Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®

Abstract

Objective: Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks.

Methods: This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure.

Results: Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection.

Conclusions: Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Keywords: CSF leak; Cerebrospinal fluid production rate; spinal closure; surgical innovation.

Figure 1.

Illustration of the instituted wound repair & CSF diversion protocol. A mid-thoracic wound, closed in layers is demonstrated. Inferiorly, a lumbar drain is in-situ, and is connected to LiquoGuard7® tubing which has an in-line sensor placed at the axilla (approximating the level of the wound in the axial plane). Distal to the sensor, the tubing connects to a portable LiquoGuard7®, by the patient’s bedside.

Figure 2.

Case of degenerative thoracic disease, with pre-operative MRI scans displaying the large calcified T7-T8 disc prolapse in sagittal (a) and axial (b) profiles.

Figure 3.

Case of benign thoracic spine tumour with pre-operative contrast MRI images showing the recurrent thoracic meningioma in sagittal (a) and axial (b) views. Post-operative images show satisfactory resection in sagittal (c) and axial (d) views.

Figure 4.

Case of benign thoracic spine tumour with immediate post-operative chest x-rays (a) and CTPA (b) showing pleural effusion. After a period of Liquoguard-driven lumbar drainage, a repeat chest x-ray 5 days later (c) shows interval improvement, and a delayed MR 4 months later shows resolution of effusion at the lung bases (d).

Figure 5.

Case of malignant thoracic spine tumour with pre-operative CT images showing the paravertebral metastatic uterine leiomyosarcoma in sagittal (a) and axial (b) views. An MRI sagittal view of the CSF leak after the first operation is displayed in c), with a subsequent MRI after operative exploration, repair and CSF diversion shown in d).^,