- 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
- 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
- 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
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.
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Figure 1
:
Basic supplies for placement of lumbar drain. On the left, from top to bottom: white Luer-Lok connector apparatus, guidewire in round sheath, and blue alternative connector. On the right, from top to bottom: 14-gauge Tuohy needle and stylet, alternative Luer-Lok connector, and white silicone lumbar drain catheter.
Figure 2
:
Column-style manometer for measuring CSF opening pressure.
Figure 3
:
Relation of spinal cord and nerves to vertebrae. From Drake L, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE: Gray’s Atlas of Anatomy. Philadelphia, Churchill Livingstone Elsevier, 2008, p 44.
Figure 4
:
Relationships and contents of subarachnoid and epidural space. From Drake L, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE: Gray’s Atlas of Anatomy. Philadelphia, Churchill Livingstone Elsevier, 2008, p 47.
Figure 5
:
Ligament and boney relationship of the spinal column. From Drake L, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE: Gray’s Atlas of Anatomy. Philadelphia, Churchill Livingstone Elsevier, 2008, p 35.
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