Vol. XVII No.

3 JOURNAL OF VASCULAR NURSING PAGE 53

Use of lumbar cerebrospinal fluid drainage in

thoracoabdominal aortic aneurysm repairs
Susan A. Bethel, MS, RN, CNRN

Thoracoabdominal aortic aneurysm repairs present many challenges,

and the complication of paraplegia remains a concern for both the sur-
geon and the nurse caring for the patient in the postoperative period.
Paraplegia can occur secondary to spinal cord ischemia from prolonged
aortic clamping during the repair of the descending thoracic aorta.
Paraplegia is a devastating complication for the patient and family.
Multiple adjunct techniques have been instituted to prevent reduced
spinal cord peifusion during and after the operation, including the use
of shunts and cardiopulmonary bypass, femoral artery-femoral vein
bypass, left atrial-femoral artery bypass, and selective revasculariza-
tion of the dominant intercostal artery. Other methods, such as
somatosensory evoked potential monitoring during the operation and
regional spinal hypothermia techniques, have not reduced the incidence
of paraplegia. ImpJvved outcomes have been seen with the use of meth-
ods to reduce cerebrospinal fluid (CSF) pressure. One such method is
the use of external CSF drainage during the operation, followed by use
of a lumbar drain system for as long as 72 hours after the operation.
This system setup uses a transducer to monitor CSF pressure and a drip
chamber to drain CSF to maintain a normal pressure. This article
describes thoracoabdominal aneurysms, surgical techniques to repair
the aneurysm, and the use of external CSF drainage and related nurs-
ing care measures. (J Vasc Nurs 1999;17:53-8)
Figure 1. Type H thoracoabdominal aortic aneurysm with multicuff
The surgical treatment of the descending thoracic aorta and implantation technique for repair. From Moore W. Vascular surger); 4th
thoracoabdominal aneurysms involves the vasculature of mul- ed. Philadelphia: WB Saunders; 1993. p. 394. Reprinted with permis-
tiple organs, with the potential for major complications and sion of WB Saunders.
high operative risk. The devastating complication of paraple-
gia, resulting from spinal cord ischemia secondary to aortic
clamping during surgery, continues to be reported ranging from from the ascending aorta to the diaphragm and into the
6% to 40%. Multiple adjunct methods have been studied and abdomen, resulting in a thoracoabdominal aneurysm as shown
used to prevent paraplegia, including intercostal artery reim- in Figure 1. This aneurysm continues to dilate and expand and
plantation, assisted circulation with anatomic shunts, cardio- eventually leads to progressive enlargement and rupture. The
vascular pump bypass, somatosensory evoked potential moni- estimated incidence of thoracic aortic aneurysms is 5.9 cases
toring, and, recently, the use of external cerebrospinal fluid per 100,000 persons per year. ] Several factors have been cited
drainage (CSFD). CSFD started during the operation and con- as etiologies for thoracic aneurysms, including arteriosclero-
tinued after the operation has been shown to improve neuro- sis, syphilis, bacterial infections, congenital anomalies, trau-
logic outcome and prevent the effects of spinal cord ischemia. ma, and Marfan's syndrome. 2 Thoracoabdominal aortic
aneurysms (TAA) have been classified into types to better
E T I O L O G Y OF T H O R A C O A B D O M I N A L A N E U R Y S M S define the extent of the aneurysm. A type I aneurysm extends
The intrathoracic aorta may have a localized enlargement from below the left subclavian to above the celiac axis. A type
of all layers of the aortic wall. This enlargement can extend II aneurysm extends from below the left subclavian and
includes the infrarenal abdominal aorta to the level of the aor-
tic bifurcation. A type III aneurysm extends from the sixth
intercostal space, tapering to just above the infrarenal abdom-
inal aorta to the iliac bifurcation. A type IV aneurysm extends
from the twelfth intercostal space, tapering to above the iliac
bifurcation. Sail 3 includes a classification as type V aneurysm,
which extends from the sixth intercostal space, tapering to just
above the renal arteries.
PAGE 54 JOURNAL OF VASCULAR NURSING SEPTEMBER 1999

Anterior Spinal A

Radicular A. (Adomkiewicz)
Posterolateral S Intercostal or Lumber A.)

tlA.

