Continuous Lumbar Cerebrospinal Fluid Drainage Research Articles

Systematic review and meta-analysis of the efficacy and safety of cerebrospinal fluid drainage and lumbar puncture in the treatment of cerebrospinal fluid leakage after craniocerebral injury

Commonly used clinical treatments for intracranial hypertension include continuous lumbar cerebrospinal fluid drainage (CLCFD) and conventional lumbar puncture. However, lumbar puncture is more invasive, requires multiple punctures. CLCFD has less trauma, and drainage can be manipulated to avoid repeated lumbar puncture. However, CLCFD may also lead to complications such as intracranial hematoma and intracranial pneumothorax. Therefore, there is no agreement on which method is more effective. This study evaluated the efficacy of CLCFD and conventional lumbar puncture in the treatment of cerebrospinal fluid leakage after craniocerebral injury. The search terms 'brain injury' and 'CLCFD' were used to search CNKI, Wanfang, VIP, Longyuan, PubMed, Embase, Cochrane Library and other databases (from inception to November 1, 2022). Inclusion criteria: (I) randomized controlled trials (RCTs), CLCFD and conventional lumbar puncture drainage for patients with cerebrospinal fluid leakage after craniocerebral injury; (II) evaluation of indicators such as cerebrospinal fluid leakage stop time, clearance time, intracranial infection and complications. Cochrane systematic review was performed to assess the quality of the literature. RevMan 5.3 software was used for systematic analysis. A total of 8 studies, involving 568 patients. There is some publication bias in the statistics. The cessation time of cerebrospinal fluid leakage (95% confidence interval (CI): -3.65 to -2.86, Z=16.21, P<0.00001), the time to return to normal pressure (95% CI: -3.13 to -2.09, Z=9.79, P<0.00001), cerebrospinal fluid clearing time (95% CI: -1.96 to -1.09, Z=6.91, P<0.00001), hospitalization time (95% CI: -1.99 to -0.91, Z=5.27, P<0.00001), incidence of intracranial infection (95% CI: 0.07-0.27, Z=5.84, P<0.00001) and complications (95% CI: 0.10-0.43, Z=4.22, P<0.0001) in the CLCFD group were lower than those in the conventional group. The cure rate of the CLCFD group was significantly higher than that of the conventional group (OR =3.75, 95% CI: 2.26-6.23, Z=5.11, P<0.00001); the difference in mortality between the two groups was not statistically significant (P>0.05). Compared with conventional lumbar puncture, CLCFD can significantly increase the cure rate, shorten the recovery time of cerebrospinal fluid, and significantly reduce the incidence of intracranial infections, reduce complications, is conducive to the prognosis of patients.

Incidence and management of surgical site infection in the cervical spine following a transoral approach.

Transoral approach can accomplish ventral decompression directly. However, surgical site infection (SSI) cannot be ignored. This paper aims to review the prevalence of infection and conduct advice for the treatment of SSI in the cervical spine following the transoral approach. A retrospective analysis of patients with SSI after transoral atlantoaxial reduction plate (TARP) surgery was performed. SSI was classified into three kinds according to the modified American CDC criteria. 2.9% (17/581) patients who underwent TARP surgery, experienced SSI, of which five had superficial SSI (SI), eight had deep SSI (DI), and four had organ/space SSI (O/SI). The patients with SI underwent intravenous antibiotic treatment and were ultimately cured. Among the remaining 12 patients with DI and O/SI, 11 underwent reoperation for TARP system removal and subsequently one-stage posterior occipitocervical fixation, and one patient experienced infection twomonths post-operatively and died without receiving treatment. Among patients who underwent revision surgery, three experienced intracranial infection due to intra-operative dural tears, and continuous lumbar cerebrospinal fluid drainage and intrathecal injection of antibiotics were used as effective and appropriate treatments, with outcomes of one recovery and two deaths. All patients with SSI were begun on intravenous antibiotics with conversion to oral antibiotics. The incidence of SSI was 2.9% (17/581). Adequate peri-operative preparation, early diagnosis, and appropriate treatment of SSI require further research.

