Preoperative Lumbar Drain Placement in Anterior Skull Base Surgery

Inserting a drain into the lumbar subarachnoid cistern is an acceptable strategy in managing postoperative cerebrospinal fluid (CSF) leak. The technique promotes closure of dural defects that plague 12–18% of posterior fossa craniotomies and reduces the incidence of open correction in the operating room. This retrospective study evaluates the safety and effectiveness of preoperative lumbar drain (LD) placement in preventing CSF rhinorrhea following anterior cranial fossa (ACF) surgery. Since 2006, 93 LDs have been placed at our institution: 43 before ACF tumor resection (predominantly pituitary adenomas, meningiomas, and esthesioneuroblastomas), 21 before encephalocele repair, 13 before either traumatic or postoperative CSF leak, 9 prior to aneurysm clipping or non-ACF tumor resection, and 7 as part of an LD trial in normal pressure hydrocephalus. We had no difficulty introducing the catheter into the lumbar cistern at the L4–5 disc space using a 14-gauge Touhy needle with the patient in the left lateral decubitus position. In 41 of the 93 cases, the LD was placed in patients undergoing elective ACF surgery unrelated to trauma without a preoperative CSF leak. Of those 41 patients, we report four iatrogenic CSF leaks (4/41 = 9.8%), all in our endoscopic patient population (n = 21; 4/21 = 19%), with two of those instances occurring in the same patient. We encountered no postoperative CSF leaks in our open ACF cohort (n = 20). In nearly all cases, 10 cc/hour of CSF were removed via the LD in the neurological ICU for 1 to 2 days. The LD was then routinely clamped for 24 hours prior to its removal. No instances of tension pneumocephalus were noted. However, two postoperative mortalities merit discussion. One patient underwent uncomplicated anterior cranial base reconstruction for spontaneous CSF rhinorrhea and later developed a cerebral abscess with subsequent, fatal intraventricular rupture. Another patient developed malignant cerebral edema and intractable seizures following an uneventful bicoronal craniotomy and resection of a giant olfactory groove meningioma with fatal consequences. Preoperative LD placement is an effective means by which to minimize postoperative CSF leak after anterior skull base craniotomy, but potential, significant intracranial complications may occur and merit careful consideration prior to LD placement in any patient.