Lumbar Drain

[TP]

I had my AN removed, few weeks later had major CSF leak from incision, had surgery, got menigitis ugh, then a few weeks later had another CSF leak went back into the hospital for a lumbar drain. Unfortunately I needed to have another CSF leak surgery two days later. My Dr apologized to me and said he probably should have given me a lumbar drain after my second surgery. The lumbar drain was a little uncomfortable while he inserted it in my lower back. I had it for about 8 days and then went home. I think your Dr is doing the right thing. I am sure your Dr has done a lot of research and maybe the trend is to do lumbar drains after these types of surgeries. I loved my Dr  and I believe he did everything he could to take care of me- I think my CSF leaks were due to my very hard head and small pee brain 

[Sammict]

Thanks everyone

I am hearing that it is becoming more of a normal procedure to put one in place during this type of surgery.

Thanks Sam

[jerseygirl]

Sam,

I had my first AN surgery in 1988 and they put in a lumbar drain during the surgery. It was in the operating report and I was told a few times as well. It was a standard procedure back in those days but my understanding is it is actually becoming less common. The lumbar drain was removed when the surgery was over.

              Eve

[Jim Scott]

Prior to my surgery, I asked my neurosurgeon about the possibility of a CSF leak.  He stated that he hadn't had a CSF leak 'in years'  He used the titanium mesh instead of belly fat, which may be why - or, he just does very neat work.  I think it could be a bit of both.    I'm pleased to report that I had no CSF leaks.

I suspect that because of growing experience and using the titanium mesh, CSF leaks associated with AN surgery are getting rarer and the lumbar drain less necessary.  However, as nothing can be guaranteed, putting one in during the surgery is not illogical and does save the patient future discomfort should a drain later be required.  Hopefully, that requirement will become less common in the coming years.

Jim   

[leapyrtwins]

He used the titanium mesh instead of belly fat, which may be why - or, he just does very neat work.  I think it could be a bit of both.

Jim -

I had the belly fat and a titanium plate & titanium screws for my AN surgery - and no CSF leak for me.

I just assumed that sometimes CSF leaks happen and sometimes they don't - regardless of the surgeon and his work; kind of like lots of other AN surgery side effects.

But now you've got my curiosity.  How does titanium mesh and "neat work" cut down on CSF leaks 

Jan

[lori67]

Jan, maybe he put some spackle over the mesh?   

I didn't have a leak either, but I'm sure they were able to get enough excess fat from elsewhere to be sure nothing will ever leak through!

Lori

[leapyrtwins]

Jan, maybe he put some spackle over the mesh?   

Maybe.  It seems like he's got a huge tool box - drills, screwdrivers, torque wrenches, etc.  I wouldn't be a bit surprised if he had spackle also 

From a medical professional's perspective (that's you, Lori) is there any weight to Jim's theory of titanium mesh and/or neat work?  Does this make a difference between having a CSF leak or not?  I wonder what Sam Rush would say?

Just curious,

Jan

[4cm in Pacific Northwest]

I had the belly fat , the titanium mesh … and later also had CSF leaks.  ???I interviewed 9 surgeons and only one said that he always does a lumbar drain as a precautionary measure. HEI however did not think this was necessary and mentioned it can lead to other complications by having another access point to spinal fluid. They said they “ifâ€? there was a need then later a lumbar can be placed in.

I ended up with inflammation and leaks. WHO KNOWS…maybe    we should have done a lumbar drain before the surgery- hard to say… However know mine healed on its own, without a shunt, and I never had an infection. 

The key is to ask your surgeon what his infection rate is.

RE quoting  Lori,

“maybe he put some spackle over the mesh?â€? 

Actually some surgeons do this- it is called “calcium phosphate cement pasteâ€?. Other surgeons feel that it increases the chance of infection and are very opposed to this. My neurosurgeon did not to do this and consequently I can very much feel my big indentation below the skin.    (BTW my tumor was 4cm)

I brought the “lumbar drainâ€? and the “spackleâ€? issue up and got different answers form each different surgeon I interviewed. 

I know of one person, on this forum, that went with one of the surgeons, I personally interviewed and later crossed off my list  , and he DID seal her with the calcium phosphate cement. I asked him what his infection rate was and he basically indicated it was “almost nilâ€?. Later she and I connected and communicated after my surgery. She informed me she actually suffered from meningitis after a shunt was later put in (to deal with CSF leaks) …and she now complains of cognitive issues. (Does that make her one of the “nillâ€? stats being that she had her surgery before I interviewed him?!? Our AN world is small and eventually us patients do get to talk to each other… I am wondering how much honest infection rate reporting took place-in her case.)

I am thinking:
a) that the calcium phosphate may have introduced the bacteria to her CSF
b) she would not have needed a shunt if a lumbar drain was in place  (I am not a surgeon - so not sure)
c) the cognitive issues are not from an AN but more likely from the meningitis she got as a complication of the CSF leak (I.e. inflammation of the brain)

This is a very valid question to ask?

Again-Know that my leaks cleared up on its own without a shunt. Meanwhile as I was experiencing periodic leaks at home- I was taking my temp, ever hour, ready to fly into emergency at the 1st sign of meningitis. It was a stressful and tense time- expspecially since I live out in the country and not in the same state where my surgeon practiced -when this was all happening.    I never got an infection! (9 Months later I am doing fine- here  )

Patients also need to be aware that meningitis can also enter in through a lumbar drain… but also know that to treat meningitis a lumbar drain is put in… to alleviate any inflammation to the brain.

