Management of Persistent Postoperative Cerebrospinal Fluid Leak Following Removal of Lumbar Spinal Drain After Thoracoabdominal Aortic Aneurysm Repair

To the Editor, Cerebrospinal fluid (CSF) drainage is a component of the multimodal strategy used for spinal cord protection during the repair of thoracoabdominal aortic aneurysm (TAAA).[1] It is performed by placing a continuous spinal drainage catheter in the lumbar region, which is usually removed after 48 hours of TAAA repair. This letter highlights the management of persistent CSF leaks after the removal of the lumbar spinal drain in the postoperative period. A 69-year-old man presented with a diagnosis of Crawford type 4 TAAA with contained hematoma for a surgical repair. After induction of general anesthesia as per our institutional protocol, a thoracic epidural catheter was placed for postoperative analgesia, and a spinal drainage catheter for CSF drainage was placed at the L3–L4 level [Figure 1a]. Under femoral–femoral cardiopulmonary bypass and thoracic aortic clamp, open repair of the TAAA was executed with Dacron aortic graft and bypass grafts to the superior mesenteric artery and right renal artery. The left renal artery was reimplanted directly to the abdominal aortic graft. He had an uneventful recovery in the postoperative period, and his lumbar spinal catheter was removed after 48 hours. On postoperative day 3, we noticed continuous soakage of the dressing of the lumbar drain site. The patient did not complain of headaches, neck rigidity, or other neurological symptoms and imaging of the spine was normal. Since the patient was receiving continuous epidural local anesthetic infusion for postoperative analgesia, we doubted the leak from the lumbar site could be the local anesthetic solution. The fluid was collected from the lumbar site and subjected to a glucose strip and thiopental precipitation tests. Both tests confirmed that the fluid leaking from the lumbar drain site was CSF. A figure of 8 stitch was taken with 3-0 nylon at the puncture site, and a tight dressing was applied [Figure 1b]. No further CSF leak occurred from the lumbar drainage site, and the patient was discharged on the seventh postoperative day. Antibiotic prophylaxis was continued till discharge to prevent occurrence of meningitis.Figure 1: (a) Intraoperative picture showing the cerebrospinal fluid drainage catheter placed in the lumbar region. (b) Postoperative picture showing the site of cerebrospinal fluid leak in the lumbar region closed with a figure of 8 stitch using 3-0 nylon suture (yellow arrow)Persistent CSF leak after lumbar drain removal is very uncommon. We postulate that the obese habitus of our patient could have led to spinal tissue edema, causing difficulty in healing and approximation of tissues after the removal of the lumbar drainage catheter, resulting in a persistent CSF leak. Beta-2 transferrin assay is the most sensitive and specific test for confirming CSF.[2] Since it was unavailable, we performed the CSF glucose test and thiopental precipitation test, which were proven valid.[3] The management of persistent CSF leak includes adequate bed rest, hydration, strict asepsis, analgesics, and epidural blood patch.[4] Since there were not many reports on managing CSF leaks after TAAA repair, we sutured the lumbar puncture site by taking a deep bite with a figure of 8 suture which could have approximated the subcutaneous tissue tract to promote healing and fibrosis of the CSF drainage tract. The precise mechanism behind this complication and the specific treatment modalities are yet to be studied in detail. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.