Lumbar drains: Practical understanding and application for the otolaryngologist

The Role of Lumbar Drains in the Perioperative Management of Primary Spontaneous Temporal Lobe Encephaloceles and Cerebrospinal Fluid Leaks

OBJECTIVE

To examine the role of lumbar drains (LDs) in the success of spontaneous temporal cerebrospinal fluid (CSF) leak and encephalocele repair.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic health system.

PATIENTS

Patients undergoing repair of spontaneous temporal lobe encephaloceles or middle fossa CSF leaks during years 2017 to 2023.

INTERVENTIONS

Transmastoid, middle fossa craniotomy, or combination approaches to CSF leak repair.

OUTCOME MEASURES

Failure rate, complication rate, length of stay (LOS), readmission.

RESULTS

Sixty-nine patients were included, with a combination approach performed in 78.3%, transmastoid in 17.4%, and isolated middle fossa craniotomy in 4.3%. Mean body mass index was 33.2, mean bony defect size width was 6.51 mm, and defect locations included the epitympanum, antrum, mastoid, and petrous apex. Multilayer closure with three or more layers was performed in 87.0%. LD was used in 73.9% of cases for a mean duration 2.27 days and was associated with longer LOS (3.27 vs. 1.56 d, p = 0.006) but not with failure rate, complications, discharge destination, or readmission. Only one major complication occurred as a result of the drain, but low-pressure headache was anecdotally common.

CONCLUSIONS

Use of LD in the repair of spontaneous CSF leaks and temporal lobe encephaloceles is associated with longer LOS but not failure rates or other admission-level outcomes.

Improving Quality Care and Patient Safety With Implementation of an Oversew Stitch in Lumbar Drains

ABSTRACT

The lumbar drain exit site purse string oversew stitch is a well-described bedside intervention to stop or prevent cerebrospinal fluid (CSF) leak. It is not routinely placed at the time of lumbar drain placement. Via four plan-do-study-act (PDSA) cycles, we test the effect of prophylactic utilization of the lumbar drain exit site oversew stitch on house officers' paging burden, need to redress the drain, need to oversew the drain to stop a CSF leak, and need to replace the drain. We found that the simple act of placing an oversew stitch at the time of lumbar drain placement significantly reduced paging burden and reduced the frequency at which an oversew stitch was required to stop a CSF leak. Subjectively, during PDSA cycles during which overstitches were placed prophylactically, in-house residents perceived that there were less lumbar drains on service, although objectively, the overall number was unchanged. We conclude that prophylactic lumbar drain exit site stitch placement reduces risk and bedside interventions for patients and also reduces overall call burden on house officers. This simple intervention may therefore provide a more widespread improvement in care quality beyond lumbar drain care because house officers experience less burnout during their call shifts.

Continuous Erector Spinae Plane Block for Pain Management Following Thoracotomy for Aortic Coarctectomy

Pain following thoracotomy is one of the most severe forms of postoperative pain. Post-thoracotomy pain may increase the risk of post-surgical pulmonary complications, postoperative mortality, prolong hospitalization, and increase utilization of healthcare resources. To mitigate these effects, anesthesia providers commonly employ continuous epidural infusions, paravertebral blocks, and systemic opioids for pain management and improvement of pulmonary mechanics. We report the use of a continuous erector spinae plane block (ESPB) via a peripheral nerve catheter for postoperative pain management of an 18-year-old patient who underwent complex aortic coarctation repair via lateral thoracotomy, aided by cardiopulmonary bypass. Continuous ESPB proved to be an acceptable alternative for postoperative pain control, producing a substantial multi-dermatomal sensory block, resulting in adequate pain control, reduced opioid consumption, and a potentially shorter hospital stay.

Prediction of Lumbar Drainage-Related Meningitis Based on Supervised Machine Learning Algorithms

Background

Lumbar drainage is widely used in the clinic; however, forecasting lumbar drainage-related meningitis (LDRM) is limited. We aimed to establish prediction models using supervised machine learning (ML) algorithms.

Methods

We utilized a cohort of 273 eligible lumbar drainage cases. Data were preprocessed and split into training and testing sets. Optimal hyper-parameters were archived by 10-fold cross-validation and grid search. The support vector machine (SVM), random forest (RF), and artificial neural network (ANN) were adopted for model training. The area under the operating characteristic curve (AUROC) and precision-recall curve (AUPRC), true positive ratio (TPR), true negative ratio (TNR), specificity, sensitivity, accuracy, and kappa coefficient were used for model evaluation. All trained models were internally validated. The importance of features was also analyzed.

Results

In the training set, all the models had AUROC exceeding 0.8. SVM and the RF models had an AUPRC of more than 0.6, but the ANN model had an unexpectedly low AUPRC (0.380). The RF and ANN models revealed similar TPR, whereas the ANN model had a higher TNR and demonstrated better specificity, sensitivity, accuracy, and kappa efficiency. In the testing set, most performance indicators of established models decreased. However, the RF and AVM models maintained adequate AUROC (0.828 vs. 0.719) and AUPRC (0.413 vs. 0.520), and the RF model also had better TPR, specificity, sensitivity, accuracy, and kappa efficiency. Site leakage showed the most considerable mean decrease in accuracy.

Conclusions

The RF and SVM models could predict LDRM, in which the RF model owned the best performance, and site leakage was the most meaningful predictor.

Case Series of Rapid Surgical Interventions in Fulminant Intracranial Hypertension

AIMS

Examine ophthalmologic outcomes and complications of lumbar drain and cerebrospinal fluid shunts in pediatric fulminant intracranial hypertension.

METHODS

Patients under 21 years of age with a diagnosis of fulminant intracranial hypertension with temporary lumbar drain only, shunt after lumbar drain, and shunt only were included. Parameters investigated include lumbar drain data, medication freedom, time to resolution of papilledema, improvement in cranial nerve palsy, afferent pupillary defects, visual fields, visual acuity, and complications of each intervention.

RESULTS

Four patients had temporary lumbar drain, 2 temporary lumbar drain and cerebrospinal fluid shunt, and 3 shunt only. All achieved medication freedom and resolution of papilledema and cranial nerve palsies (if present). Most had resolution of preprocedure afferent pupillary defects. Minor residual visual field deficits occurred in 67%, and all had visual acuity improvement. One patient's lumbar drain dislodged, and one patient had 2 cerebrospinal fluid shunt revisions.

CONCLUSION

Temporary lumbar drain with medical therapy may be a viable first approach to fulminant intracranial hypertension.