Treatment Approach for Conditions Requiring Lumbar Drain
Lumbar drains are indicated for specific conditions requiring CSF diversion, but should not be used routinely for posthemorrhagic hydrocephalus in premature infants due to lack of efficacy. 1
Indications for Lumbar CSF Drainage
- Lumbar CSF drainage is recommended for patients with acute symptomatic hydrocephalus following aneurysmal subarachnoid hemorrhage (aSAH) to improve neurological outcomes 2
- Lumbar drainage is indicated for management of elevated intracranial pressure (ICP), especially when CSF diversion is needed 2
- Lumbar CSF drainage is used as an adjunct for reducing risk of spinal cord ischemia during complex aortic aneurysm repair 2, 3
- Lumbar drainage can help remove blood products from CSF following aSAH, which may reduce the incidence of delayed cerebral ischemia 2, 4
- Lumbar drainage is indicated for management of cryptococcal meningitis with elevated intracranial pressure 2
Pre-procedure Assessment
- Brain imaging (CT or MRI) must be performed before lumbar drain placement to rule out mass lesions or obstructive hydrocephalus that could increase the risk of cerebral herniation 5, 2
- Evaluation of patient's coagulation status before insertion of a drainage device is necessary 2
- Consider reversal of anticoagulation or platelet transfusion for patients on warfarin or antiplatelet agents, respectively 2
CSF Drainage Management
- CSF drainage should be carefully controlled, with pressure reduction typically targeted to 50% of the initial pressure or to a normal pressure of ≤20 cm of CSF 5, 2
- For cryptococcal meningitis, lumbar drainage should remove enough CSF to reduce opening pressure by 50% 2
- In patients with elevated baseline opening pressure, daily lumbar punctures may be initially required to maintain CSF opening pressure in the normal range 2
Monitoring and Complications Management
- Monitor patients closely for signs of increased ICP during and after lumbar drain placement 5, 2
- Maintain cerebral perfusion pressure (CPP) of 50-70 mmHg in patients with intracerebral hemorrhage (ICH) and elevated ICP 2
- Monitor drain sites regularly for signs of infection 2
- Consider antibiotic-impregnated catheters in high-risk situations 2
Potential Complications and Management
- Nonfunctionality is a common complication (16% in one series) 3
- Bleeding complications can range from asymptomatic blood in CSF (11%) to subarachnoid hemorrhage with intraventricular hemorrhage (3%) 3
- Other complications include catheter dislodgment/fracture (4%), CSF leak (7%), and postdural puncture headache (4%) 3, 6, 7
- Serious neurological complications can occur, including unilateral occlusion of the posterior cerebral artery and vocal cord paralysis 6
- Complications can be mitigated by cessation of lumbar drainage 6
Duration of Drainage
- The majority of lumbar drains (82%) are typically left in place for ≤48 hours 3
- Drains should not be left in place for more than 5 days due to increased infectious risk 7
Special Considerations
- For patients with persistently elevated ICP despite lumbar drainage, additional measures may be necessary, including consideration of ventriculoperitoneal shunting 5
- For patients with intracerebral hemorrhage (ICH), ventricular drainage as treatment for hydrocephalus is reasonable, especially in patients with decreased level of consciousness 2
- Permanent CSF diversion is recommended for patients with aSAH and chronic symptomatic hydrocephalus 2
- The routine use of serial lumbar puncture is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants 1
- Navigation systems like Medtronic's SureTrak can be used for difficult lumbar drain placements, particularly in patients with large body habitus 8