Conception and design of novel lumbar drain insertion simulator

The effects of cerebrospinal fluid (CSF) diversion on post-operative CSF leak following extended endoscopic anterior skull base surgery

Lumbar drain (LD) insertion is a common cerebrospinal fluid (CSF) diversion method in neurosurgery; however, infection remains a major complication with significant morbidity. We evaluated the incidence, etiology, and associated risk factors of LD infection across 4 neurosurgical units over 15 years. This retrospective multicenter cohort study included all adults requiring a LD between January 2009 and February 2024. Demographic, clinical, and microbiological characteristics were analyzed. LD infections were defined by positive CSF cultures and clinical symptoms. Risk factors were assessed by multivariate logistic regression analysis using IBM SPSS®. A total of 1017 patients required a LD, and the overall infection rate was 11.4% (116 infections). Significant risk factors for LD infection identified by univariate analysis were preoperative use of oral steroids (P < .001), previous CSF drainage (P = .019), LD insertion for 2 or more days (P = .001), out-of-hours surgery (P = .008), and CSF leak at the operation site (P = .007). Conversely, factors reducing the risk of infection were LD insertion during the primary surgery (P = .015) and the reason for insertion (P = .029). Multivariate analysis confirmed increased incidence of LD infection with oral steroid use (P = .01), LD insertion >7 days after the primary surgery (P = .019), no previous CSF drainage (P = .029), LD removal ≥2 days (P = .002), out-of-hours primary surgery (P = .024), CSF leak from the LD puncture site >2 days after LD insertion (P = .074), LD disconnection >3 days postinsertion (P = .028), and bleeding from the LD puncture site >2 days after drain insertion (P = .026). We report a large patient series evaluating the factors associated with LD infections across multiple neurosurgical subspecialties. To reduce infection risk, LDs should be inserted during primary surgery, kept for the shortest duration, and promptly removed if disconnected, avoiding unnecessary sampling.

OBJECTIVESThe infective potential of lumbar drainage is an important topic deserving particular study. The aetiology, incidence, and clinical findings associated with bacterial meningitis are described in patients having continuous lumbar...

Complications associated with lumbar drain placement for endovascular aortic repair

Lumbar drain complications in patients undergoing fenestrated or branched endovascular aortic aneurysm repair: Development of an institutional protocol for lumbar drain management

Background: Lumbar drain (LD) placement can be a difficult procedure leading to postprocedure complications, particularly in patients with persistent cerebrospinal fluid leaks or a large body habitus. The objective of this technical case report is to describe the use of Medtronic’s SureTrak Navigation system for navigated LD placement.Case Description: The patient was an 18-year-old morbidly obese male who initially underwent a suboccipital craniectomy with duraplasty and a C1 laminectomy for Chiari Malformation. Postoperatively, he developed a pseudomeningocele and was taken to the operating room for wound revision, duraplasty repair, and LD placement. Medtronic’s SureTrak Navigation system was used for LD placement before wound revision. Successful LD placement was achieved in a single pass using the SureTrak Navigation. The patient did well postoperatively, and LD removal occurred on postoperative day 6. The patient was discharged in good condition without evidence of a cerebral spinal fluid leak.Conclusion: Navigation using the SureTrak system is a reasonable option to use in patients with a high body mass index and a persistent cerebrospinal fluid leak. When the patient is already undergoing an operative procedure, it can aid in an efficient low-risk intervention completed in a single prone positioning.

The effect of temporary CSF diversion modality on shunt-dependency following aneurysmal subarachnoid hemorrhage: A nationwide assessment.

