Ventriculostomy for treatment of persistent cervical cerebral spinal fluid leak after excision of cervical schwannoma: a case study.
Benign tumors arising from the Schwann cells of nerve sheaths are called schwannomas. These tumors can occur in any part of the body, but 25%-45% tend to occur in the head and neck (Devender & Pinjala, 2006; Gooder & Farrington, 1980). The treatment of choice for these benign tumors is total resection. Dural involvement of these tumors can lead to potential alterations in wound healing including cerebrospinal fluid (CSF) leaks. The following case report outlines the course of one patient's diagnosis, surgical treatment, and recovery following excision of a cervical schwannoma with an associated CSF leak.
A 59-year-old, white female presented as an outpatient after experiencing a 2-3 year history of progressive right shoulder, back, and upper-arm pain. Despite taking over-the-counter pain medications, the pain worsened during the year, resulting in right lateral neck and arm tingling with referral into her right lateral thumb. Physical examination demonstrated 5/5 muscle strength in upper and lower extremity muscle groups. Tone, coordination, gait, station, and cranial nerves II-XII were grossly intact. Deep tendon reflexes were 2+ with no pathologic findings, with the exception of a positive Hoffman's sign on the right. Past medical/surgical history was noncontributory, and her medications were limited to nonsteroidal anti-inflammatory agents.
Diagnostic exams included an electromyogram (EMG), cervical spine X rays with flexion/extension views, and a cervical spine magnetic resonance imaging (MRI) scan. The EMG reflected an acute right C7 and chronic right C6 radiculopathy. X rays showed no instability but demonstrated moderate degenerative disc disease at C5-C6 with uncovertebral hypertrophic spurring on the left at C5-C6. The cervical spine MRI revealed a dumbbell-shaped mass at C6-C7 within the spinal canal with extension into the right neural foramen; it measured 27 mm x 11 mm transversely and 14 mm craniocaudally. Heterogeneous signal on T2 was noted with intermediate signal noted on T1. Cord signal was within normal limits indicating that the patient had not yet experienced significant cord damage from the tumor's compression.
After the diagnosis of probable cervical schwannoma was made, surgical excision of the mass was planned. She underwent a hemilaminectomy and intradural exploration at C6-C7 with tumor resection followed by fusion. After an uneventful postoperative hospital course, the patient was discharged to home.
The patient did well for the first 48 hours following discharge, after which she began experiencing severe dysesthetic right shoulder, scapular, and arm pain and a fever of 102 [degrees]F. CSF obtained via lumbar puncture was negative for meningitis. A second cervical spine MRI demonstrated a postoperative seroma and postoperative changes. No external wound drainage was noted; the incision remained intact. The patient's status improved after several days of prophylactic antibiotics, muscle relaxants, and medications for neuropathic pain. The patient was again discharged to home.
Several days after her second discharge, she began experiencing intermittent but persistent problems with severe arm pain and incisional erythema. Two weeks after her initial discharge, she was admitted a third time with an intact but fluctuant wound, indicative of pseudomeningocele. She underwent an operative repair of the pseudomeningocele, with placement of artificial dura and a drain on top of the dural repair. No infection was found.
After approximately 1 week, her wound began leaking CSF, and she experienced postural headaches for the first time. She returned to the operating room for operative repair of persistent CSF leak, wound debridement, and a lumbar drain placement. Two additional surgical repairs of her dura were performed within 3 weeks of her initial surgery utilizing fascia lata, artificial dura, and dural glue. She required replacement of three additional lumbar drains as maintaining patency was difficult.
Because of the multiple treatment failures, a decision was made to place a ventriculostomy with intensive care unit monitoring during the third operative repair of the wound and dura. With proximal drainage of CSF, no further CSF leak was noted, and the wound began to heal. The ventriculostomy was removed, and a right-sided ventriculoperitoneal shunt (VPS) was placed and set at 1.5 cm hydrostatic pressure to promote continued wound healing. Due to the prolonged nature of her hospitalization and limited mobility secondary to the external drainage devices, the patient was deconditioned. She was subsequently discharged to an inpatient rehabilitation unit to increase her strength before returning home.
At her 1-month follow-up visit, her incision was well healed. However, she complained of postural headaches. After a head computed tomography (CT) scan showed stable ventricular size, her shunt was increased to 2.5 cm hydrostatic pressure. One month later, the patient returned without complaints, and her wound was intact. Unfortunately, she returned the next month stating that her postural headaches had returned. An outpatient procedure to surgically tie off her shunt was completed with successful resolution of her headache.
