External lumbar cerebrospinal fluid drainage for cerebrospinal fluid fistula [Neurosurgery Wiki]

This page is read only. You can view the source, but not change it. Ask your administrator if you think this is wrong.
====== External lumbar cerebrospinal fluid drainage for cerebrospinal fluid fistula ======

A [[external lumbar cerebrospinal fluid drainage]] is a convenient and economical method of managing the problem initially failing which more invasive methods like re-exploration may be employed
((Balasubramaniam C, Rao SM, Subramaniam K. Management of Cerebrospinal fluid fistula following
spinal surgery. Childs Nerv Syst. 2014 Sep;30(9):1543-7. doi:
10.1007/s00381-014-2496-2. Epub 2014 Jul 20. PubMed PMID: 25038841.
)).

via percutaneous catheter. Two (of many) management options:

● keep HOB elevated 10–15° and place drip chamber at shoulder level (lower the chamber if leak persists) and leave open to drain (uses pressure to regulate drainage—may be dangerous e.g. if drainage bag falls to floor)

● allow 15–20 cc to drain, then clamp tubing. Repeat q 1 hour

c) CLD may require ICU monitoring. If the patient deteriorates with the drain in place: immediately stop
drainage, place patient flat in bed (or slight Trendelenburg), start 100% O2, get CT or bedside
cross-table skull X-ray (to R/O tension pneumocephalus due to drawing in of air)

----
Ninety-six procedures on 60 consecutive patients performed July 2008 to December 2013 were evaluated. The patients were referred for the fluoroscopy-guided procedure due to failed attempts at a bedside approach, a history of lumbar surgery, difficulty cooperating, or obesity. Fluoroscopy-guided lumbar drainage procedures were performed in the lateral decubitus position with a midline puncture of L3/4 in the interspinous space. The catheter tip was positioned at the T12/L1 level, and the catheter was visualized on contrast agent-aided fluoroscopy. A standard angiography system with a rotatable C-arm was used. The definitions of technical success, clinical success, and complications were defined prior to the study.

The technical and clinical success rates were 99.0% (95/96) and 89.6% (86/96), respectively. The mean hospital stay for an External lumbar cerebrospinal fluid drainage was 4.84 days. Nine cases of minor complications and eight major complications were observed, including seven cases of meningitis, and one retained catheter requiring surgical removal.

Fluoroscopy-guided External lumbar cerebrospinal fluid drainage is a technically reliable procedure in difficult patients with failed attempts at a bedside procedure, history of lumbar surgery, difficulties in cooperation, or obesity
((Chee CG, Lee GY, Lee JW, Lee E, Kang HS. Fluoroscopy-Guided lumbar drainage of
Cerebrospinal Fluid for Patients in Whom a Blind Beside Approach Is Difficult.
Korean J Radiol. 2015 Jul-Aug;16(4):860-5. doi: 10.3348/kjr.2015.16.4.860. Epub
2015 Jul 1. PubMed PMID: 26175586; PubMed Central PMCID: PMC4499551.
)).
----
Postoperative CSF fistulas were described in 16 of 198 patients (8%) who underwent spine surgery between 2009 and 2010 in the Department of Oncologic and Degenerative Spine Surgery Rizzoli Orthopedic Institute, Bologna,  Department of Neurosurgery Bellaria‑Maggiore Hospital, [[Bologna]], Orthopedics and Traumatology Division Reggio Emilia Hospital, Reggio Emilia, Italy.

The choice of the therapeutic strategy was based on the clinical condition of the patients, taking into account the possibility to maintain the prone position continuously and the risk of morbidity due to prolonged bed rest. Six patients were treated conservatively (position prone for three weeks), ten patients were treated by positioning an external CSF lumbar drainage for ten days. The mean follow-up period was ten months.

All patients healed their wound properly and no adverse events were recorded. Patients treated conservatively were cured in a mean period of 30 days, while patients treated with CSF drainage were cured in a mean period of 10 days.

lumbar drainage seems to be effective and safe both in preventing CSF fistula in cases of large dural tears and debilitated/irradiated patients and in treating Cerebrospinal fluid fistulas
((Barbanti Bròdano G, Serchi E, Babbi L, Terzi S, Corghi A, Gasbarrini A,
Bandiera S, Griffoni C, Colangeli S, Ghermandi R, Boriani S. Is lumbar drainage
of postoperative cerebrospinal fluid fistula after spine surgery effective? J
Neurosurg Sci. 2014 Mar;58(1):23-7. PubMed PMID: 24614789.
)).
----
While most Cerebrospinal fluid fistulas will cease without treatment, patients with persistent Cerebrospinal fluid fistulas may be at increased risk for meningitis, and many will require surgical intervention. 