Complications Associated With Lumbar Drain Placement for Endovascular Aortic Repair

This study assesses the efficacy of preoperative lumbar drain (LD) placement prior to elective open cranial and endoscopic anterior skull base (ASB) surgery in reducing postoperative cerebrospinal fluid (CSF) leak. A retrospective review of 93 patients who underwent LD placement at our institution between 2006 and 2011 was performed. Of these patients, 43 underwent elective LD placement prior to ASB surgery; 2 patients had evidence of CSF rhinorrhea prior to surgery, and 41 had no evidence of a preoperative CSF leak. Of those 41 patients, 2 developed CSF rhinorrhea (2/41= 4.9%) as a result of surgery—all in our endoscopic patient population (N = 21; 2/21= 9.5%). No postoperative CSF leaks were noted in our open ASB surgery cohort (N = 20). Other complications were rare, but we encountered two instances of delayed malignant cerebral edema in the open ASB cohort that are discussed in detail. Overall, preoperative LD placement was found to be an effective means of preventing postoperative CSF leaks after ASB approaches, but potential and significant intracranial complications may occur in select patients that merit careful consideration prior to LD placement.

Lumbar drain (LD) use in the management of cerebrospinal fluid (CSF) rhinorrhea remains controversial. We analyzed the relationship between LD placement and CSF leak recurrence after endoscopic repair. A retrospective case series was conducted. Patients who underwent CSF leak repair from 1999 to 2010 were identified. Data collected included demographics, body mass index (BMI), history of obstructive sleep apnea (OSA) or idiopathic intracranial hypertension (IIH), associated meningoencephalocele, etiology and site of leak, LD placement, fluorescein and antibiotic use, recurrence, and site of recurrence. Correlation between LD placement and leak recurrence was analyzed. A total of 105 patients underwent CSF leak repair. A total of 68 patients had an LD. Of these 68 patients, 15 (22%) had a recurrent leak. Of the 105 patients, 37 did not have an LD, and 5 of the 37 (14%) recurred. Recurrence rates with and without LD were not significantly different (p = 0.15). Of the 105 patients, 40 (38%) had a spontaneous leak, 15 (14%) had a traumatic leak, and 50 (48%) had an iatrogenic leak. In the spontaneous group, 30 of 40 patients had an LD and 10 of 40 did not. Recurrence was not significant between these subgroups (p = 1.0). LD was used in 11 of 15 patients with traumatic leaks. Of these 15 patients, 4 did not have a drain. Recurrence was not significant between these subgroups (p = 1.0). In 27 of 50 patients with an iatrogenic leak, an LD was placed. Of 50 patients, 23 did not have an LD. There was no statistical significance when the recurrence rates for these subgroups were compared (p = 0.26). In our study, there was no association identified between LD placement and recurrence rates after endoscopic repair of CSF rhinorrhea.