From my experience the lumbar drain is still a much debated issues within the AN medical community (it was right up there with T/L vs R/S for large tumors and facial nerve preservation  )

Daisy Head Mazy


PS
Some people do not want to know all of this information as it is overwhelming. I was one who wanted to know all I could- thus I interviewed so many world renown surgeons and specifically asked about the “lumbar drain� and “the skull spackle�

Here is more information “IF� you care to know

Meningitis
http://en.wikipedia.org/wiki/Meningitis

calcium phosphate cement – article that mentions infection
http://linkinghub.elsevier.com/retrieve/pii/S0278239104012662
(my understanding is that this is still under research- re infection rate)

Risks with the lumbar drain
http://uscneurosurgery.com/infonet/surgery/understand/risks/procedure/lumbar%20drain.htm
&
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1736582
quote
“CONCLUSIONS—External lumbar drainage seems to carry a low risk of infectious meningitis and offers a safe alternative to ventriculostomy or serial lumbar punctures. Antibiotics do not seem to protect completely against developing the infection. The infection happens most often with skin organisms. The meningitis often appears within 24 hours after lumbar drain placement. Daily CSF samples should include bacterial cultures but cell counts may not offer any additional useful information in diagnosing the complication. Lumbar drain insertion and management need not be confined to the intensive care unit.�

[leapyrtwins]

4 -

thanks for the info on the "spackle".

I think Lori was just joking around with me 

Who knew there was such a thing 

Jan

[Captain Deb]

"Skullspackle!" Another one for the AN dictionary!

Don't worry Sam, there is no question you can't ask here.  Feel free.

Capt Deb

[Sammict]

WOW much information to take in about Lumbar drains. I am a bit nervous because i have had migranes since I was 3 yrs old.

I feel confident my doctors are in steering me in the right direction. They were honest with me that my migranes will most likely increase after surgery. I guess thats a stone I will turn if the time comes.

Thanks for all the info.

Sam

[Jim Scott]

Jan:

I never asked my neurosurgeon, the sainted Dr. Issac Goodrich, why his AN surgical patients didn't have CSF leaks, only if his AN surgical patients had them.  His answer was that he hadn't had a CSF leak in an Acoustic Neuroma surgical patient in ( all together now)"years".  He went on to explain (in his usual, helpful manner) that he used the titanium mesh to seal the incision site and that it had proved "very effective".  I simply speculated that, because I had so few complications and Dr. Goodrich is known (and highly esteemed) for being a very cautious and careful surgeon, that he was very meticulous.  The fact that other surgical patients have had CSF leaks with the surgeon using the same kind of material to close the incision presumably validates my (admitted) guess that some surgeons do slightly more precise handiwork than others.  In this kind of demanding neurosurgery, we're talking about tiny gradations of surgical skill, not anything major or even very conspicuous. 

I'm very grateful that I didn't experience a post-op CSF leak but installing a lumbar drain during surgery still seems like a reasonable idea.  However, I can why some surgeons might consider installing the drain during surgery as tacitly admitting that the patient will have a CSF leak, which (they might assume) would make them appear as less than fully competent.   If so, perception would trump caution, but again, I'm simply speculating.  I have no idea what any particular neurosurgeon might be thinking about installing a lumbar drain during surgery, before a CSF leak is indicated.  It's probably just a technical decision, based on their personal experience 

I will state, unequivocally, that not every surgeon is equal in skill and knowledge.  I was very fortunate to have one that is highly skilled and experienced.  No wonder he's been an ANA member for many years. 

Jim

[leapyrtwins]

I will state, unequivocally, that not every surgeon is equal in skill and knowledge.  I was very fortunate to have one that is highly skilled and experienced. 

Jim -

I totally agree with this.  I too was fortunate to have highly skilled and experienced doctors.  I'm grateful for them each and every day 

Thanks for your thoughts on the CSF leaks and titanium mesh.  If I think of it on Wednesday when I get my BAHA processor, I'm going to ask my doc if he feels titanium mesh and neat work make for less CSF leaks.   I'm not really looking for a scientific answer here; I'm just curious to find out his opinion.

Jan

[lori67]

I would venture to say that all surgeons say they perform "neat work".  Except maybe orthopedists, who generally feel it doesn't matter what it looks like, as long as it works!

I guess a leak is just one of those things... some people get AN's - some people don't.  Some people get leaky heads - some people don't.  Maybe those of us that are normally more thickheaded don't get them as often?

Jan, sorry I didn't get back to your spackle question...had to fly out of town unexpectedly last Tuesday to be with my Dad, who passed away on Wednesday.  Still trying to catch up on what I missed around here while I was away.  I did briefly see something about Jim in a coconut bra.... 

Lori

[leapyrtwins]

Lori -

I'm so sorry to hear about your dad - very sad news 

It seems that in your absence Jim decided to take a cruise on the PBW - he's the 2nd moderator in attendance - no word on Joef or Steve (unless I just missed their presence).

I, too, believe that CSF leaks happen for some, don't for others - but it's just my gut reaction; no medical studies to back me up that I'm aware of 

Don't know if my doc will say he does "neat work" or not - worth asking him though.  If nothing else, he'll be amused by the question.  But then again, I always amuse him 

Jan