Optimization of Spinal Cord Perfusion Pressure for Improvement of Neurological Outcome in Traumatic Spinal Cord Injury: A Systematic Review and Meta-Analysis.

The optimal hemodynamic management of traumatic spinal cord injury (tSCI) is not well established. We performed a systematic review and meta-analysis of patients with acute tSCI to assess the role of lumbar cerebrospinal fluid drainage (CSFD) and to identify factors predictive of neurological improvement. Three studies involving 46 patients with acute tSCI, lumbar drain placement with CSFD, and available pre- and post-intervention American Spinal Injury Association (ASIA) Impairment Scale or International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor scores were identified. One study was analyzed separately (Cohort A) using ASIA grade because post-intervention ISNCSCI motor scores were not reported. In the remaining two studies (Cohort B), two independent meta-analyses with meta-regressions were performed to determine the mean difference in ISNCSCI motor scores by CSFD and time to decompression. Individual patient data were used for all analyses. In Cohort A, there was no significant difference in ASIA grade before lumbar CSFD and at the last follow-up (Wilcoxon signed rank test: p = 0.130). In Cohort B, female sex and anterior decompression were associated with greater neurological recovery compared with male sex (p = 0.045) and a combined approach to decompression (p = 0.048), respectively. There were no other significant indicators of better motor scores in either cohort. CSFD with a target intrathecal pressure, rather than volume restrictions, may allow for sufficient fluid drainage to maximize spinal cord perfusion pressure (SCPP). Patients may benefit most from individualized management of SCPP because of the wide variance in interpatient and chronological intrathecal pressure.