Infrarenal Radi
(From Lumbar A.)

Figure 2. Diagram of the spinal cord blood supply in the lumbosacral segment showing the great radicular
artery: Artery of Adamkiewicz supplying the anterior spinal artery. From Szilagyi DE, Hageman JH, Smith RF,
Elliott JP. Spinal cord damage in surgery of the abdominal aorta. Surgery 1978;83:38-56. Reprinted with per-
mission of Mosby, Inc.

SPINAL CORD P R O T E C T I O N A N D PERFUSION

Figure 3. Illustration of closed external CSF drainage system. Becker
External Drainage and Monitoring System H manufactured by
Medtronic PS Medical, Goleta, Calif. Used with permission of Medtron-
ic PS Medical.
It is important to understand the anatomy and physiology
associated with the spinal cord to relate the potential for para-
plegia or paraparesis during aortic surgery. The arterial blood
supply to the spinal cord consists of 3 longitudinal vessels: the
anterior spinal artery and the 2 posterior spinal arteries. The
anterior spinal artery provides 75% of the perfusion to the spinal
cord. Thirty-one pairs of radicular arteries penetrate the spinal
canal and define 3 major spinal artery territories: cervicotho-
racic, midthoracic, and thoracolumbar. The dorsal lumbosacral
or lower spinal cord area receives its largest volume of blood
supply from the artery of Adamkiewicz or arteria radicularis
magna as seen in Figure 2. This artery originates from the left
intercostal artery between T9-T12 in approximately 80% of
persons and from T5-T8 in the remaining population.], 4-6
Autoregulation provides for constant blood flow to the spinal
cord with changes in vessels affected by carbon dioxide partial
pressure and hypoxia. In the anterior spinal artery, the blood
flow is mainly caudal and unidirectional; however, in the poste-
rior artery, it is bidirectional.
Cerebrospinal fluid (CSF) serves to protect the brain and
spinal cord by circulating throughout the subarachnoid space.
The spinal cord lies within the vertebral column and is covered
by the meningeal layers of dura mater, arachnoid, and pia mater.
CSF flows within the subarachnoid space. The majority of CSF
is secreted by the choroid plexus that protrudes into the fourth
ventricle of the brain and along the inferior surfaces of the later-
al ventricles. These structures produce about 800 mL per day,
Vol. XVII No. 3 JOURNAL OF VASCULAR NURSING
and the pressure of the CSF system is normally about 10 mm Hg.
CSF is reabsorbed by the arachnoid granulations, which are pro-
jections from the subarachnoid space, and flows back into the
venous sinuses of the brain.
Whenever circulation to the spinal cord is compromised by
reduction in blood flow, spinal cord infarction results. Spinal
cord ischemia can occur during the aortic cross clamp period of
thoracoabdominal aneurysm surgical repair. In animal models,
the maximum ischemic time for the spinal cord is 8 minutes. 7
Sustained hypotension in the lower body can lower spinal cord
perfusion, and a rise in CSF pressure further impairs spinal cord
circulation. The pathways in the spinal cord are tightly arranged,
and small infarctions can produce signs and symptoms. The clin-
ical signs will depend on the vascular territory involved and may
PAGE 55
include paraparesis, tetraparesis, paraplegia, or loss of bowel or
bladder sphincter control.
SURGICAL REPAIR OF THORACOABDOMINAL
AORTIC ANEURYSMS
Lain and Aram were successful in surgically treating tho-
racic aneurysms in 1951 with a clear transparent plastic tube in
an aortic homograft. Etheredge et al performed the first thora-
coabdominal aneurysmectomy with a homograft, temporary
aorto-aortic shunt, and reimplantation of the celiac and superi-
or mesenteric artery into the graft. 5 Crawford changed the sur-
gical techniques in the 1980s by leaving the posterior wall of
the aneurysm and implantation of the celiac, superior mesen-
