainage together with other treatment and monitoring strategies to optimize care and improve outcomes. Innovative clinical trial designs could more efficiently evaluate multimodal treatments.