Application of continuous lumbar cerebrospinal fluid drainage in cerebrospinal fluid leakage after severe craniocerebral injury

Objective To investigate the treatment effect of continuous lumbar cerebrospinal fluid drainage(CLCFD)on patients with cerebrospinal fluid leakage after severe craniocerebral injury operation. Methods Fifty-two patients with postoperative cerebrospinal fluid leakage following severe traumatic brain injury admitted to the Intensive Care Unit, Qinghai Provincial People's Hospital from January 2014 to December 2014 were enrolled. According to the different treatment methods, the 52 patients were divided into either a routine lumbar puncture group(n=26)or a CLCFD group(n=26). The differences of the stop time of cerebrospinal fluid leakage, the clinical cure rate within 14 d, and the intracranial infection rate were compared in patients between the 2 groups. Results The stop time of cerebrospinal fluid leakage of the CLCFD group and the routine lumbar puncture group was 6.3±1.4 d and 12.2±2.1 d respectively(P<0.001). There was significant difference between the 2 groups. The cure rates of the CLCFD group and the routine lumbar puncture group within 14 d were 92%(24/26)and 77%(20/26)respectively. There was significant difference between the 2 groups(P<0.001). One patient(4%)had intracranial infection in the CLCFD group, and 8(31%)had intracranial infection in the routine lumbar puncture group. The incidence of intracranial infection of the CLCFD group was significantly lower than that of the routine lumbar puncture group(P<0.001). Conclusions Using early CLCFD for the treatment of postoperative cerebrospinal fluid leakage following severe traumatic brain injury may shorten the duration of cerebrospinal fluid leakage in patients, improve the clinical cure rate within 14 d, and decrease the incidence of intracranial infection. Its clinical efficacy is significantly superior to releasing cerebrospinal fluid of conventional lumbar puncture. Key words: Craniocerebral trauma; Lumbar cerebrospinal fluid drainage; Cerebrospinal fluid leakage

Continued lumbar cerebrospinal fluid drainage in surgery for intracranial aneurysms

Objective To compare the advantages and disadvantages of continuous lumbar cerebrospinal fluid drainage and repeated lumbar puncture for ruptured intracranial aneurysm surgery.Methods 295 patients were enrolled who had ruptured intracranial aneurysm and were treated surgically between Jan 2010 and Jan 2011 in department of neurosurgery.Patients were classified into 2 groups:patients who were performed with continuous lumbar cerebrospinal fluid drainage (group A) and patients who were performed with repeated lumbar puncture (group B).The incidence rates of major surgical complications of both groups were compared and analyzed,including delayed cerebral ischemia,postsurgical hydrocephalus and postsurgical intracranial infection.All patients were followed-up for over 6 months and the surgical outcomes were assessed using modified Rankin scale (mRS).Results The incidence rates of delayed cerebral ischemia were 4.38％ (7/160) and 7.41％ (10/135) in group A and B respectively.There was no significant difference between 2 groups.The incidence rates of postsurgical hydrocephalus were 2.50％ (4/160) and 3.70％ (5/135) in group A and B respectively.There was no significant difference between 2 groups.The incidence rates of intracranial infection were 8.13％ (13/160) and 2.22％ (3/135) in group A and B respectively.There was a higher rate of intracranial infection in group A (P ＜ 0.05).There was no significant difference in mRS between 2 groups after 6-months follow-up.Conclusions Continuous lumbar cerebrospinal fluid drainage showed little advantage over repeated lumbar puncture in reducing the occurrence of major surgical complications,including delayed cerebral ischemia and postsurgical hydrocephalus.While continuous lumbar cerebrospinal fluid drainage had a higher incidence rate of intracranial infection.Continuous Lumbar cerebrospinal fluid drainage might enhance the risk of intracranial infection.The therapeutic indications of continuous lumbar cerebrospinal fluid drainage for ruptured intracranial aneurysm surgery should be considered carefully.The standardized surgical operations should be followed strictly and the importance of asepsis during the surgery should be valued. Key words: Intracranial aneurysm ; Cerebrospinal fluid ; Brain ischemia ; Hydrocephalus ; Central nervous system infections

Continuous Lumbar cerebrospinal fluid drainage in children . Can we facilitate ?

