Controlled lumbar drainage in medically refractory increased intracranial pressure. A safe and effective treatment.

BACKGROUND: A prospective study of lumbar CSF drainage in the setting of raised intra-cranial pressure refractory to medical management and ventriculostomy placement is presented. There have been no controlled trials of its use reported in the literature, to the best of our knowledge.
METHOD: An IRB approved prospective study was conducted. 8 patients with increased intracranial pressure secondary to traumatic brain injury or aneurysm rupture were initially managed with sedation, ventriculostomy placement, mild hyperventilation (pCO2 = 30-35), and hyperosmolar therapy (Na = 150-155). A lumbar drain was placed if ICP continued to be above 20 mmHg despite optimization of medical therapy.
FINDINGS: After lumbar drain placement, ICP was reduced from a mean of 27 +/- 7.8 to 9 +/- 6.3, an average decrease of 18 mm H2O (p < 0.05). Requirements for hypertonic saline and/or mannitol boluses and sedation to control ICP were also decreased. There were no complications noted.
CONCLUSIONS: We have shown that controlled lumbar drainage is a safe, efficacious and minimally invasive method for treatment of elevated ICP refractory to medical management. Ventriculostomies are always placed before utilizing lumbar drains to minimize the risk of cerebral herniation. We would advocate making controlled lumbar drainage a standard part of ICP control protocols.