Li et al. Chinese Neurosurgical Journal (2016) 2:14 DOI 10.1186/s41016-016-0033-8 ˖ӧӝߥ͗ᇷፂܰመߥѫ͗ CHINESE NEUROSURGICAL SOCIETY CHINESE MEDICAL ASSOCIATION REVIEW Open Access Some cool considerations of external lumbar drainage during its widespread application in neurosurgical practice: a long way to go Guichen Li1, Yang Zhang2, Jinchuan Zhao2, Zhiguo Han3, Xiaobo Zhu2* and Kun Hou2* Abstract External lumbar drainage (ELD) has gained wide popularity in neurosurgical practice since its’ first introduction by F. Vourc’h in 1963. It manifests encouraging prospects in control of refractory intracranial hypertension, prevention of complications secondary to aneurysmal subarachnoid hemorrhage, prediction of shunt respondency in normal pressure hydrocephalus, management of cerebrospinal fluid (CSF) leakage, and application in bacterial meningitis and ventriculitis. But many questions on the efficacy and safety of ELD are remained to be answered by future studies. CSF overdrainage and ELD-related meningitis are the two most common and fatal complications due to inappropriate usage of ELD. Randomized controlled trials are badly in need to more safely and rationally guide the clinical application of ELD. Keywords: Aneurysmal subarachnoid hemorrhage, Cerebrospinal fluid overdrainage, Complication, Meningitis, External lumbar drainage, Indication, Intracranial hypertension Background also reviewed. Furthermore, a search of ClinicalTrials.- External drainage of cerebrospinal fluid (CSF) from the gov was also conducted for ongoing studies. lumbar cistern via a plastic catheter was primarily ’ described by F. Vourc h in 1963 [1]. Since then, external Main indications lumbar drainage (ELD) of CSF has gained wide popular- Controlling of intracranial hypertension ity in a variety of neurosurgical activities and procedures Since the 1920s, when ELD had not been introduced, e.g. intraoperative cerebral relaxation, drainage of bloody there were some reports of cerebral herniation second- or infectious CSF, control of refractory intracranial ary to lumbar puncture (LP) [11–13]. But most of the hypertension, preoperative evaluation of normal pressure reports of cerebral herniation at that time were those pa- hydrocephalus (NPH), prevention of complications sec- tients harboring intracranial tumors. The forefather of ondary to aneurysmal subarachnoid hemorrhage (aSAH) – modern neurosurgery Harvey Williams Cushing had [2 7]. However, just as each coin has its two sides, issues ever advocated that lumbar drainage of CSF should be concerning the complications and unduly usage of ELD – forbidden in patients with intracranial hypertension has also come [8 10]. In order to further explore the (ICH) for fear of cerebral herniation. And it has been indications, contraindications, complications, recent and even still is treated as a solid doctrine by many developments and future considerations of ELD, we per- neurosurgeons. Since the time when ELD was first intro- formed a comprehensive review of the related studies duced by F. Vourc’h [1], debates on its indications, com- written in English on ELD in PubMed. And related arti- plications, and contraindications have never ended. cles in the reference lists of the identified studies were Many neurosurgeons still considered ELD a contraindica- tion of ICH. Nevertheless, till in the 1990s, ELD was grad- * Correspondence: [email protected]; [email protected] 2 ually and prudently used to control refractory ICH and Department of Neurosurgery, The First Hospital of Jilin University, 3302 Jilin – Road, Changchun 130031, China encouraging results were observed [5, 14 21] (Table 1). In Full list of author information is available at the end of the article 1996 Brain Trauma Foundation recommended a two-tier © 2016 Li et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Li et al. Chinese Neurosurgical Journal (2016) 2:14 Page 2 of 8 Table 1 Some of the studies that focusing on control of refractory ICH with ELD First author Year Type of study No. of patients Age group Outcome Complications during ELD CH Meningitis Baldwin HZ [14] 1991 5 Children Significant decrease in ICP (3) 0 0 Survived (3) GOS ≥4 (2) Levy DI [15] 1995 Retrospective 16 Children Significant decrease in ICP (14) 0 0 Survived (14) GOS ≥4 (11) Willemse RB [16] 1998 Retrospective 7 Adults Significant decrease in ICP (NA) 0 0 Survived (5) GOS ≥4 (3) Münch EC [17] 2001 Prospective 23 Adults Significant decrease in ICP (23) 2 0 Survived (15) GOS ≥4 (10) Murad A (18) 2008 Prospective 