Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery.
BACKGROUND
During aortic aneurysm surgery, cross-clamping can lead to inadequate blood supply to the spinal cord resulting in neurological deficit. Cerebrospinal fluid drainage (CSFD) may increase the perfusion pressure to the spinal cord and hence reduce the risk of ischaemic spinal cord injury.


OBJECTIVE
To determine the effect of CSFD during thoracic and thoracoabdominal aortic aneurysm (TAAA) surgery on the risk of developing spinal cord injury.


METHODS
For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 31 2012) and CENTRAL (2012, Issue 5) for publications describing randomised controlled trials of cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Reference lists of relevant articles were checked.


METHODS
Randomised trials involving CSFD during thoracic and TAAA surgery.


METHODS
Both authors assessed the quality of trials independently. SNK extracted data and GS verified the data.


RESULTS
Three trials with a total of 287 participants operated on for Type I or II TAAA were included.In the first trial of 98 participants, neurological deficits in the lower extremities occurred in 14 (30%) of CSFD group and 17 (33%) controls. The deficit was observed within 24 hours of the operation in 21 (68%), and from three to 22 days in 10 (32%) participants. CSFD did not have a significant benefit in preventing ischaemic injury to the spinal cord.The second trial of 33 participants used a combination of CSFD and intrathecal papaverine. It showed a statistically significant reduction in the rate of postoperative neurological deficit (P = 0.039), compared to controls. Analysis was undertaken after only one third of the estimated sample size had entered the trial.In the third trial TAAA repair was performed on 145 participants. CSFD was initiated during the operation and continued for 48 hours after surgery. Paraplegia or paraparesis occurred in 9 of 74 participants (12.2%) in the control group versus 2 of 82 participants (2.7%) receiving CSFD (P = 0.03). Overall, CSFD resulted in an 80% reduction in the relative risk of postoperative deficits. Meta-analysis showed an odds ratio (OR) of 0.48 (95 % confidence interval (CI) 0.25 to 0.92). For CSFD-only trials, OR was 0.57 (95% CI 0.28 to 1.17) and for intention-to-treat analysis in CSFD-only studies, the OR remained unchanged.


CONCLUSIONS
There are limited data supporting the role of CSFD in thoracic and thoracoabdominal aneurysm surgery for prevention of neurological injury. Further clinical and experimental studies are indicated.
Quaid-i-Azam International Hospital, Rawalpindi, Pakistan. shaukat777@yahoo.com
Shaukat Nawaz
SN
Khan
Gerard
G
Stansby
D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D002555:Cerebrospinal Fluid; D015170:Cerebrospinal Fluid Pressure; D004322:Drainage / Q000379:methods*; D006801:Humans; D007511:Ischemia / Q000150:complications / Q000517:prevention & control*; D010208:Papaverine / Q000008:administration & dosage; D020335:Paraparesis / Q000209:etiology; D010264:Paraplegia / Q000209:etiology; D011183:Postoperative Complications / Q000209:etiology; D013116:Spinal Cord / Q000098:blood supply*; D014665:Vasodilator Agents / Q000008:administration & dosage
D014665:Vasodilator Agents; D010208:Papaverine