Large Skull Defect is Associated with the Development of Brain Herniation during Continuous Lumbar Drainage

Research Article

Austin Neurosurg Open Access. 2016; 3(1): 1045.

Large Skull Defect is Associated with the Development of Brain Herniation during Continuous Lumbar Drainage

Qian Zhouqi and Wang Ke*

Neurosurgical Department, Shanghai Tenth People’s Hospital, Tongji University, China

*Corresponding author: Wang Ke, Neurosurgical Department, Shanghai Tenth People’s Hospital, Tongji University, 301 Middle Yanchang Road, Shanghai, China

Received: November 09, 2015; Accepted: March 01, 2016; Published: March 04, 2016


Objective: This study investigated risk factors associated with the development of brain herniation during Continuous Lumbar Drainage (CLD) in neurosurgical patients.

Methods: We reviewed medical charts of the patients who consecutively received CLD in our department between January 2010 and Dec 2013. Clinical signs combined with radiographic evidence made the diagnosis of CLD-induced brain herniation. Clinical characteristics between the patients with and without CLD-induced brain herniation were compared.

Results: A total of 108 patients were enrolled, including 80 male and 28 female patients. Among them, 8 (7.4%) patients developed CLD-induced brain herniation. There was no significant difference in patient age, gender, and surgical history before drainage between the patients with CLD-induced brain herniation and those without. Patients with CLD-induced brain herniation showed faster draining speed of Cerebrospinal Fluid (CSF) and a higher rate of large skull defect due to decompressive craniectomy than those without (12.8 ± 4.4 mL/h vs. 10.0 ± 3.3 mL/h, p=0.029; 62.5% vs. 17.0%, p=0.008, respectively). They also demonstrated lower pre-drainage Glasgow Coma Scale (GCS) scores than those without CLD-induced brain herniation although the difference was not significant (p=0.085). After adjusting the effects of the draining speed and pre-drainage GCS score by logistical regression analysis, large skull defect was independently related to a nearly nine-fold increased risk of CLD-induced brain herniation.

Conclusion: Large skull defect is a risk factor with the development of brain herniation during CLD. Altered CSF dynamics in the presence of large skull defect may play a role in the process.

Keywords: Brain herniation; Lumbar drainage; Large skull defect


Continuous Lumbar Drainage (CLD) is a commonly used procedure in neurosurgical practice. This procedure is used to prevent cerebral vasospasm after aneurysmal Subarachnoid Hemorrhage (SAH) [1,2], to treat postoperative or posttraumatic Cerebrospinal Fluid (CSF) fistula [3,4], to manage communicating hydrocephalus after intracerebral hemorrhage [5], or even to reduce refractory intracranial hypertension in traumatic brain injury [6,7]. However, it is not a risk-free procedure. Complications of this procedure have been reported in previous studies, including headache, nerve root pain, meningitis, pneumocephalus, intracerebral hemorrhage, and brain herniation [8-10]. Among them, brain herniation is the most severe complication during CLD, which may result in brain stem dysfunction or even death [11]. Few studies have investigated risk factors associated with such a catastrophic complication in neurosurgical patients who receive CLD treatment. Here, we conducted a retrospective study to reveal its incidence and risk factors.

Patients and Methods

With a waiver of written consent from the Institutional Review Board, we retrospectively reviewed medical charts and radiographic information of the patients who consecutively received CLD in our department between January 2010 and December 2013. Patients with concomitant internal or external ventricular drainage during CLD were excluded from this study. Indications for the usage of CLD in our department included aneurysmal or traumatic SAH, CSF infection, CSF fistula, and communicating hydrocephalus.

Before CLD, We routinely measured opening pressure in lumbar cistern lumbar puncture, and patients with a pressure exceeding 26 cmH2O were excluded from CLD. Patients with coagulation disorders or clinical signs of impending brain herniation were also excluded, which included pupillary abnormalities, compression or absence of basal cisterns on Computered Tomography (CT) scans. The Medtronic Neurosurgical EDM Lumbar Drainage Kit Catheter (Medtronic, MN: USA) was used according to manufacturer’s instructions. The patient was placed in the lateral decubitus position and flexed for insertion of the draining catheter. A 14-gauge Tuohy needle was introduced into the subarachnoid space via the L4/L5 or L3/L4 interspinous space using routine sterile technique. The catheter was inserted through the needle, with the proximal end of 5 cm in the subarachnoid space. The distal end of the catheter was hooked up to a closed draining system with a drip chamber. After the procedure, the patient was strictly kept at bed rest but allowed to turn from side to side and could sit up to less than 45-degree in bed. A target draining speed of 8-10 mL/h was set and the drip chamber was adjusted according to patient’s head. Clinical and neurological conditions were evaluated hourly during the drainage.

CLD-induced brain herniation was diagnosed by clinical signs combined with radiographic evidence: (1) a decrease of Glasgow Coma Scale (GCS) score; (2) unilateral or bilateral pupillary abnormalities; (3) compression or absence of basal cisterns on CT scans, which was not ascribed to new formation or progression of intracranial mass lesions.

Patient demographic features and medical history were reviewed. Average draining speed was calculated by total CSF volume drained out divided by the duration of lumbar drainage in the patients without cerebral herniation. However, this value in those with cerebral herniation referred to the average draining speed before the occurrence of brain herniation.

Continuous data were expressed as mean ± Standard Deviation (SD), and categorical data were expressed as median (Interquartile Range, IQR) or the percentage. All statistical analyses were performed with SPSS 16.0 for windows. The p values were derived from a twotailed unpaired Student’s t-test, the Mann–Whitney test, Pearson’s chi-square test, or the Fisher’s exact test. Logistical regression analysis was performed to adjust the effects of confounders. Differences were considered significant if p value was below 0.05.


A total of 108 patients, 80 male and 28 female, were enrolled, with a mean age of 53.2 years old (Table 1). Indications for CLD included SAH in 36 patients, CSF infection in 53 patients, CSF fistula in 15 patients, and communicating hydrocephalus in 4 patients. Seventyseven patients (71.2%) received brain or spine surgery before the drainage. Among them, 22 patients received decompressive frontotempero- parietal craniectomy, which left them a unilateral large supratentorial skull defect. Sixty-one patients (56.5%) showed obviously decreased mental status (GCS<14) before the drainage.