Cerebrospinal fluid spinal lumbar drainage: indications, technical tips, and pitfalls

Since the publication by F. Vourc'h in 1963 [Br J Anaesth (1963) 35:118-120] describing the use of a plastic catheter inserted percutaneously for the drainage of lumbar cerebrospinal fluid (CSF) the indications for spinal drainage are numerous, but not very well systematized. The bibliographical review shows few recent papers concerning the techniques, indications, complications and pitfalls. The authors considered it interesting to analyze nine papers, in particular those dedicated to the use of spinal drainage in skull base surgery and in the prevention and/or treatment of CSF fistulas. Two papers describe for the first time pachymeningeal gadolinium enhancement associated with orthostatic headaches, owing to CSF hypotension mimicking an inflammatory or infiltrative disease. The results of the treatment of CSF fistulas are good with a high success rate, avoiding direct surgical repair. The use of a specially designed subarachnoid catheter is clearly superior to the epidural catheter, with good flow of CSF and minimal complications. The main problems are deficient flow and infections. Overdrainage is potentially dangerous, with acute pneumocephalus, brain collapse and neurological deterioration. Infrequent but possible is Chiari II-like syndrome with vocal cord paralysis and life-threatening aspiration, or temporal downward herniation with kinking of the posterior cerebral artery and acute brain infarct. The key to success lies in a rigid protocol, intermittent CSF drainage with a closed circuit, and daily biochemical and microbiological monitoring. Highly qualified medical and nursing staff are essential.