teric artery, and renal arteries into a prosthetic graft. Surgical
PAGE 56 JOURNAL OF VASCULAR NURSING
repair of this aneurysm requires an incision in the fourth or fifth
intercostal space for a type I or II aneurysm or at the level of
seventh to ninth interspace for a type III aneurysm. The length
of time for aortic clamping during resection contributes to the
risk for spinal cord ischemia. The risk has been shown to
increase with cross clamp times exceeding 30 minutes) Pro-
longed aortic clamping results in sustained hypotension and
lower spinal cord perfusion. Selective spinal angiography
before surgery to identify the patency of a critical intercostal or
lumbar artery can help to identify if it arises from the aneurys-
real wall and will increase the risk of postoperative paralysis, s
To reduce the incidence of spinal cord ischemia, the intercostal
arteries, if patent and supplying the spinal cord circulation, are
reimplanted between T8 and L1 level. The addition of left atri-
al to left femoral bypass or distal aortic perfusion during the
surgical procedure is also used to augment spinal cord perfu-
sion. Other intraoperative adjunctive techniques have been
used, including the use of hypothermia and somatosensory or
motor-evoked potential monitoring. 6-8
SEPTEMBER 1999
Studies have reported 5-year survival rates of 7% to 19% for
untreated thoracoabdominal aneurysms. Survival after repair has
been reported as a 5-year survival rate of as high as 59% percent.
Several complications can occur with extensive operative repair,
such as myocardial infarction, renal failure, pulmonary insuffi-
ciency, and stroke. The devastating complication of paraplegia
remains a major complication, with rates ranging from 6% to
40%.6,9,10
E X T E R N A L CSF D R A I N A G E
The current knowledge of spinal cord ischemia associated
with thoracoabdominal aortic aneurysm repair has evolved from
animal research and clinical experience as outlined in Table 1.
This table outlines several studies in which CSF pressure was
measured and drained during thoracoabdominal aneurysm oper-
ations.
Studies have shown that distal aortic pressure decreases
markedly during cross clamping and thus causes a decrease in
spinal artery pressure and a rise in CSF pressure of 30% to 100%
Vol. XVII No. 3 JOURNAL OF VASCULAR NURSING
higher than baseline values.ll Clinical research during the 1990s
used sequential clamping of the aorta and reimplantation of
patent intercostal arteries. The use of CSF drainage was initiated
before aortic clamping and continued after the operation for as
long as 72 hours. CSF pressure was monitored to maintain pres-
sure at <10 m m Hg, with intermittent drainage as needed.
Researchers concluded that drainage of CSF during the opera-
tion and as long as 3 days after the operation can lower the inci-
dence of neurologic complications. Sail 3 reported the paraplegia
rate decreased to 9%.
Reduction of CSF pressure by lumbar spinal drainage can
help to maintain a sufficient perfusion gradient between the local
spinal arterial and venous pressures and serves to maintain some
cord blood flow.1 External drainage can also permit a longer safe
period to allow reinclusion of vital arteries into a thoracoabdom-
inal prosthetic graft.
L U M B A R DRAINAGE SETUP
During the operative preparation and after intubation and
anesthesia induction, the anesthesiologist inserts a spinal needle
into the subarachnoid space at the L4-5 intervertebral space. The
lumbar drainage catheter is advanced through the needle to
approximately the T12-L1 space. The needle is withdrawn, and
the lumbar catheter is left in place. The catheter is secured to the
skin and covered with a sterile occlusive dressing. During the
operation, the anesthesiologist may use the catheter to manually
withdraw CSE An external CSF drainage system must be set up
PAGE 57