Continuous Lumbar cerebrospinal fluid drainage in children . Can we facilitate ?

Sellar Reconstruction Using Biomaterials After Transsphenoidal Surgery in 449 Cases of Pituitary Adenomas

Background: We report the methods and effects of sellar reconstruction using biomaterials in 449 cases of pituitary adenoma undergoing transsphenoidal surgery from August 2009 to August 2010. Methods: During transsphenoidal surgery (including 15 cases assisted with endoscope), diaphragma sellae damage and cerebrospinal fluid (CSF) leakage occurred in 52 cases intraoperatively. The resection cavity was packed with absorbable hemostatic cotton and gelatin sponge, and then artificial dura mater and fibrin glue were used to seal and reconstruct the sellar floor. Postoperative and delayed CSF leakage occurred in 6 and 2 cases, respectively. To manage the CSF leakage, the removal of intranasal vaseline gauze was postponed; and meanwhile, continuous lumbar CSF drainage and/or mannitol were used to decrease the intracranial pressure. Results: The incidence of CSF leakage was 12% (52 cases) intraoperatively, 1.3% (6 cases) postoperatively, and incidence of delayed CSF leakage was 0.45% (2 cases). For cases of postoperative CSF leakage, postponed removal of intranasal vaseline gauze and reducing intracranial pressure were effective methods. Most cases were cured in 1 week. Conclusion: In transsphenoidal surgery of pituitary adenoma, an exact intrasellar packing and sellar floor reconstruction with artificial dura mater and fibrin glue are effective and affirmative to prevent postoperative CSF leakage.

Cerebral venous thrombosis: an unexpected complication from spinal surgery

To provide new insights into the pathophysiology, prevention and diagnosis of cerebral venous thrombosis (CVT) associated with iatrogenic cerebrospinal fluid (CSF) leaks and/or external CSF drainage. Case report and literature review. We describe the case of a 30-year-old woman who developed a CSF fistula after lumbar spinal surgery. The treatment included rest, hydration, caffeine, and continuous lumbar CSF drainage. After closure of the fistula, the patient complained of severe orthostatic headache. Thrombosis involving the superior sagittal sinus, the right transverse sinus, the right sigmoid sinus, and the right jugular vein was diagnosed after neurological deterioration. A few reports have associated CVT with various forms of spinal meningeal injury. However, it has been rarely documented following spinal surgery complicated by accidental durotomy and/or external lumbar CSF drainage. CSF hypovolemia may precipitate CVT in patients having prothrombotic risk factors. Patients who have or had CSF leaks and/or lumbar CSF drains who present with symptoms of intracranial CSF hypotension should remain in the horizontal position to prevent CVT. In that context, the diagnosis of CVT depends on a high degree of suspicion.

Repairing front skull base and saddle bottom of cerebrospinal fluid rhinorrhea under endoscopy

To explore the methods and techniques of repairing cerebrospinal fluid (CSF) rhinorrhea and reconstructing the defects of skull base under endoscopy. The clinical data of 26 patients undergoing endoscopic repair of CSF rhinorrhea were analyzed retrospectively. There were 19 males and 7 females with an average age of 31.5 years old. Rhinorrhea was classified into 4 types: ethmoidal sinus type (n = 6), sphenoid sinus type (n = 14) and mixed type (n = 6) and frontal sinus type (n = 0). The causes of rhinorrhea were as follows: traumatic leakage (n = 17), post-operative breakage of saddle area (n = 6), damage after endonasal surgery (n = 2) rhinorrhea after gamma-knife for pituitary (n = 1). All cases were successfully repaired via an endoscopic endonasal approach. Among them, 22 patients were repaired only once while 4 patients with recurrent CSF rhinorrhea were repaired again. The follow-up period was from 6 months to 4 years. And satisfactory outcomes were achieved in all. Accurate localization of CSF leakage, reliable reconstruction of skull base, secure fixation of adhesive materials and continuous lumbar CSF drainage are keys surgical techniques. Endoscopic repair of front skull base and saddle bottom of CSF rhinorrhea is a reliable, effective and mini-invasive surgical approach worth further popularization.