Despite the importance of providing expert anesthesia care to children undergoing neurosurgery, few resources exist that are devoted solely to this subject. Dr Hemanshu Prabhakar’s book, “Paediatric Neuroanaesthesia,” published by Oxford University Press, adds to the literature and is a comprehensive text on the subject. The book provides a detailed picture of neurosurgical conditions that a pediatric anesthesiologist may encounter. A major advantage of this textbook is its comprehensiveness. The book is divided into 11 sections, starting with the basics, such as neuroanatomy, neurophysiology, neuropharmacology, and preanesthetic evaluation. Specific types of lesions, monitoring and diagnosis, radiology, and special considerations are then covered. The section on neurosurgery is particularly useful for anesthesiologists. Many anesthesiology residency programs dedicate only a few months to specific neuroanesthesia training, which may not include formalized teaching on the distinctions between neurosurgical procedures. For each chapter in this section, a detailed explanation of characteristic pediatric neurosurgical lesions is organized in a formalized, easy-to-follow structure, including sections on anatomy and comprehensive pathophysiology. The authors continue with a brief introduction to each lesion and then a description of the specific perioperative anesthetic considerations. The authors emphasize both the pathogenesis of each condition and its implications for anesthetic management. The concise descriptions of surgical procedures and explanation of anesthetic techniques make the chapters in this section useful for practicing clinicians, teaching faculty, and residents who do not often encounter neurosurgical procedures. Another particularly useful section was “Clinical Procedures.” Most anesthesia textbooks do not give detailed descriptions on how to perform anesthetic procedures, because many of these concepts are naturally taught in the operating room. The authors of this textbook describe common operative room procedures, such as central venous cannulation and arterial cannulation. They also focus on specific neuroanesthesia procedures, such as lumbar drain and intracranial pressure catheter insertion. The chapters describe not only the indication for each procedure but also briefly describe the technique to perform each procedure. Patient positioning, equipment, and tables with a description of equipment specifics are provided. Postprocedure care and complications are also described. This section is helpful for clinicians who are supervising junior physicians through procedures and serves as a great resource for quick refreshers on procedures that are not performed on a daily basis. An outstanding feature of this book is its abundant and numerous tables placed throughout, which assist with making this book a practical resource for the day-to-day management of patients. These tables help with understanding and rapid referencing. For example, a list of abbreviations, placed at the beginning of the book, assists with overall comprehension, as do its relatively larger print size and ample white space. For example, Tables 20.4 and 20.5 are especially useful for a quick reminder about common congenital cardiac defects and clinical concerns relevant to specific heart defects during neurosurgical procedures. Similarly, IV fluid management is of utmost important in neurosurgery. Table 24.2 lists common IV fluids and their unique properties. The composition of various IV fluids with regard to osmolality and individual electrolytes makes this table a convenient reference for deciding which fluid would best suit each individual patient. Figures, in color, were placed in an inset in the center of the book on photo paper. Although the text is clearly written, awkward phrasing throughout many chapters does detract from its overall quality, specifically an absence of conjunctions in many places. A free DVD is included as a complementary resource with every print version. The DVD has visual guidance for 5 common anesthetic procedures, including venous cannulation, arterial and central venous placement, lumbar drain insertion, and performing a tracheostomy. The videos are short and concise, with captions on the bottom providing step-by-step instruction as to how to perform each procedure. These videos are excellent adjuncts for teachers to assist with instruction for difficult procedures. For individuals who are unfamiliar with these particular procedures, these videos provide a valuable reference to help memorize the steps of each procedure. Paediatric Neuroanaesthesia is a worthwhile resource for both pediatric anesthesiologists and general and neurosurgical anesthesiologists taking care of patients with childhood neurosurgical diseases. Aisha Sozzer, MDAnna Clebone, MDDepartment of Anesthesia and Critical CareUniversity of ChicagoChicago, Illinois[email protected]

Lumbar Drain Complications in Patients Undergoing Fenestrated/Branched Endovascular Aortic Aneurysm Repair

Lumber drain morbidity in endonasal endoscopic skull base surgery

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 &gt;20 to 30 mL of CSF/hour was significantly associated with better surgical conditions (p &lt; 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 &lt; 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.

Objective Sphenoid wing meningiomas (SWMs) can present surgical challenges, in that they are often obscured by overlying brain, encase critical neurovascular structures, and obliterate cerebrospinal fluid (CSF) cisterns. While brain retraction can enable access, its use can have potentially deleterious effects. We report the benefits and outcomes of the criteria we have developed for use of cerebrospinal diversion to perform retractorless surgery for SWMs. Design Technical report. Setting Yale School of Medicine and Yale New Haven Hospital. Participants Between May, 2019 and December, 2020, ten consecutive patients were included who met the presented criteria for SWM surgery with preoperative lumbar drain (LD) placement. Main Outcome Measures Length of hospital stay, surgical complications, and extent of resection. Results We have developed the following criteria for LD placement in patients with SWMs such that LDs are preoperatively placed in patients with tumors with one or more of the following criteria: (1) medial location along the sphenoid wing, (2) vascular encasement resulting in obliteration of the optic carotid cistern and/or proximal sylvian fissure, and/or (3) the presence of associated edema. CSF release, after craniotomy and sphenoid wing removal, allowed for optimization of exposure, leading to the maximal safe extent of tumor resection without brain retraction or any complications. Conclusions Preoperative LD placement is effective in allowing for maximal extent of resection of SWMs and may be considered in cases where local CSF release is not possible. This technique is useful in those tumors located more medially, with encasement of the vasculature and/or associated with edema.