Spinal cord ischemia (SCI) resulting in paralysis is a devastating complication following thoracoabdominal aortic aneurysm (TAAA) repair. Guidelines recommend lumbar spinal drain insertion and perioperative cerebrospinal fluid (CSF) drainage during TAAA repair to prevent and/or treat SCI and paralysis.1,2 Lumbar spinal drains are usually inserted preoperatively by anesthesiologists blindly without imaging guidance. However, placement of the drain may be challenging in certain clinical situations such as obesity, severe scoliosis, and previous back surgery, and in patients with poor anatomical landmarks.3 Difficult drain placement may lead to multiple insertion attempts, procedure cancellation, or other potential complications. Successful placement of a lumbar spinal drain is required before TAAA repair and failure to insert a lumbar drain in the operating room creates a clinical dilemma for the perioperative team about the subsequent steps.
In this study, we present a case series of 11 TAAA repair patients from a single institution in which the spinal drain was successfully inserted by an interventional neuroradiologist under fluoroscopic guidance after referral from anesthesiologists.
After getting approval from the institutional review board, the need for written informed consent was waived. We retrospectively reviewed the medical records of 11 patients who were referred by anesthesiologists to an interventional neuroradiologist for fluoroscopic-guided insertion of a lumbar spinal drain before or after TAAA open or endovascular repair between January 2010 and June 2015. Our anesthesiologists referred these patients because of anticipated difficult insertion on preoperative assessment, failure of drain insertion after multiple attempts, or postoperative patients with coagulopathy in whom anesthesiologists were uncomfortable inserting the drain blindly. This article adheres to the applicable EQUATOR guidelines (Supplemental Digital Content, http://links.lww.com/AA/B559).
Spinal Drain Insertion Technique
Patients were transferred to the interventional radiology suite. All patients were placed in the prone position. The patient’s back was sterilely prepared with betadine and draped under complete aseptic technique. Standard American Society of Anesthesiologists monitoring was used for the duration of the procedure. Oxygen was supplied by a nasal cannula. Conscious sedation was given to patients with 1–2 mg midazolam and 50 μg fentanyl IV boluses as needed. We used the lumbar drainage kit (Hermetic Lumbar Catheter Closed Tip, Integra, Añasco, Puerto Rico) that has an 80-cm-long catheter (OD: 1.5 mm) and 8.8-cm long 14G Touhy needle. A 15.2-cm 14G Touhy needle was available and used when needed, primarily in obese patients. The appropriate lumbar space (L2–3 or L3–4) was identified under fluoroscopy. After subcutaneous injection of 3–5 mL of 1% lidocaine, the needle was inserted by using a paramedian technique under fluoroscopic guidance with the real-time imaging (Figure 1A). Once the dura was punctured, the catheter preloaded with a hydrophilic 0.018 guidewire (Glidewire, Terumo Medical Corporation, Ashitaka, Japan) was threaded through the needle. The needle was then carefully removed, followed by the removal of the guidewire. Measured from the tip, at least 10 cm of the catheter was left in the subarachnoid space. The position of the catheter tip in the subarachnoid space was confirmed under fluoroscopic imaging (Figure 1B). The lumbar spinal drain was secured by sterile adhesive, and proper functioning of the catheter was checked by free flowing of clear CSF. All patients tolerated the procedure well. All the lumbar spinal drains were successfully inserted and were properly functioning until their postoperative removal.
The patient demographics included 4 men and 7 women, mean age 67.5 years (range: 44–79), mean weight 92.7 kg (range: 51.8–139.1), mean height 1.69 m (range: 1.54–1.88), and mean body mass index 32.5 kg/m2 (range: 19–42.6). Seven (63.6%) patients had history of smoking, 2 (18.2%) had diabetes mellitus, 10 (90.9%) had hypertension, 5 (45.4%) had chronic obstructive pulmonary disease, 5 (45.4%) suffered from renal disease, 4 had coronary artery disease (36.4%), and 2 (18.2%) had a history of stroke.
Table 1 illustrates the perioperative clinical course as well as the outcomes for the 11 patients. All drains were successfully placed with only 1 attempt. There were no immediate complications related to lumbar drain insertion; however, 3 (27.3%) patients developed mild postoperative complications related to spinal drain management. One patient suffered from CSF leak after drain removal that resolved spontaneously after 4 hours of keeping the patient flat and avoiding head elevation greater than 30°. Blood-tinged pink CSF was observed in another patient in the immediate postoperative period. The last patient developed a postoperative dural puncture headache on the first postoperative day, which was treated with fluids and caffeine tablets with the resolution of his symptoms.
