Controlled lumbar cerebrospinal fluid drainage effectively decreases the need for second and third tier interventions for intracranial hypertension in severe traumatic brain injury patients.

Introduction: Early treatment of elevated intracranial pressure (ICP) is a cornerstone of the therapy in severe traumatic brain injury (TBI) patients. Treatment of refractory high ICP however, remain challenging as only limited and risky third-tier therapeutic interventions are available. Controlled lumbar cerebrospinal fluid (CSF) drainage has been known as an efficient method of ICP reduction after TBI for decades, but it is not recommended in international guidelines because of low evidence background and safety issues. Our centre has a long-standing experience using this intervention for more than 15 years. Here we present our data about the safety and efficacy of controlled lumbar drainage to avoid further second- and third tier ICP lowering therapies and beneficially influence functional outcome.

Methods: Observational (retrospective and prospective) analysis was performed using demographic, clinical and outcome data of severe TBI patients admitted to our centre. Analysis was retrospective between 2008 and 2013 and prospective from 2014 to 2019. Only severe TBI patients (GCS<9) with ICP monitoring were enrolled. Lumbar drainage (LD) was used as a second-tier therapy to control intracranial hypertension in salvageable patients with normal haemostasis and discernible basal cisterns on pre-interventional CT scan.

Results: Data of 45 patients were analysed. Patients were young, comatose and with severe injuries (median age: 29, GMS: 4, ISS: 25). Lumbar drain was inserted mainly on the first week and maintained for further 5 days. Episodes of intracranial hypertension (ICP>20 Hgmm) within one day (10 vs 2) were reduced. The need of additional second- and third-line therapies (deep sedation, hyperventilation, barbiturate administration, decompressive craniectomy) also significantly decreased (60 vs 25 interventions, p<0.001). The in-hospital mortality and 6-month functional outcome were more favourable than the whole TBI population and as predicted by prognostic calculations (mortality: 16% vs. 48 %; GOSE 1-4: 49% vs. 65% vs CRASH: 87% vs. IMPACT: 51 %) in this period.

Conclusions: Our results support the view that controlled lumbar drainage is a highly efficient method to manage intracranial hypertension and significantly decreases the need of further harmful ICP lowering therapies without altering functional outcome of severe TBI patients.