8 Adults Significant decrease in ICP (8) 0 0 Survived (NA) GOS ≥4 (NA) Tuettenberg J [5] 2009 Prospective 100 Children and adults Significant decrease in ICP (NA) 12 7 Survived (55) GOS ≥4 (36) Llompart-Pou JA [19] 2011 Retrospective 30 Adults Significant decrease in ICP (NA) 0 1 Survived (23) GOS ≥4 (18) Murad A [20] 2011 Prospective 6 Adults Significant decrease in ICP (NA) 0 0 Survived (4) GOS ≥4 (NA) Murad A [21] 2012 Prospective 15 Adults Significant decrease in ICP (NA) 1 0 Survived (12) GOS ≥4 (NA) NA not applicable, GOS Glasgow Outcome Scale, ICP intracranial pressure, CH cerebral herniation strategy for the management of patients with ICH, which neurosurgeons, cerebral herniation did happen in patients was treated as a standard protocol for control of intracra- with ICH after the application of ELD. The reported nial pressure (ICP) in many centers [20–22]. This strategy incidence of cerebral herniation ranged from 0 to is not only used in patients with traumatic brain injuries 12 % (Table 1). But just as Tuettenberg J and col- (TBI) but also in patients with other intracranial diseases. leagues stated temporary clinical signs of cerebral her- The first-tier measures include osmotic solutions, ven- niation do not lead to lower rates of neurological tricular drainage of CSF, moderate hyperventilation and recovery or a higher mortality rate [5]. the second-tier include decompressive craniectomy, bar- However, the published studies on control of ICH with biturate coma or therapeutic hypothermia. But there were ELD merely include a relative small number of patients usually some cases in which the two-tier strategy was inef- and no prospective randomized controlled trial (RCT) fective or inappropriate. Emerging evidences have demon- has ever been published till now. As was pointed by strated that application of ELD leads to a significant Tuettenberg J et al. that ELD of CSF in patients with decrease in ICP and an increase in cerebral perfusion intracranial hypertension leads to a significant and clin- pressure (CPP) [5, 21]. CPP and ICP have been demon- ically relevant reduction in ICP, however, it remains un- strated to independently affect outcome in patients with clear whether drainage of CSF improves clinical severe brain injury [5, 23–26]. As was worried by some outcome by reducing ICP [5]. This calls for future RCTs. Li et al. Chinese Neurosurgical Journal (2016) 2:14 Page 3 of 8 Aneurysmal subarachnoid hemorrhage Osmotic solution as mannitol or diuretic as furosemide Aneurysmal subarachnoid hemorrhage manifests a chal- would decrease intravascular fluid volume. Sedation and lenge to the public health not only for the risk of fatal barbiturate coma carry the risk of hypotension. Consider- aneurysmal rebleeding but also for the high morbidity ing the side effects of hypovolemia and hypotension, of cerebral vasospasm (CVS), ICH and shunt-dependent which are inconsistent with the 3-H therapy of aSAH, the hydrocephalus. CVS and ICH are two of the most two-tier guideline is not always suitable for ICP control in common complications of aSAH. They might occur in- aSAH patients [20, 21]. Even the two-tier therapy is initi- dependently or reciprocally. Although treatments tar- ated consecutively there still would be some refractory geting at the prevention of CVS as 3-H therapy, cases in whom ICP could not be satisfactorily controlled calcium-channel blocker, arterial papaverine infusion, [5]. However, some reports have demonstrated encour- and angioplasty have been applied in the past decades, aging results of ICP control with the utility of ELD in symptomatic CVS, of which the incidence could be as aSAH patients [5, 20, 21]. The one that should be pointed high as 40 %, is still the main indicator of unfavorable out was conducted by Tuettenberg and colleagues [5]. outcomes [27, 28]. The occurrence of CVS involves This prospective study included 100 patients (45 with TBI, many pathophysiological processes, but there is no 55 with aSAH) and followed a stepwise design according doubt that subarachnoid blood and its degradation to the two-tier therapy before ELD. When the two-tier products contribute mostly. Some Japanese authors therapy was ineffective, ELD was initiated. It demon- have been using CSF drainage in aSAH patients since strated a significant and long-lasting reduction in ICP and the early 1980s, but with conflicting results [29, 30]. an increase in CPP after application of ELD but failed to Klimo P Jr and colleagues showed a marked