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Pullout-proofing external ventricular drains: Technical note

Article  in  Journal of Neurosurgery Pediatrics · August 2012

DOI: 10.3171/2012.7.PEDS1280 · Source: PubMed

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 J Neurosurg Pediatrics 10:320–323, 2012

Pullout-proofing external ventricular drains

Technical note

Nathaniel L. Whitney, M.D., M.S., and Nathan R. Selden, M.D., Ph.D.

Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon

Object. The authors describe a method of securing an external ventricular drain (EVD) to prevent dislodgement
and discourage CSF leakage and infection.
Methods. The EVD is secured using a single permanent suture, creating a box stitch around the exit site attached
to a modified roman sandal. Multiple knots are tied after each loop to avoid “telescoping,” loosening, and pullout.
Results. In 12 years of high-volume pediatric practice by one of the authors, only one drain has broken, and none
have pulled out.
Conclusions. The modified roman sandal technique tightly secures EVDs against pullout. Anecdotal evidence
suggests that the strength of the suture construct securing the drain is greater than that of the drain tubing itself.
(http://thejns.org/doi/abs/10.3171/2012.7.PEDS1280)

Key Words      •      external ventricular drain      •      hydrocephalus      •      complication      •     

quality outcome

P
lacing an external ventricular drain is one of the
most basic and important procedures routinely
performed by neurosurgeons.2,4 When used in the
care of pediatric neurosurgical patients, EVDs are typi-
cally left in place for several days.6 During this time,
patient movement and transport to and from procedures
and imaging studies exposes the EVD to the risk of dis-
lodgement or complete pullout. Additional morbidity and
resource utilization may result from the need to replace
dislodged EVD catheters, particularly with decompressed
ventricles.1 Cerebrospinal fluid leakage associated with a
dislodged drain may also result in ventriculitis.7
External ventricular drains are subject to various
technical complications, including inaccurate placement3
and disconnection.6 Little published evidence regarding
the rate of EVD pullout exists. The senior author (N.R.S.)
has observed dozens of cases of EVD dislodgement or
total pullout during training and practice, generally asso-
ciated with the use of a roman sandal technique (Fig. 1).
Typically, this technique fails because the roman sandal
portion of the suture may shorten, increasing the diam-
eter of the loops (“telescoping”), which are then wider
than the outer diameter of the catheter (Fig. 2).
We here describe and illustrate a simple technique
Abbreviations used in this paper: EVD = external ventricular
drain; VP = ventriculoperitoneal.
for using a single permanent suture to secure an EVD
to the scalp, which prevents pullout and discourages
CSF leakage. Although the technique is undoubtedly not
unique, having been inherited and modified by the senior
author (N.R.S.), it has not been described in the literature
and is not commonly used.
Methods
After placing and tunneling the EVD, a box-shaped
purse string suture is placed around 3 sides of the drain
exit site, with the fourth side tied over the top of the skin
so that the drain is not injured in its subcutaneous tun-
nel (Fig. 3). This suture is tied down snugly, closing off
the drain exit tract and thus discouraging CSF leakage
and infection. The use of a long knot consisting of ap-
proximately 6 throws creates a few millimeters of suture
“travel” along the drain. The suture is then looped once
around the drain and knotted again, slightly crimping
but not occluding the drain. Using only a single loop, the
circle cannot subsequently loosen its grip on the drain
catheter. Six throws again creates travel along the drain,
so that a second individual loop may be created a few mil-
This article contains some figures that are displayed in color
on­line but in black-and-white in the print edition.