In 51 patients treated between 1984 and 1998, with Cerebrospinal fluid fistulas that persisted for 24 hours or longer after head trauma. Twenty-eight patients (53%) had spontaneous resolution of the leakage at an average of 5 days. Twenty-three patients (47%) required surgery. Eight patients (16%) had occult leaks presenting with recurrent meningitis at an average of 6.5 years posttrauma. Forty-three (84%) patients with Cerebrospinal fluid fistulas had an associated skull fracture, most commonly involving the frontal sinus, while only 18 patients (35%) had parenchymal brain injury or extra-axial hematoma. Eight patients (16%) had delayed leaks at an average of 13 days posttrauma. Among patients with clinically evident Cerebrospinal fluid fistula the frequency of meningitis was 10% with antibiotic prophylaxis, and 21% without antibiotic prophylaxis. Thus, prophylactic antibiotic administration halved risk of meningitis. A variety of surgical approaches was used, with minimal morbidity. Three of 23 surgically treated patients (13%) required additional surgery for continued leakage. Patients with Cerebrospinal fluid fistulas that persist greater than 24 hours are at risk for meningitis, and many will require surgical intervention. Prophylactic antibiotics may be effective and should be considered in this group of patients. Patients with skull fractures involving the skull base or frontal sinus should be followed for delayed leakage. Surgical outcome is excellent
((Friedman JA, Ebersold MJ, Quast LM. Post-traumatic cerebrospinal fluid
leakage. World J Surg. 2001 Aug;25(8):1062-6. PubMed PMID: 11571972.)).

====== After extended endoscopic transsphenoidal approach ======

There is a paucity of high quality [[evidence]] regarding the routine placement of [[external lumbar cerebrospinal fluid drainage]] (LD) in reducing post-operative (op) [[Cerebrospinal fluid fistula]] after [[extended endoscopic transsphenoidal approach]] for anterior skull base lesions. In a study, Huo et al. sought to compare the incidence of post-op [[cerebrospinal fluid fistula]] between patients with upfront LD insertion and those without it. This was a prospective randomized controlled trial conducted over a period of 5 years with patients undergoing extended endoscopic trans-sphenoidal surgery randomly assigned to either LD insertion at the time of surgery, or no LD placement. Thirty-eight patients with anterior skull base tumors were accrued from three tertiary hospitals of [[Melbourne]]. Post-op leak was confirmed by [[Beta-2 transferrin]]-positive rhinorrhea, and/or worsening [[pneumocephalus]] on brain imaging. Skull base defect size and pedicled nasoseptal flap viability were assessed on post-op CT and MRI, respectively. There was no significant difference in post-op Cerebrospinal fluid fistula incidence between the two subgroups (12.50% in LD arm vs. 9.10% in no LD arm). Patients with [[external lumbar cerebrospinal fluid drainage]] insertion however, demonstrated substantially raised complication rates, longer hospital lengths of stay and lower subjective quality of life measures at 12 months compared with those without LD. In conclusion, routine placement of LD at the time of surgery for extended anterior skull base trans-nasal approach did not reduce the risk of post-op Cerebrospinal fluid fistula. Discretion is warranted when using [[external lumbar cerebrospinal fluid drainage]] as an adjunct due to its associated morbidities, prolonged hospital stay and adverse effect on patients' subjective outcome measures
((Huo CW, King J, Goldschlager T, Dixon B, Chen Zhao Y, Uren B, Wang YY. The effects of cerebrospinal fluid (CSF) diversion on post-operative Cerebrospinal fluid fistula following extended endoscopic anterior skull base surgery. J Clin Neurosci. 2022 Feb 18;98:194-202. doi: 10.1016/j.jocn.2022.02.006. Epub ahead of print. PMID: 35189544.)).
----
Lumbar drainage seems to be effective and safe both in preventing CSF fistula in cases of large dural tears and debilitated/irradiated patients and in treating CSF leaks
((Barbanti Bròdano G, Serchi E, Babbi L, Terzi S, Corghi A, Gasbarrini A, Bandiera S, Griffoni C, Colangeli S, Ghermandi R, Boriani S. Is lumbar drainage of postoperative cerebrospinal fluid fistula after spine surgery effective? J Neurosurg Sci. 2014 Mar;58(1):23-7. PMID: 24614789.)).