Lumbar Cerebrospinal Fluid Drain

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS
  • Reduction of intracranial pressure or brain volume
    • Surgery on the base of the skull
    • Certain otorhinolaryngologic procedures
    • Surgery for thoracic aortic aneurysms
    • Intracranial aneurysm surgery
  • Treatment of conditions that benefit from lowering intracranial pressure
    • CSF fistulas, both cranial and spinal
    • Intracranial hypertension
    • Traumatic otorrhea, traumatic rhinorrhea
  • Test for possible efficacy of placement of a CSF shunt
    • Normal pressure hydrocephalus
CONTRAINDICATIONS
  • Coagulopathy
  • Thrombocytopenia (platelet count <50,000/mm3)
  • Anticoagulants such as Coumadin, heparin, or low-molecular-weight heparin
  • Meningitis
  • Infection at the insertion site
  • Potential high rostral–caudal CSF pressure gradient, caused by, for example, a supratentorial mass (noncommunicating hydrocephalus)
  • Inability to monitor the catheter and its drainage 24 hours a day
EQUIPMENT
  • Sterile drape, gloves, gown, and mask
  • Sterile prep
  • Column-style manometer for measuring CSF opening pressure (can be found in most prepackaged lumbar puncture sets)
  • Cerebral spinal fluid drainage set
    • There are several brands available.
    • They all come with the following:
      • 14-gauge Tuohy needle (with a curved end, cutting bevel, and tightly fitting stylet)
      • Long guidewire to stiffen the catheter for insertion
      • 16-gauge silicone catheter and miscellaneous hardware to attach a Luer-Lok connector to the end of the catheter
  • Spinal drain manometer and reservoir, which is typically packaged separately and contains tubing, a CSF collection monometer, and a storage bag for drained CSF
ANATOMY

The distal termination of the spinal cord varies from about the level of the third lumbar vertebrae (L3) in infants to the lower border of L1 in adults. Lumbosacral cerebrospinal fluid (CSF) volume varies from patient to patient, in part according to body habitus and weight. Although the spinal cord ends at about L1 in adults, the subarachnoid space continues to about the second sacral vertebrae (S2).


Anatomic landmarks most important to placement of a lumbar drain are the iliac crests, the midline of the back, and the vertebral spinous processes. Palpation of the midline of the back identifies the spinous processes and vertebral interspaces in most patients but may be difficult in obese patients. Even in markedly obese patients, C7 can be palpated and may serve as a guide to the location of the midline of the back. A line drawn between the upper borders of the iliac crests across the midline of the back identifies the approximate level of L4 or the L4-L5 interspace.


Lumbar drains are usually placed at the level of the L3 or L4 vertebrae in the adult patient, so that the introducing needle enters below the level at which the spinal cord ends. Lumbar and sacral nerve roots extending below the border of L1 form the cauda equina. The relative mobility of these nerve roots within the CSF compared to the spinal cord reduces the risk that the introducing needle will cause direct trauma to the nerve roots at the lower lumbar levels.


PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Keep insertion site dry and covered with a sterile occlusive dressing.
  • Inspect daily for infection and/or CSF leakage around the catheter.
  • Limit use to 5 days or less to minimize risk of infection.
  • Remove the catheter using a slow steady pull. Improper technique while removing the catheter can break it, and fragments may be retained within the patient. DO NOT continue to pull against significant resistance. 
Clinical Pearls:If resistance is encountered during catheter removal, sometimes placing the patient in the lateral flexed position used for catheter insertion will allow removal of the catheter.

  • The spinal drain catheter and drainage of CSF must be monitored by appropriately trained practitioners. Excessive or rapid drainage of CSF can cause complications ranging from headache to brain herniation. Some authors recommend intermittent rather than continuous drainage to reduce the probability of this complication. 
  • The spinal drain catheter can become disconnected from the drainage system, resulting in uncontrolled loss of CSF. Care must be taken to avoid strain on connectors in the system. The Luer-Lok insertion into the drainage catheter is at particularly high risk of separation. 
COMPLICATIONS
  • Headache
  • Paresthesia
  • Radicular pain
  • Extremity weakness
  • Paralysis
  • Cerebral herniation
  • Infection, localized as well as meningitis
  • Sepsis
  • Retention of catheter fragments in the subcutaneous, intramuscular, epidural, or subarachnoid space
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