The use of lumbar drains in preventing spinal cord injury following thoracoabdominal aortic aneurysm repair: an updated systematic review and meta-analysis

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Paraplegia and paraparesis following aortic aneurysm repair occur at a substantially high rate and are often catastrophic to patients, their families, and the overall health care system. Spinal cord injury (SCI) following open thoracoabdominal aortic aneurysm (TAAA) repair is reported to be as high as 20% in historical controls. The goal of this study was to determine the impact of CSF drainage (CSFD) on SCI following TAAA repair.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>In August 2015 a systematic literature search was performed using <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="clinicaltrials.gov" xlink:type="simple">clinicaltrials.gov</jats:ext-link>, the Cochrane Library, PubMed/MEDLINE, and Scopus that identified 3478 articles. Of these articles, 10 met inclusion criteria. Random and fixed-effect meta-analyses were performed using both pooled and subset analyses based on study type.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>The meta-analysis demonstrated that CSFD decreased SCI by nearly half (relative risk 0.42, 95% confidence interval 0.25–0.70; p = 0.0009) in the pooled analysis. This effect remained in the subgroup analysis of early SCI but did not remain significant in late SCI.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>This meta-analysis showed that CSFD could be an effective strategy in preventing SCI following aortic aneurysm repair. Care should be taken to prevent complications related to overdrainage. No firm conclusions can be drawn about the newer endovascular procedures at the current time.</jats:p></jats:sec>

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

“…125 To date, evidence is insufficient for a recommendation to use prophylactic MEP and/or cerebrospinal fluid (CSF) pressure monitoring and drainage in aortic arch repair with the use of FET. 125,126 However, the use of lumbar CSF pressure monitoring and drainage may be considered based on individualized risk assessment for spinal cord ischaemia. 127,128 In situations of delayed SCI, selective secondary insertion of drainage as part of a treatment bundle is recommended.…”

“…127,128 In situations of delayed SCI, selective secondary insertion of drainage as part of a treatment bundle is recommended. 126,129 As imaging is still not able to provide us with a detailed description of intraspinal collateralization, which might be the answer to who is at increased risk for SCI, risk prediction models remain approximations, e.g. the collateral network concept and, developed on that basis, the 4-territory concept.…”

Spinal cord injury after thoracic endovascular aortic aneurysm repair

“…7 In 2015, the European Association for Cardiothoracic Surgery similarly recommended CSF drainage for TAAA repair for patients at high risk for SCI. 8 Although randomized controlled studies showed benefit for CSF drainage in open TAAA repair, 9 its routine use in TEVAR procedures remains uncertain and a topic of considerable debate . 8, 10, 11 …”

Education on Management of Cerebrospinal Fluid Drainage: What Does Really Matter?

“…4 A recent systematic review found that CSF drainage decreased early SCI by nearly half; however, these findings were not consistent in delayed or late SCI. 5 At present, no firm conclusions can be drawn with regard to the role of CSF drainage in endovascular aortic procedures. The potential benefits of CSF drainage also need to be considered in the context of tangible complications associated with this intervention.…”

“…The potential benefits of CSF drainage also need to be considered in the context of tangible complications associated with this intervention. 5 Recently, Rong et al 6 reported that CSF drainageÀrelated complications occur in 6.5% of patients. The most common adverse events included bloody CSF, headache, and subarachnoid hemorrhage.…”