with sterile technique and filled with sterile isotonic preservative
free saline before connecting to the lumbar catheter. An example
of this system is seen in the photograph in Figure 3. A nonflush
transducer is attached to the system and connected to the bedside
monitor with the stopcock open to the transducer and patient line
to obtain a waveform and pressure value. The transducer must be
attached at the zero reference level of the system and then zeroed
to atmospheric pressure when connected to the bedside monitor.
The transducer at the zero reference line must be aligned to an
anatomic level of the patient before monitoring of CSF pressure.
The zero reference level for the system is usually the spinal cord
level or the site of the catheter. The surgeon should verify the spe-
cific anatomic patient level for zeroing to be used if different. The
CSF drip chamber with its reference level must be moved up to
the pressure level of 10 mm Hg or as ordered by the physician.
Most systems have premarked levels in either millimeters of mer-
cury or centimeters of water for setting the correct drip chamber
level. The surgeon will order the CSF pressure (either millimeters
of mercury or centimeters of water) to be maintained. When CSF
pressure exceeds the ordered level, the cerebrospinal spinal fluid
is drained into the drip chamber and measured.
Lumbar drains are indicated for the treatment of various other
types of problems. Lumbar drainage can also be used for treat-
ment of postoperative or traumatic dural fistulae (cerebrospinal
leaks). There are 3 types of lumbar drain management tech-
niques: (1) draining at a specific level, (2) draining to a specified
volume, and (3) draining at a specified pressure) 4 A sample of
PAGE 58 JOURNAL OF VASCULAR NURSING
standing orders, which were developed for all 3 types of drain
management, are found in Box 1 and can be used. The purpose
of the use of lumbar drains with thoracoabdominal aneurysm
repair is to drain to maintain a specified pressure. This type of
drainage is shown as option No. 3 on these standing orders.
When draining CSF, the fluid will drain into the drip cham-
ber until the preset level of millimeters of mercury is achieved.
When the system is set to monitor pressure, no CSF is drained
into the drip chamber. When CSF pressure exceeds the specific
ordered pressure level, the stopcock is opened to drain the CSF
and turned off to monitoring of the pressure.
NURSING CARE OF CSF LUMBAR SYSTEM
Specific key components of nursing care are outlined in
Box 2. The external CSF drainage system must be maintained as
a closed system at all times during the postoperative phase. A
comprehensive neurologic assessment should be done at least
every hour or per hospital policy. Clarify with the physician spe-
cific orders for level of activity and whether head of bed should be
elevated. The lumbar catheter and closed CSF drainage system is
maintained for a period of 48 to 72 hours after the operation, and
the CSF pressure and volume of drainage closely monitored.
A working knowledge of thoracoabdominal aneurysms and
the effects of prolonged aortic clamping during surgical repair
are important for the nurse in the postoperative phase. Neuro-
logic assessment, especially of motor functioning of the
lower extremities and bowel and bladder functioning, must be
included in the care plan. Other potential complications
that need to be considered are myocardial infarction, renal
failure, pulmonary insufficiency, and stroke. Aseptic tech-
nique becomes essential in the maintenance of the lumbar
catheter and the closed external CSF drainage system to pre-
vent infection. The nurse must know the normal characteris-
tics of CSF, the pressure level to be maintained, and assess for
signs of abnormal CSF drainage.
Key aspects of patient education to be included in the care
plan are an explanation of why the lumbar catheter is being used,