320 J Neurosurg: Pediatrics / Volume 10 / October 2012

Pullout-proofing external ventricular drains
Fig. 1.  Photograph of the “roman sandal” portion of the suture, which
encircles the drain multiple times between knots, allowing the suture to
contract lengthwise and loosen. In addition, there is no purse string in
the scalp around the drain exit site, leaving it loose. The suture anchors
to the scalp too far from the exit site, allowing the EVD to toggle in and
out of its tract.
limeters further along the catheter. This sequence is re-
peated approximately 6 times. Nylon (3-0) suture has the
ideal characteristics to grip but not injure standard EVD
catheters and may be used for this purpose in patients of
any age undergoing EVD placement. Proper placement of
Fig. 2.  Drawing depicting a traditional roman sandal technique. The
suture is wound repeatedly around the EVD but is limited by knots only
at each end (left). The suture may thus shorten in overall length (right),
widening the diameter of each loop (“telescoping”), which creates loops
that are wider than the outer diameter of the EVD and allows the EVD to
dislodge. Printed with the permission of Andy Rekito, 2012.
J Neurosurg: Pediatrics / Volume 10 / October 2012
Fig. 3.  Drawings of EVD placement.  A: Creation of a subcutane-
ous tunnel ≥ 5 cm in length may reduce the occurrence of infection.  B
and C: Creation of a purse string suture at the catheter exit site discour-
ages CSF leakage and ventriculitis.  D and E: Creation of a modified
roman sandal tie discourages catheter dislodgement or pullout. Multiple
knots are used to “travel” along the catheter. Only a single loop secures
the suture to the catheter between each row of knots, preventing widen-
ing and loosening of each loop. Printed with the permission of Andy
Rekito, 2012.
the suture slightly kinks but does not occlude the drain lu-
men. If the suture is excessively tightened, occluding the
lumen, the entire construct must be removed and started
over again. Fortunately, this occurs extremely rarely even
with inexperienced users.
Additional considerations promote quality outcomes
from external ventricular drainage in children. A sub-
cutaneous tunnel length ≥ 5 cm is associated with lower
infection rates (Fig. 4).5 In children for whom EVD place-
ment may be followed by later VP shunt implantation, us-
ing a curvilinear incision around the bur hole site will
321

Fig. 4.  Photograph of a child who had presented with a fourth ven-
tricular tumor and hydrocephalus. A curvilinear incision away from the
bur hole was used in case a permanent VP shunt was subsequently
implanted. The EVD catheter is tunneled 5 cm from the bur hole to the
scalp exit site, in a direction that would not interfere with the intended
course of a subsequent shunt implantation. Finally, the purse string and
modified roman sandal technique was used to secure the EVD to the
scalp and discourage CSF leakage.
avoid incision complications related to placement directly
over hardware. In such patients, the EVD should not be
tunneled in a direction that will later interfere with subse-
quent VP shunt implantation (Fig. 5).
Results
Minor technical details of even intensive care unit–
based surgical procedures may have a profound impact
on clinical quality and outcomes. Nevertheless, these
details are rarely studied, described, or technically vali-
dated. Similarly, we have not formally validated the cur-
rently described technique for securing EVD catheters.
Nevertheless, we believe the technique has meaning-
ful face validity. In 12 years of high-volume pediatric
neurosurgical practice, including trauma-, tumor-, and
hydrocephalus-related EVD use, the senior author has
never recorded drain dislodgement or pullout with the
placement of 245 EVDs. In 1 case in which a toddler
climbed over the rail of the intensive care unit bed and
fell to the floor, the EVD was fractured and disconnected
at the most distal end of the modified roman sandal ties,
without any movement or compromise of the subcutane-
ous or intracranial portion of the catheter. This anecdote
suggests that the strength of the modified roman sandal
construct may be greater than that of the EVD catheter
itself.
322
N. L. Whitney and N. R. Selden
Fig. 5.  Photograph showing an EVD catheter that was tunneled lat-
erally, potentially interfering with the intended course of a subsequent
VP shunt. In addition, bur hole placement was excessively anterior.
In addition, a colleague has adopted the technique in
a large pediatric neurosurgical practice with a high vol-
ume of endoscopy and hydrocephalus management in the
developing world, in a setting with limited institutional
and nursing resources. He has found that the technique
markedly reduces complications related to EVD dis-
lodgement (L. Albright, personal communication, 2012).
Discussion
External ventricular drain dislodgement or pullout re-
quiring replacement may be a significant morbid event for
pediatric patients undergoing external ventricular drain-
age. Moreover, EVD dislodgement typically represents a
surgical emergency that negatively impacts resource utili-
zation. Preventing EVD dislodgement is therefore a high
priority in clinical care.
The technique described here does not require any
additional suture or material resources other than those
used in the simplest and most commonly applied tech-
niques for securing EVD catheters. The senior author
utilizes approximately 60 additional seconds to complete
the purse string and modified roman sandal technique as
compared with the time required to complete the stan-
dard technique. The technique addresses 2 common and
potentially very morbid problems with EVD placement:
dislodgement and CSF leakage around the catheter lead-
ing to ventriculitis.
Traditionally, technical neurosurgical education has
occurred principally in the context of one-on-one interac-
tions between a faculty member and trainee in the live
clinical environment, leading to tremendous variability in
practice for even the simplest technical maneuvers. New
developments in residency training offer an opportunity
to systematize various aspects of didactic and skills learn-
ing. These trends include the introduction of national
J Neurosurg: Pediatrics / Volume 10 / October 2012
 Pullout-proofing external ventricular drains

