Cerebrospinal Fluid Drainage in Patients with Acute Spinal Cord Injury: A Multi-Center Randomized Controlled Trial

OBJECTIVE: The secondary phase of spinal cord injury (SCI) is characterized by ischemic injury. Spinal cord perfusion pressure (SCPP), calculated as the difference between mean arterial pressure (MAP) and intrathecal pressure (ITP), has arisen as a therapeutic target for improving outcomes. Cerebrospinal fluid drainage (CSFD) may reduce ITP and thereby increase SCPP. Randomized controlled trial to evaluate the safety and feasibility of CSFD to improve SCPP and outcomes after acute SCI.METHODS: Inclusion criteria included acute cervical SCI within 24 hours of presentation. All patients received lumbar drain placement and appropriate decompressive surgery. Patients randomized to the control group received MAP elevation only. Patients in the experimental group received MAP elevation and CSFD to achieve ITP <10 mmHg for 5 days. ITP and MAP were recorded hourly. Adverse events were documented and patients underwent functional assessments at enrollment, 72 hours, 90 days, and 180 days post-injury.RESULTS: Eleven patients were enrolled; 4 were randomized to receive CSFD. CSFD patients had a mean ITP of 5.3 +/- 2.5 mmHg versus. 15 +/- 3.0 mmHg in the control group. SCPP improved significantly, from 77 +/- 4.5 mmHg in the control group to 101 +/- 6.3 mmHg in the CSFD group (P < 0.01). Total motor scores improved by 15 +/- 8.4 and 57 +/- 24 points in the control and CSFD groups, respectively, over 180 days. No adverse events were attributable to CSFD.CONCLUSIONS: CSFD is a safe, effective mechanism for reducing ITP and improving SCPP in the acute period post SCI. The favorable safety profile and preliminary efficacy should help drive recruitment in future studies.