Sellar floor reconstruction after transsphenoidal surgery using fibrin glue without grafting or implants: technical note

Background Different techniques have already been described for reconstructing the sellar floor after transsphenoidal (TS) procedures. This paper reports on the use of fibrin glue alone without grafting or the use of implants in the reconstruction of the sellar floor after TS. Methods Five hundred sixty-seven patients who submitted to TS for pituitary and sellar region tumors were studied. No intraoperative cerebrospinal fluid (CSF) leak occurred in 503 patients (group 1); in the remaining 64 patients (group 2), intraoperative CSF leak was noted. In group 1 patients, closure of the sellar floor consisted of packing the surgical bed with hemostatic material only. When CSF leak was noted, the surgical bed was covered with a layer of hemostatic material and the intrasellar space was filled up with fibrin glue. An additional layer of hemostatic material was added at the topography of the preexisting sellar floor, and a second amount of fibrin glue was applied over it. At the end of surgery, a continuous lumbar CSF drainage system was installed in group 2 patients and kept for 5 days. Prophylactic antibiotics were administered during this period. Results We did not observe delayed CSF leak, meningitis, or visual loss in group 1 patients. In group 2, 2 patients presented with complications: 1 patient got meningitis but no overt CSF leak, and the other disclosed a delayed postoperative leak treated by reoperation. Discussion Our results showed that closure of the sellar floor with hemostatic material and fibrin glue without grafting or the use of implants is a safe and efficient method to prevent postoperative complications after TS. Generally speaking, there is no need for grafting or the use of implants at the end of TS.

Incidence of cerebrospinal fluid leak after microsurgical removal of vestibular schwannomas.

Cerebrospinal fluid (CSF) leak still remains an unresolved problem after microsurgical removal of vestibular schwannomas (VS). 14 (6%) Cases of cerebrospinal fluid rhinorrhea and 3 cases with subcutaneous retro-auricular CSF collection, occurring in a series of 224 patients operated on by the senior author (JMG) on VS between 1989-2000 via the suboccipital retrosigmoidal approach were studied retrospectively. Prophylaxis of CSF leak was usually attempted by packing the unroofed posterior wall of internal acoustic meatus with muscle. The mastoid air cells were packed first with collagen then with muscle and bone dust. All CSF leaks were diagnosed within 2-7 days after surgery. We found no relation to tumour size. Treatment was initiated in all patients with continuous external lumbar cerebrospinal fluid drainage (CELCFD) for 7 days. In 11 cases with CSF rhinorrhea and all cases with retro-auricular CSF collection, the CSF leak was stopped. However, in 3 cases the CSF leak persisted despite the lumbar drain. These patients were operated on again with sealing the IAM and the mastoid cells again with muscle and collagen. No recurrence of CSF leak was noted after the second operation. There was no case of late onset CSF leak during the follow-up of one year. Although CSF leak is a common complication (6%) after vestibular schwannoma removal, aggressive treatment is required only in a few cases (1%). Most of the cases are successfully treated by (CELCFD). The suboccipital approach offers an advantage of opening only a part of mastoid air cells, which are in our opinion the second most common site of CSF leakage.

Continuous lumbar drainage for the preoperative management of patients with aneurysmal subarachnoid hemorrhage.

