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An external ventricular drain (EVD) placement procedure starts with proper patient positioning. Hair is clipped, skin is prepared, and an incision is made. A drill is used to create the burr hole. The burr hole must follow a well-planned trajectory. Next, the dura is fenestrated, and the tract is created. The catheter is passed, and cerebrospinal fluid (CSF) flow is confirmed. The catheter is tunneled and secured to the skin. Finally, the incision is closed, and the catheter is attached to the transducer. Lumbar drain (LD) placement also starts with proper patient positioning. After the skin is prepared, the Tuohy needle is passed into the thecal sac. Once CSF flow is confirmed, the catheter is passed and the needle is removed. The drain is secured and connected to the transducer.


In this chapter, we cover the pertinent steps of both the external ventricular drain (EVD) and the lumbar drain (LD) procedure. We describe how to troubleshoot problems that can occur at each point of the procedure, and we review the management of complications. Our intent is to give not only the surgeons but also all other members of the medical team an understanding of what occurs during EVD and LD placement so that each drain can be managed successfully after placement.


The patient is positioned for the EVD procedure only after any necessary stabilization. Then, after laboratory workup, medication reversal, and equipment preparation are complete, the patient is positioned for the procedure.

Kocher Point

The Kocher point is the most commonly used approach, as introduced in Chap. 2 (“Anatomy”). If the EVD is being placed at the bedside and in an urgent or emergent manner, the Kocher point should always be used. Its use requires the patient to be positioned supine, with the head in a neutral position. Care should be taken to avoid extending the head, and even slight flexion may be helpful. Extension of the head will bring the exit point of the tunneling trocar closer to the head of the bed, thus increasing the difficulty in exiting the skin. The head of the bed can initially remain elevated to 30° or more (Fig. 4.1). Once the head of the bed has been elevated, the head of the patient should be secured. Some surgeons secure the patient’s head to the bed using tape across the patient’s forehead. However, we have moved away from this practice because we have found that having a second person hold the head steady is more stable than tape. Tape also can induce some extension, especially if the patient sinks lower in the bed, which, as noted previously, can be problematic.


Skin preparation. After hair clipping, scalp cleansing, and marking of the appropriate landmarks, the sterilizing ...

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