International Journal of Medicine and

Pharmaceutical Sciences (IJMPS)

ISSN(P): 2250-0049; ISSN(E): 2321-0095
Vol. 4, Issue 5, Dec 2014, 11-16
TJPRC Pvt. Ltd.

EPIDURAL DRAIN INDICATED OR NOT INDICATED UP TO

THREE LEVEL LUMBER SURGERIES
HUSSEIN IMRAN MOUSA1 & ALAA HUSSEIN ABED2
1
2

Department of Neurosurgery, Al-Sedir Teaching Hospital, Basrah, Iraq

University Teaching-Staff Member, Department of Community Medicine, College of Medicine,

University of Thi-Qar, Thi-Qar, Iraq

ABSTRACT
Background
Postoperative spinal epidural drain (PSED) is traditionally used for prevention collectionof postoperative spinal
epidural hematoma (PSEH) and associated neurologic compromise after lumbar spine surgery, but it remains unclear
whether epidural drain reduces or elevates other postoperative complications.
Questions/Purposes
PSED up to three level lumber surgeryindicated or not indicated to decrease postoperative complications.
Patients and Methods
A prospectively study 332 patients who underwent up to three-level lumbar spine surgery. We comparative study
between two groups, First group 152 patients used PSED from March 2006 to May 2009. Second group 180 patients not
used PSED from May 2009 to March 2013.
Results
There are significant reductions in postoperative complications regarding backache and CSF leak but not for
discitis.
Conclusions
There are no afraid from postoperative neurologic compromise due to PSEH when good intraoperative
hemostasis.

KEYWORDS: Postoperative Spinal Epidural Drain= SED, Postoperative Spinal Epidural Hematoma= EH,
Backache, CSF leak and Discitis

INTRODUCTION
Large number of lumber spinal operations performed each year, spinal epidural hematomas are surprisingly rare
after spinal surgery.1,2,3First described by Jackson in 1869,4Although asymptomatic PSEHhas been identified by CT and
MR imaging studies in 33% to 100% of patients who underwent lumbar disc ordecompression surgery,5,6,7,8,9 most cases
are asymptomaticand only in rare conditions does PSEH becomesymptomatic.

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Hussein Imran Mousa & Alaa Hussein Abed

Nonetheless, spinal surgeons should be aware of this clinical entity and its predisposing factors. spinal epidural
hematomas result fromanticoagulation,hemophilia, pregnancy, trauma, garlic ingestion, a complication of anterior cervical
discectomy, aspirin, hypertension, epidural anesthesia, Paget's disease, hemangioma, arteriovenous malformation (AVM),
and epidural varicose veins.10,11,12,13,14 They also may occur spontaneously with no obvious etiology.15,16,17
In spine surgeries, postoperative epidural hematomas and wound infections can have devastating neurologic
sequences.18,19 The quoted incidence of postoperative symptomatic epidural hematoma occurring after all spinal procedures
requiring surgical intervention ranges from 0.2% to 2.9%.20,21PSED is believed effective in preventing these complications
in spine surgery. PSEDconfers no benefit after single-level decompression surgery in the lumbar spine.22
In this study used intraoperative warmed saline sucked cottoned or gausses after well hemostasis and closed the
woundup without the use of prophylactic PSED to decrease postoperative complications, pain, CSF leakand infection.
Patients and Methods
A prospective study for 332 consecutive patients who underwent up to 3 level lumbar discectomy, decompression,
spinal tumor and othersduring a period between March 2006 and March 2013. First group 152 patients with lumber surgery
follow by PSED from March 2006 to May 2009. Second group 180 patients with lumber surgery without PSED from
May 2009 to March 2013.
In both group fusion surgeries were not included in this study. Also no patients were predisposing factors,
anticoagulation, hemophilia, trauma, garlic ingestion, aspirin, hypertension, hemangioma, arteriovenous malformation
(AVM), and epidural varicose veins.
Based on the Centers for Disease Control and Prevention (CDC) guideline, we revised the protocol of
antimicrobial prophylaxis (AMP). In the revised AMP protocol, antibiotics were given only the day of surgery.
A first-generation cephalosporin was administered unless the patient had a history of a significant allergy such as
anaphylactic shock, systemic skin eruption, or toxic liver dysfunction.
The surgery was performed with the decrease blood pressure of the patient but not under hypotensive anesthesia
in which systolic blood pressure was keptmore than 90 mm Hg. Before wound closure, blood pressure was returned to
normotension; Skin incision 5 to 10 cm. homeostasis bony bleeding by bone wax, epidural bleeding by gelfoam and
surgicele, bipolar electrocautery for hemeostasis of the muscles and subcutaneous bleeding.
In second group in addition to above procedure Backing the wound after hemostasis with big piece of warmed
saline cottoned or gases for 5 minutes and some time need repeated applied up to three time. Kept of the postoperatively
patient in supine position.