Due to the intradural involvement of schwannomas, CSF leaks are an anticipated risk of surgical excision (Acciarri, Padovani, & Riccioni, 1999). As a well-nourished nonsmoker and nondiabetic, her risks for delayed wound healing were low. However, intermittent low-dose steroids used postoperatively and an increased body mass increased her risk for delayed healing. CSF leaks after spinal surgery can occur in the presence of an intact wound. A pseudomeningocele is a CSF leak that occurs with an intact wound. Characteristics include fluctuant bulging of a wound, postural headaches, or focal neurologic findings caused by fluid compression on the nerve roots. Activity limitations, including bed rest with the head of the bed elevated for patients with cervical incisions, and weight-lifting and exertion restrictions may allow healing to occur spontaneously. This limits the pressure placed at the surgical repair site and may encourage dural healing without further intervention. Placement of a CSF diversion device, such as a lumbar drain or ventriculostomy, may be necessary when activity restriction is unsuccessful. If the pseudomeningocele enlarges over time or the wound opens to the outside environment, surgical repair is recommended and can be postoperatively coupled with conservative activity restrictions and diversion measures (Lemole, Henn, Zabramski, & Sonntag, 2001).
In this patient's case, the pseudomeningocele was initially observed. As the patient's symptoms worsened, the patient was taken for her first dural repair. After the first procedure, her wound opened to the external environment. Because this situation increased the likelihood of meningitis, antibiotics were given prophylactically and surgical repair was reattempted along with external CSF diversion via a lumbar drain. Unfortunately, lumbar decompression was ineffective because of problems maintaining patency. Initially, it was presumed that this was due to high CSF protein counts, which are often seen after surgery. Nurses attempted to manage flow by adjusting the height of the drainage system. Repositioning the patient from side to side to assure the tubing was not kinked or broken and distal flush away from the patient were other measures attempted to facilitate drainage. When these efforts failed, the nurse practitioner or neurosurgeon was contacted to attempt sterile flushing of the system toward the patient with preservative-free saline. When these attempts were unsuccessful, replacement of the lumbar drain occurred. However, after three failed attempts to maintain patency with new systems, localized, lumbar CSF depletion was suspected. Further supporting this latter theory was that the patient experienced radicular pain with each irrigation attempt. This was presumed to equate to the collapse of the nerve roots into the drain, which promoted direct lavage of the nerves with irrigation. Due to the prolonged nature of this patient's CSF leak, the risks of ventriculostomy placement for diversion of proximal CSF flow were considered reasonable, and a ventriculostomy was placed. The hypothesis was that with proximal CSF control the patient's wound could heal. As her wound began to heal during the week, the decision was made to convert proximal diversion to a VPS to prevent delayed wound dehiscence. Despite intermittent postural headaches, which were managed by eventually tying off the shunt, the patient suffered no ill effects, and the wound eventually healed during a 6-week period.
Anticipating CSF leaks following excision of dural-based tumors, specifically schwannomas, can prompt early identification and treatment of this phenomenon. Wound fluctuation, clear wound drainage, persistent or worsening neurologic signs, or postural headaches should be reported early to enable a collaborative postoperative plan of care. For patients with persistent CSF leaks following excision of cervical schwannomas, ventriculostomy and VPS placement may be viable options to prevent pseudomeningocele development and wound dehiscence and to enable total wound healing, especially when lumbar drainage has failed.
The author wishes to express appreciation and thanks to Gregory Balturshot, MD, and Suzanne M. Burns, MSN RN RRT ACNP CCRN FAAN FAANP FCCM, for their assistance with the preparation of this manuscript. Balturshot, a neurosurgeon at Riverside Methodist Hospital in Columbus, OH, assisted with the compilation of the clinical content. Burns, a professor of nursing in acute and specialty care and APN2 at the University of Virginia Health System, thoughtfully reviewed the article and provided editorial support. Their expertise and assistance were greatly appreciated.
Acciarri, N., Padovani, R., & Riccioni, L. (1999). Intramedullary melanotic schwannoma. Report of a case and review of the literature. British Journal of Neurosurgery, 13, 322-325.
Devender, S., & Pinjala, R. K. (2006). Schwannoma of the cervical vagus nerve: A case report and review of the literature. Internet Journal of Surgery, 7(2), 1-7.
Gooder, P., & Farrington, T. (1980). Extracranial neurilemmomata of the head and neck. Journal of Laryngology and Otology, 94, 243-249.
Lemole, G. M., Jr., Henn, J. S., Zabramski, J. M., & Sonntag, V. K. H. (2001). The management of cranial and spinal CSF leaks. Barrow Neurological Institute Quarterly, 17(4). Retrieved July 1, 2007, from www.emergemd.com/bniq/article.asp?article_ref_id=17-4-1.
Questions or comments about this article may be directed to Susan Yeager, MS RN ACNP CCRN, at firstname.lastname@example.org. She is a trauma nurse practitioner at The Ohio State University Medical Center, Columbus, OH.
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|Publication:||Journal of Neuroscience Nursing|
|Article Type:||Case study|
|Date:||Apr 1, 2008|
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