Two patients within this case series had their drains inserted on the first postoperative day, as opposed to the preoperative period, for management of postoperative paralysis. One patient presented for an emergency thoracic endovascular aortic aneurysm repair (TEVAR) for ruptured TAAA, and we were not able to insert a drain preoperatively. The second patient underwent fenestrated endovascular aortic repair (FEVAR) for treatment of abdominal aortic aneurysm. Because he was considered low risk for the development of SCI, the drain was not inserted preoperatively. Both patients were referred to the interventional neuroradiologist for lumbar spinal drain insertion because of coagulopathy (platelet count: 90,000 and 97,000 cells/μL; international normalized ratio: 1.4 and 1.5 for patients 1 and 2, respectively).
Guidelines in the United States and Europe recommend CSF drainage in TAAA open and endovascular repair to aid in the prevention and management of SCI.1,2 Failure of lumbar drain placement by anesthesiologists blindly in the operating room creates a dilemma for the perioperative team about the subsequent steps. This case series shows that interventional neuroradiologists using fluoroscopy can be a backup for anesthesiologists when they face difficult or failed drain insertions, and they can also be used in patients with known coagulopathy.
It is important to preoperatively identify patients with a low chance of successful drain insertion using the standard blind technique, or those who may require repeated attempts before successful insertion. Sprung et al4 and Attalah et al5 examined factors that can predict difficult neuraxial block, and they determined that the quality of anatomical landmarks was the most significant independent predictor of difficulty. de Oliveira Filho et al6 prospectively studied 1481 patients for the predictors of successful neuraxial spinal and epidural blocks on first attempt and reported that quality of anatomical landmarks, patient positioning, and provider’s experience were the independent predictors of success. They also showed that anatomical landmark quality was negatively affected by age >40 years, body mass index >25 kg/m2, and the brevilineal biotype (short and obese). It should also be noted that the placement of the lumbar drain may sometimes be challenging in certain clinical situations such as in patients with previous back surgery because of scar formation and lack of bony landmarks as well as because of the presence of hardware (Figure 2).
Role of Imaging Guidance in Lumbar Spinal Drain Insertion
Imaging techniques should always be considered for patients with expected difficult drain insertions. Fluoroscopy imaging improves the accuracy of lumbar spinal drain insertion by confirming correct needle placement and providing constant direct visualization of the spinal canal.
Practices for insertions of lumbar spinal drains vary among institutions. In 2000, Wynn et al7 changed their institutional practice to routinely use fluoroscopy for lumbar spinal drain insertion in elective TAAA cases. However, Estrera et al8 do not see imaging guidance necessary for drain insertion. At our institution, we believe in using fluoroscopy guidance as an alternative to blind drain insertion in cases of difficult or failed insertions.
Other imaging guiding techniques for lumbar spinal drain insertion like computed tomography (CT) and ultrasound-guided drain placement have also been mentioned in the literature.9,10
Prone Position During Lumbar Spinal Drain Insertion
Anesthesiologists usually use the sitting or the lateral position with the spine flexed to facilitate lumbar spinal drain insertion. In contrast, our interventional neuroradiologist uses the prone position during fluoroscopy imaging, which has the advantage of reduced CSF pressure avoiding excessive CSF loss. Improved patient satisfaction is also another advantage of this position compared with the sitting or lateral lumbar flexion position in awake patients.
Fluoroscopic-guided spinal drain insertion by interventional neuroradiologists is an alternative for the conventional, nonimage-guided, blind technique used by the anesthesiologists when they encounter difficult or failed cases of insertions.
Name: Hamdy Awad, MD.
Contribution: This author conceived the idea, interpreted the data in the literature, and helped prepare the manuscript.
Name: Mohamed Ehab Ramadan, MD.
Contribution: This author collected the data from the medical records, interpreted the data in the literature, and helped prepare the manuscript.
Name: Esmerina Tili, PhD.
Contribution: This author conceived the idea, interpreted the data in the literature, and helped prepare the manuscript.
Name: Kathryn Hackett, BA.
Contribution: This author helped prepare the manuscript.
Name: Eric C. Bourekas, MD, MBA, FACR.
Contribution: This author performed the procedures of fluoroscopic guided spinal drain insertion for the study subjects, and helped prepare the manuscript.
This manuscript was handled by: Richard C. Prielipp, MD.
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