RESULTS
Mean operating time (50 and 140 minutes)
First group, 152 patients, mean of the age 45.8 year lumber surgery withPSED, 74 discectomy, 57 degenrative,
17 spinal tumor and 4 cases other. 67 single level, 51 two level and 34 three level. Backache in 80, 11 patients develop
CSF leak, 16 patient postoperative discitis, and average of hospitalization 2.63 day. 52.6% radiological finding CT or MRI
epidural hematoma but never cases with sign and symptom of PSEH.

Impact Factor (JCC): 5.1064

Index Copernicus Value (ICV): 3.0

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Epidural Drain Indicated or Not Indicated Up to Three Level Lumber Surgeries

Second group, 180 patients mean of the age 41 year lumber surgery without PSED, 71 discectomy,
70 degenerative, 34 spinal tumor and 5 cases other. 72 single level, 64 two level and 44 three level. Backache in 70,
2 patients had developed CSF leak both of them had spinal tumor, 8 patient postoperative discitis and average of
hospitalization 1.7 day.58.9% radiological finding CT or MRI epidural hematoma but never cases with sign and symptom
of PSEH.
There were no statistically significant for two group regarding age, sex, type of operation, level of operation and
post-operative EDH in CT scan or MRI. P value 0.750, 0.629, 0.750, 0.184 and 0.252 respectively.
Table 1

Postlaminectomy
with drain
Postlaminectomy
without drain
Total
P value

Backache
with
without
Backache Backache
80
72
52.6%
47.4%
70
110
38.9%
61.1%
150
182
45.2%
54.8%
= 0.012

CSF Leak
CSF
without
Leak
CSF Leak
11
141
7.2%
92.8%
2
178
1.1%
98.9%
13
319
3.9%
96.1%
0.004

Desicitis
without
Desicitis
Desicitis
12
140
7.9%
92.1%
8
172
4.4%
95.6%
24
308
7.2%
92.8%
0.188

DISCUSSIONS
PSED has commonly been used in patients having lumbar spine surgery to prevent postoperative complications,
including epidural hematoma and associated complication neurologic compromise. In this study lumber PSED that seem in
CT or MRI asymptomatic this might to be not high pressure to be increase risk of neurological compression due to

Intraoperative warmed saline sucked cottoned or gausses more stimulation tolocal chemical material that liberated
fromincised soft tissue and muscle (surgical trauma)to induced clotting mechanism.

Warmed saline sucked cottoned or gausses had pressure effect to stop bleeding.

Lacerated tissue act as sponge like absorbed blood.

Open spinal canal that prevent risk of pressure effect.

Lumber root tolerate pressure.

postoperative supine position of patient prevent collection of hematoma respectively.

Postoperative CT scan or MRI show traumatizes tissue rather than real blood collection.
There were statistically significant p value 0.012 decrease backaches in patients without PSED as compared with

patients with PSED this most might properly inflame tissue at site of surgery more sensitive to touch so even micro
movement of the drain elicited pain in additional to psychological when the patient look to the drain as knife in his body.
CSF leak show also statistically significant with p value 0.004 was a comparedpatient with PSEDand without
PSEDdue to elimination tunnel that form by drain in patient with PSEH. There were no statistically significant with p value
0.188 regarding discitis in patients with PSED and without PSED this might be the source of discitis internal not decrease
by elimination of external drain or might be required large number of cases. The decrease backache and CSF leak reflected
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Hussein Imran Mousa & Alaa Hussein Abed

decrease time of hospitalization from average day 2. 63 in patients with PSED as compared with 1. 7 in patient without
PSED.

Figure 1
Several limitations to this study should be addressed. The prospective design with small number and the rarity of
the complications limit this study. Tenney et al.23 calculated 2000 patients having spinal surgery would need to be entered
in a study to ensure statistical significance at 5%, assuming prophylaxis was 80% effective in terms of preventing
postoperative wound infections. Dimicket al.24 also determined 5036 patients would need to be enrolled to show a
reduction in the infection rate from 2% to 1%. Clearly, the magnitude of this number indicates a clinical trial is unlikely.
The rare occurrence of these complications precludes any other reasonable study design unless there is a multicenter effort.
Payne et al.25 conducted a prospective randomized controlled study to determine the indications for closed-suction
drainage after single-level lumbar laminectomy without fusion. They randomized 200 operative candidates into two groups
based on the presence or absence of a drain and found two of 103 patients with a drain and one of 97 patients without a
drain had wound infections develop. They concluded closed-suction drainage provided no benefit with respect to rates of
infection and wound healing in lumbar laminectomy without fusion.

CONCLUSIONS
There are no afraid from postoperative neurologic compromise due to PSEHwhen not used PSEDin additional
There were a significant decrease postoperative complications backache and CSF leak but not discitis for up to three level
in lumbar spine surgery in patient without PSED as compared with PSED.

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Impact Factor (JCC): 5.1064

Index Copernicus Value (ICV): 3.0

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Epidural Drain Indicated or Not Indicated Up to Three Level Lumber Surgeries

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Hussein Imran Mousa & Alaa Hussein Abed

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Impact Factor (JCC): 5.1064

Index Copernicus Value (ICV): 3.0