External Lumbar Drainage for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Systematic Review

Abstract

BackgroundExternal lumbar drainage remains a controversial therapy for medically refractory intracranial hypertension in patients with acute TBI. This systematic review sought to compile the available evidence for the efficacy and safety of the use of lumbar drains for ICP control. MethodsA systematic review of the literature was performed with the search and data extraction performed by two reviewers independently in duplicate.ResultsNine independent studies were identified enrolling 230 patients, 159 with TBI. Efficacy for ICP control was observed across all studies, with immediate and sustained effect, reducing medical therapy requirements. Lumbar drainage with medical therapy appears effective when used alone and as an adjunct to ventricular drainage. Safety reporting varied in quality. Cerebral herniation (with unclear relationship to lumbar drainage) was observed in 14/230 patients resulting in one incident of morbidity without adverse patient outcome. ConclusionsThe available data is generally poor in quality and volume, but supportive of efficacy of lumbar drainage for ICP control. Few reports of adverse outcome are suggestive of, but are insufficient to confirm, safety of use in the appropriate patient and clinical setting. Further large prospective observational studies are required to generate sufficient support of an acceptable safety profile.

Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension: A United Kingdom and Ireland Survey on Practice Variation

“…Therefore, the predominant main concerns from non-users are shared by users. This highlights that there are clear circumstances, agreed across respondents, where lumbar drainage is not safe, in keeping with the selection criteria of studies utilising this method in the literature [ 23 - 24 ]. This also highlights prevalent concerns about the safety profile of ELD amongst practitioners.…”

“…The common rationale for using ELD was in patients who had intracranial hypertension but no surgical haematoma in the posterior fossa with no radiological evidence of tonsillar herniation. As identified by systematic reviews in the literature, protocols varied greatly between studies [ 23 - 24 ]. The lack of standard operating procedures or locally accepted policy is unlikely to support clinicians to utilise ELD in circumstances that they may otherwise deem preferable to EVD.…”

“…Our systematic review of the use of ELD in ICP control in TBI found 159 patients across nine studies [ 23 ]. The review identified three studies, which combined TBI and vascular patients, finding that, in total, 159 patients with TBI had been reported in the literature.…”