Intraoperative Lumbar Drain Placement in Endoscopic Neurosurgical Procedures: Technical Challenges and Complications—A Prospective Observational Study
Background Perioperative placement of lumbar drain (LD) is being increasingly preferred in the endoscopic base of skull procedures to provide optimal surgical conditions. This study aims to determine the incidence of technical difficulties and complications associated with LD placement.
Materials and Methods A total of 50 patients undergoing transnasal transsphenoidal surgery were included in the study after obtaining written informed consent. Intraoperatively, LD was placed using an 18-gauge epidural catheter. Technical difficulties in LD placement were assessed by the number of attempts, levels attempted, difficulty in siting catheter, and obtaining free flow of cerebrospinal fluid (CSF). The incidence of complications such as postdural puncture headache (PDPH), meningitis headache, and backache was studied.
Results Successful LD placement in the first attempt was obtained in 36% of the patients. Technical difficulties were encountered in 64% of the patients. Despite successful LD placement in 90% of the patients, 32% required manipulations to increase CSF flow. The drain failure rate was 10%. Drainage of >20 to 30 mL of CSF/hour was significantly associated with better surgical conditions (p < 0.05). The incidence of headache was 56% and that of backache was 26%. Headache was significantly related to difficulty in tapping CSF (p = 0.032), and backache was significantly related to the number of attempts (p < 0.001), levels attempted (p = 0.001), and large CSF volume (p = 0.004). There were no incidences of PDPH or meningitis in our series.
Conclusion We conclude that the incidence of technical difficulties in LD placement with epidural catheters is high. Use of standard well-functioning LD catheters will assist in improving surgical conditions.
Keywordslumbar drain - epidural catheter - endoscopic surgery - transnasal transsphenoidal surgery - technical difficulties - complications
30 June 2020 (online)
Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India
- 1 Mehta GU, Oldfield EH. Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg 2012; 116 (06) 1299-1303
- 2 Caggiano C, Penn DL, Laws Jr ER. The role of the lumbar drain in endoscopic endonasal skull base surgery: a retrospective analysis of 811 cases. World Neurosurg 2018; 117: e575-e579
- 3 Jung H, Shah A, Ajlan A. Perioperative cerebrospinal fluid diversion utilizing lumbar drains in transsphenoidal surgery. Neurosciences (Riyadh) 2018; 23 (01) 46-51
- 4 Governale LS, Fein N, Logsdon J, Black PM. Techniques and complications of external lumbar drainage for normal pressure hydrocephalus. Neurosurgery 2008; 63 (04) (Suppl. 02) 379-384
- 5 Açikbaş SC, Akyüz M, Kazan S, Tuncer R. Complications of closed continuous lumbar drainage of cerebrospinal fluid. Acta Neurochir (Wien) 2002; 144 (05) 475-480
- 6 Stokken J, Recinos PF, Woodard T, Sindwani R. The utility of lumbar drains in modern endoscopic skull base surgery. Curr Opin Otolaryngol Head Neck Surg 2015; 23 (01) 78-82
- 7 Hagel S, Bruns T, Pletz MW, Engel C, Kalff R, Ewald C. External ventricular drain infections: risk factors and outcome. Interdiscip Perspect Infect Dis 2014; 2014: 708531
- 8 Qureshi AI, Khan AA, Malik AA. et al. Lumbar catheter placement using paramedian approach under fluoroscopic guidance. J Vasc Interv Neurol 2016; 8 (05) 55-62
- 9 Ransom ER, Chiu AG. Prevention and management of complications in intracranial endoscopic skull base surgery. Otolaryngol Clin North Am 2010; 43 (04) 875-895
- 10 DePuy Synthes. Lumbar External Drainage System. Available at: https://www.depuysynthes.com/hcp/codman-neuro/products/qs/LumbarExternal-Drainage-System. Accessed May 26. 2020
- 11 Wynn MM, Mell MW, Tefera G, Hoch JR, Acher CW. Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008. J Vasc Surg 2009; 49 (01) 29-34
- 12 Shapiro SA, Scully T. Closed continuous drainage of cerebrospinal fluid via a lumbar subarachnoid catheter for treatment or prevention of cranial/spinal cerebrospinal fluid fistula. Neurosurgery 1992; 30 (02) 241-245
- 13 VIVO. Prolonged lumbar spinal drainage after the resection of tumors of the skull base: a cautionary note. Available at: http://vivo.med.cornell.edu/display/pubid0025803759. Accessed May 26. 2020
- 14 Graf CJ, Gross CE, Beck DW. Complications of spinal drainage in the management of cerebrospinal fluid fistula. J Neurosurg 1981; 54 (03) 392-395
- 15 Kitchel SH, Eismont FJ, Green BA. Closed subarachnoid drainage for management of cerebrospinal fluid leak after an operation on the spine. J Bone Joint Surg Am 1989; 71: 984-987
- 16 Youngblood SC, Tolpin DA, LeMaire SA, Coselli JS, Lee VV, Cooper Jr JR. Complications of cerebrospinal fluid drainage after thoracic aortic surgery: a review of 504 patients over 5 years. J Thorac Cardiovasc Surg 2013; 146 (01) 166-171