Is it Worthwhile to use Drains in Spine Surgery?

Introduction: With the widespread awareness of morbidity and health care expenditure caused by Surgical Site Infection (SSI) in spine surgeries, a multi-faceted approach involving various peri-operative pharmacological and surgical measures were being ascertained to prevent its occurrence. The use of surgical drain remains as one such surgical measure. The practice was mainly started in spine surgery to prevent the formation of epidural haematoma which could cause neurological deficit by its mass effect on the cord and increasing the tension on the incisions resulting in wound-related complications. Wound drain being a double-edged sword, apart from aiding in SSI prevention, wound drains could cause retrograde infection, increase post-operative blood loss which increases the need for blood transfusion. Hence, we aim to analyse the literature evidence available to support the usage of wound drain in various scenarios of spine surgery and provide an evidence summary on the surgical practice. Materials and Methods:We conducted independent and duplicate electronic database searches adhering to PRISMA guidelines in PubMed, Embase, and Cochrane Library till April 2020. Quality appraisal was done as per Cochrane ROB tool and evidence synthesis was done as per GRADE approach. 5 domains of spine surgery with associated key questions were identified. Evidence tables were generated for each question and critical appraisal done as per the GRADE approach. Results: 23 studies (9-RCTs,4-Prospective studies,10- Retrospective studies) were included. Analysis of studies in cervical spine either by anterior or posterior approach and single/multilevel thoracolumbar spinal surgeries did not show any evidence of reduction in surgical site infection (SSI) or haematoma formation with the use of drain. Deformity correction surgeries and surgeries done for trauma or tumour involving spine also did not find any added benefit from the use of wound drains despite increasing the total blood loss. Conclusion: Evidence from this review suggests that routine use of drain in various domains of spine surgery does not reduce the risk of SSI and their absence did not increase the risk of haematoma formation. The current best evidence is presented with its limitations. High-quality studies to address their use in spine surgeries in cervical, trauma, and tumour domains are required to further strengthen the evidence synthesised from available literature.