Guidelines for Complications of Cancer Treatment Vol VIII Part B

Conservative treatmentIt is logical to give an adequate trial of conservative methodslike bed rest, serial lumbar punctures and lumbar drainage.Results with more conservative approaches are variable, butare welcome when they occur.a) Position: Head elevation between 45 to 75 degrees ispreferred for postoperative cranial leaks. This allows thebrain to fall down and ensures a tight seal between thebrain and the basal repair.b) Lumbar drain: Lumbar drainage should be consideredwhenever position alone does not significantly reduceor stop the leak. Early use of lumbar drain before a tractis formed is preferable. Drainage should be continuedfor 2 to 3 days after the stoppage of leak to allow healing.Repeated lumbar drainage via puncture is an alternative,though a drain is the best to ensure complete dryness.c) Prophylactic antibiotics are given as a norm. Appropriatespecific antibiotics capable of eliminating the potentialpathogen should be used. A swab from the PNS duringsurgery is advisable prior to starting antibiotics. If patientdevelops meningitis, when on prophylactic antibiotics,the antibiotics are changed to cover the appropriateorganism after culture and sensitivities are checked.Indications for prompt surgical intervention include:a) Leaks associated with obvious disruption or destructionof skull baseb) High pressure leaks acting as a safety valve forhydrocephalus.c) High volume leaks that cannot be controlled by positionand drainage.d) Failure of adequate trial of conservative treatment.e) Delayed postoperative CSF leak249