Fluoroscopic guidance improves CSF drain placement outcomes
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This document summarizes a case conference discussion on fluoroscopic-guided placement of cerebrospinal fluid drains (CSFDs). It begins with objectives for the discussion, including reviewing indications for lumbar CSFDs and relevant anatomy and techniques. It then discusses challenges associated with fluoroscopic-guided placement, such as anatomic variations, prone positioning, and dural tenting without puncture. Studies comparing fluoroscopic to landmark techniques and different catheter sizes are presented, showing lower complication rates with fluoroscopy. Future directions to improve safety are proposed, such as needle design tailored for intrathecal rather than epidural access.
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Fluoroscopic guidance improves CSF drain placement outcomes
- 1. Fluoroscopic-assisted placement of cerebrospinal fluid drains (CSFDs) Case conference Hovig Chitilian, MD David Hao, MD Yvonne Lai, MD Taylor Lloyd, MD and Raf Vazquez, MD
- 3. Presenters have no actual or potential conflict of interest in relation to this presentation.
- 5. Coselli et al.J Thorac Cardiovasc Surg. 2016;151:1323-38 Greenberg et al. Circulation. 2008;118 (8): 808-17 Incidence of Spinal Cord Injury Type I Type II Type III Type IV Open Surgery 7.8% 13.9% 10.8% 4% Endovascular 10% 19% 5% 2%
- 8. Davison et al. Journal of Vascular Surgery. 1994.
- 9. Review the indications for lumbar cerebrospinal fluid drains (CSFDs) Review relevant anatomy and techniques for fluoroscopic-guided CSFDs Discuss the challenges associated with fluoroscopic- guided technique Objectives
- 10. Spinal cord perfusion Mean arterial pressure minus intraspinal pressure SCPP = MAP - ISP PHYSIOLOGY
- 11. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair Coselli et. al. Journal of Vascular Surgery. 2002. Eligible patients Planned extent I or II TAAA repairs 202 patients Randomized 156 patients (77.2%) Not randomized 46 patients (22.8%) TAAA repair without CSFD 74 control patients (47.4%) TAAA repair with CSFD 82 patients (52.6%) Intention-to-treat analysis 74 patients Efficacy analysis 69 patients (93.2%) Withdrawn No LHB, 5 patients (6.8%) Intention-to-treat analysis 82 patients Efficacy analysis 76 patients (92.7%) Withdrawn No LHB, 4 patients (4.9%) No LHB + extent III, 1 patient (1.2%) DTA + extent IV, 1 patient (1.2%)
- 12. 2.6% 2 of 76 patients With CSFD 13.0% 9 of 69 patients Without CSFD Coselli et. al. Journal of Vascular Surgery. 2002. Incidence of paraplegia or paraparesis
- 13. Class 1B Recommendation Drainage recommended as spinal cord protective strategy in open and endovascular thoracic aortic repair for patients at high risk of spinal cord ischemic injury 2010 Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM
- 14. How confident are you in your ability to wet tap? Baatara Gorge WaterfallLebanon
- 16. Hermetic Lumbar Catheter – Integra Kit
- 17. This is NOT a benign procedure. 34 studies and 4716 patients Pooled event rate of any complications 6.5% Rong et al. British Journal of Anaesthesia. 2018 Minor 2% Puncture-site bleeding, bloody spinal fluid, CSF leak not needing intervention, hypotension, drain fracture not needing intervention, occluded or dislodged catheters Moderate 3.7% CSF leak needing intervention, spinal headache, and drain fracture needing intervention Severe 2.5% ICH, epidural hematoma, meningitis, neurological deficits
- 18. How can we do better?
- 19. 01 59-year old man Thoracic abdominal aortic aneurysm presenting for TEVAR Relevant history Paroxysmal atrial fibrillation Obstructive sleep apnea Ascending aorta and hemi-arch replacement Obesity (BMI 37.3) Chronic lower back pain Case presentation
- 21. 02 74-year old woman Two-stage thoracic endograft replacement Relevant history COPD Prior open repair of juxtarenal AAA Spinal stenosis Case presentation
- 22. L2-3 L3-4 Tip of conus medullaris (T12-L1) L1-2
- 23. Karkkainen et al. Journal of Vascular Surgery. 2019 Prospective nonrandomized study Fluoroscopic guidance 55 cases (23%) Fluoroscopic guidance had lower rate of technical difficulties compared with blind landmark (9% versus 28%; p=0.01) Technical difficulty in drain insertion Feature With feature Without feature P value DLD 35/113 (31%) 23/121 (19%) 0.03 Primary fluoroscopic approach 4/43 (9%) 54/191 (28%) 0.01 Small needle size (17-18G) 9/32 (28%) 43/189 (23%) 0.65 First puncture attempted at level L1-L3 35/139 (25%) 22/94 (23%) 0.88
- 24. Wynn et al. Journal of Cardiothoracic Vascular Surgery. 2014 Retrospective, prospectively maintained study 724 patients underwent spinal drain placement Open thoracic or thoracoabdominal and thoracic endovascular aortic aneurysm repairs
- 25. Pre-2000 19-gauge Arrow epidural catheter (through 17—gauge Touhy needle) Anatomic landmark technique Wynn et al.Journal of Cardiothoracic Vascular Surgery. 2014 Post-2000 16-gauge Medtronic lumbar drain (through 14-gauge Touhy needle) Fluoroscopic guidance technique targeted to T9-10 22-gauge finder needle to position Tuohy
- 26. Complications 19-gauge catheter 16-gauge catheter OR (95% CI) P Value Drain failure 25 of 322 (7.75%) 4 of 402 (0.99%) 6.633 (2.510- 17.531) <0.0001 Neurologic complications 2 of 322 (0.62%) 4 of 402 (0.99%) 1.621 (0.295- 8.902) 0.5752 Wynn et al.Journal of Cardiothoracic Vascular Surgery. 2014
- 31. Anatomic challenges Challenges • Baastrup’s sign Strategies • Fluoroscopic based level selection • Paramedian or oblique interlaminar approach
- 32. Anatomic challenges Challenges • Undiagnosed lumbar spinal stenosis • Decreased spinal CSF flow distal to stenosis Strategies • Preprocedural MRI and imaging review with neuro-interventional radiology
- 33. Prone positioning Challenge • Lower intrathecal pressure compared to sitting • Uncomfortable for some obese patients Strategies • Valsalva • Steep reverse Trendelenburg • Sitting position • Rotating Touhy needle
- 34. Dural tenting Challenge Dural deformation without successful puncture Strategies • 22ga Quincke puncture • Sharper needle • Contrast injection
- 35. Needle design Challenge • Contemporary large diameter needles generally designed for epidural, not intrathecal, access
- 37. Thank you!