the importance of adhering to activity limitations, and the safety
measures to ensure patency of the drainage system.
SUMMARY
The use of a lumbar drainage system for a patient after tho-
racoabdominal aneurysm repair operation can offer an adjunc-
tive treatment and preventative measure to avoid neurologic
complications. Repair of thoracoabdominal aneurysms has been
studied extensively to determine best practice for the prevention
of paraplegia. Surgical technique during repair to avoid pro-
longed aortic clamping and the maintenance of spinal cord per-
fusion pressure has been shown to reduce the effects of spinal
cord ischemia. An effective method is to monitor CSF pressure
during and after the operation and include the capability to drain
CSF to maintain a normal pressure.
A thorough understanding of the dynamics of spinal cord
circulation, spinal perfusion pressure, CSF, and the skill of
maintaining a closed lumbar drainage system can enhance the
nursing care of postoperative TAA patients. The vascular nurse,
SEPTEMBER 1999
with expertise in the care of the thoracic surgery patient, can
be instrumental in the prevention and reduction of major com-
plications.
REFERENCES
1. Fann J, Miller D. Descending thoracic aortic aneurysms In:
Bane A, Geha A, Laks H, Hammond G, Naunheim K,
editors. Glenn's thoracic and cardiovascular surgery. Stan-
ford: Appleton & Lange; 1996. p 2255-72.
2. Cohn L. Thoracic aortic aneurysms and aortic dissection.
In: Sabiston D, Spencer F, editors. Surgery of the Chest.
Philadelphia: WB Saunders; 1990. p. 1182-91.
3. Sail H, Campbell M, Ferreira M, Azizzadeh A, Miller C.
Spinal cord protection in descending thoracic and thoracoab-
dominal aortic aneurysm repair. Semin Thorac Cardiovasc
Surg 1998;10;41-4.
4. Benevente O, Barnett H. Spinal Cord Ischemia. In: Barnett
H, Mohr S, Stein B, Yatsu F, editors. Stroke pathophysiology
diagnosis and management. New York: Churchill Living-
stone; 1998. p. 571-765.
5. Connolly J. Prevention of spinal cord complications in aortic
surgery. J Surg 1998;176:92-101.
6. Griepp R, Ergin M, Galla J, Lansman S, Khan N, Quintana
C, et al. Looking for the artery of Adamkiewicz: a quest to
minimize paraplegia after operations for aneurysms of the
descending thoracic and thoracoabdominal aorta. J Thorac
Cardiovasc Surg 1996; 112:1202-15.
7. Berendes J, Bredee J, Schipperheyn J, MashourY. Mechanisms
of spinal cord injury after cross-clamping of the descending
thoracic aorta. Circulation 1982;66(Suppl I):I-112-I-116.
8. Drenger B, Parker S, Frank S, Beattie C. Changes in cere-
brospinal fluid pressure and lactate concentrations during
thoracoabdominal aortic aneurysm surgery. Anesthesiology
1997;86:41-7.
9. Crawford E, Svensson L, Hess K, Shenaq S, Cosellli J, Sail
H, et al. A prospective randomized study of cerebrospinal
fluid drainage to prevent paraplegia after high risk surgery on
the thoracoabdominal aorta. J Vasc Surg 1991; 13:36-45.
10. Hill A, Kalman R Johnston K, Vosu H. Reversal of delayed-
onset paraplegia after thoracic aortic surgery with cere-
brospinal fluid drainage 1994;20:315-7.
11. McCullough J, Hollier L, Nugent M. Paraplegia after tho-
racic aortic occlusion influence of cerebrospinal fluid
drainage. J Vasc Surg 1988;7:153-60.
12. Acher C, Wynn M, Hoch J, Popic P, Archibald J, Turnipseed
W. Combined use of cerebral spinal fluid drainage and
naloxone reduces the risk of paraplegia in thoracoabdominal
aneurysm repair. J Vasc Surg 1994;19:236-48.
13. Sail HJ, Hess KR, Randel M, lliopoulos DC, Baldwin JC, Mootha
RK, et al. Cerebrospinal find drainage and distal aortic perfusion:
reducing neurologic complications in repair of thoracoabdominal
aortic aneurysm types I and 1I. J Vasc Surg 1996;23;223-8.
14. Thompson H. Lumbar drain management; clinical guideline
series. Chicago: American Association of Neuroscience
Nurses; 1998.