Continuous drainage of lumbar cerebrospinal fluid (CSF) was analyzed for the preoperative management of patients with aneurysmal subarachnoid hemorrhage (SAH) in 50 consecutive cases of surgically treated aneurysmal SAH. Patients were divided into a lumbar drainage group, in whom continuous lumbar CSF drainage was established for preoperative management, and a non-lumbar drainage group. Rebleeding from the aneurysm during the insertion of the lumbar drainage tube and during continuous lumbar drainage, effect on the control of the systolic blood pressure, and effect on the sedation of the patient were examined. Continuous lumbar CSF drainage significantly decreased the systolic blood pressure. Seven of 17 patients in the non-lumbar drainage group had systolic blood pressure uncontrollable to below 150 mmHg even when a large amount of nicardipine was used, whereas only two of 33 patients had the same problem in the lumbar drainage group. Sedation was better in the patients in the lumbar drainage group with a smaller amount of analgesics. The rebleeding rate was 11.7% among patients in the non-lumbar drainage group, and 9.09% among patients in the lumbar drainage group. No rebleeding occurred during insertion of the lumbar drainage catheter. Continuous lumbar CSF drainage improved control of systolic pressure and sedation, and is a useful method of preoperative management for patients with aneurysmal SAH.

Cerebrospinal Fluid Drainage in the Management of CSF Leak Following Acoustic Neuroma Surgery

A retrospective analysis was performed on 174 patients operated on from 1992 to 1995 to evaluate the safety and efficacy of continuous lumbar cerebrospinal fluid drainage (CLCFD) in the management of cerebrospinal fluid (CSF) leaks following acoustic neuroma surgery. There was a 17% incidence of CSF leak. CLCFD stopped the leak in 87% of cases. There were no cases of meningitis associated with CLCFD. One deep vein thrombosis was treated without sequelae. It is concluded that CLCFD is safe and efficacious. The authors recommend that CLCFD be implemented immediately when indicated, foregoing a trial of conservative therapy. Indications and precautions are discussed.

Evaluation and Management of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks

Spontaneous temporal bone cerebrospinal fluid leak may be defined as a leak without an apparent precipitating cause. These transdural fistulas occur rarely, and diagnosis is predicated upon a high index of suspicion. Leaks have been reported through both middle and posterior fossa defects, although the vast majority involve the middle fossa plate. In a previous study we reported 7 cases of spontaneous temporal bone cerebrospinal fluid leaks, all involving the middle fossa tegmen. Upon further review of these cases and 5 previously unreported cases, the defect was localized to the tegmen tympani in 9 of the total 12 cases. Diagnostic methods are discussed, with the importance of high-resolution computed tomography stressed. The role of contrast cisternography is also evaluated. An outline for surgical management is presented based upon residual hearing and defect location and accessibility. A transmastoid procedure offers the advantage of visualization of both the middle and posterior fossa plates, and this approach can be supplemented with an obliterative procedure when indicated. The middle fossa approach provides optimal exposure of the tegmen plate with less likelihood of ossicular injury when dealing with tegmen tympani defects. Adjuncts to surgical therapy include intrathecal fluorescein dye and continuous postoperative lumbar cerebrospinal fluid drainage.

Cerebrospinal fluid leak following acoustic neuroma removal

Cerebrospinal fluid (CSF) leak has been a constant and unresolved complication of acoustic tumor surgery. This study retrospectively reviews 381 primary acoustic tumor surgeries performed by a single, senior, neurotologist and neurosurgeon team from 1979 through 1991. There were 68 cerebrospinal fluid leaks in 66 patients (66/381; 17%). There was no significant difference in the incidence of CSF leak between the translabyrinthine group (21%) and the retrosigmoid transmeatal group (16%). Translabyrinthine leaks were evenly divided between rhinorrhea and the postauricular wound while retrosigmoid transmeatal leaks were predominantly rhinorrhea. Eleven of 14 translabyrinthine wound leaks responded to pressure dressing and suture. The remaining 3 ceased with continuous lumbar cerebrospinal fluid drainage. Ten of 14 cases of translabyrinthine rhinorrhea responded to continuous lumbar cerebrospinal fluid drainage, and those in whom it failed were cured with revision of the mastoidectomy/labyrinthectomy cavity. Twenty-one of 28 cases of retrosigmoid transmeatal rhinorrhea responded to continuous lumbar cerebrospinal fluid drainage, and those in whom it failed were cured with extracranial, transmastoid revision. The incidence of cerebrospinal fluid leak was not influenced by age, sex, size of tumor, postoperative hydrocephalus, or the intraoperative use of autologous fibrin glue. Meningitis was an unusual complication, occurring in 3% of all patients.