training curricula, such as the Accreditation Council for
Graduate Medical Education (ACGME) milestones proj-
ect (www.acgme.org), as well as the use of model-based
 
and digital simulators for technical skills learning. As a
relevant example, the Society of Neurological Surgeons
PGY1 Boot Camp Courses now form a standard compo-
nent of training for all ACGME-accredited neurosurgery  
training programs and include experience with simulated
EVD placement, as well as basic suturing techniques.8,9
 
Conclusions
A simple and inexpensive method to securely attach  
EVD catheters to the scalp and discourage CSF leak-
age along the catheter tract may be accomplished using
a single suture. This technique involves the creation of a  
box-shaped purse string stitch in the scalp and a modified
roman sandal attachment. Use of this technique has been
associated with the absence of EVD dislodgement in a
high-volume pediatric practice over 12 years.  
Disclosure
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this  
paper.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Selden. Acquisition
of data: both authors. Analysis and interpretation of data: both  
au­thors. Drafting the article: both authors. Critically revising the
ar­ticle: both authors. Reviewed submitted version of manuscript:
both authors. Approved the final version of the manuscript on behalf
of both authors: Selden. Study supervision: Selden.
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2011
2.  Kakarla UK, Kim LJ, Chang SW, Theodore N, Spetzler RF:
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placement. Neurosurgery 63 (1 Suppl 1):ONS162–ONS167,
2008
3.  Lee JH, Park CW, Lee U, Kim YB, Yoo CJ, Kim EY, et al: Ac-
curacy of the free hand placement of an external ventricular
drain (EVD). Korean J Cerebrovasc Surg 12:82–86, 2010
4.  O’Neill BR, Velez DA, Braxton EE, Whiting D, Oh MY: A
survey of ventriculostomy and intracranial pressure monitor
placement practices. Surg Neurol 70:268–273, 2008
5.  Omar MA, Mohd Haspani MS: The risk factors of external
ventricular drainage-related infection at Hospital Kuala Lum-
pur: an observational study. Malays J Med Sci 17:48–54,
2010
6.  Roitberg BZ, Khan N, Alp MS, Hersonskey T, Charbel F, Aus-
man J: Bedside external ventricular drain placement for the
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7.  Scheithauer S, Bürgel U, Ryang YM, Haase G, Schiefer J,
Koch S, et al: Prospective surveillance of drain associated
meningitis/ventriculitis in a neurosurgery and neurological in-
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8.  Selden NR, Barbaro N, Origitano TC, Burchiel KJ: Funda-
mental skills for entering neurosurgery residents: report of a
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68:759–764, 2011
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VC, McCartney S, et al: A national fundamentals curriculum
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Acknowledgments
The authors thank Andy Rekito, M.S., for creating the medical
illustrations; Shirley McCartney, Ph.D., for professional assistance
with the manuscript; and Leland Albright, M.D., for encouraging
the authors to broadly communicate this technique through the peer
review process.
References
  1.  Bauer DF, Razdan SN, Bartolucci AA, Markert JM: Meta-
Manuscript submitted February 8, 2012.
Accepted July 5, 2012.
Please include this information when citing this paper: published
online August 3, 2012; DOI: 10.3171/2012.7.PEDS1280.
Address correspondence to: Nathan R. Selden, M.D., Ph.D.,
De­part­
ment of Neurological Surgery, Oregon Health & Science
Uni­ver­sity, 3303 SW Bond Avenue, Portland, Oregon 97239. email:
seldenn@ohsu.edu.

J Neurosurg: Pediatrics / Volume 10 / October 2012 323

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