Efficacy of Perioperative Lumbar Drainage following Endonasal Endoscopic Cerebrospinal Fluid Leak Repair: A Meta‐analysis

Abstract

Objective Perioperative lumbar drain (LD) use in the setting of endoscopic cerebrospinal fluid (CSF) leak repair is a well-established practice. However, recent data suggest that LDs may not provide significant benefit and may thus confer unnecessary risk. To examine this, we conducted a meta-analysis to investigate the effect of LDs on postoperative CSF leak recurrence following endoscopic repair of CSF rhinorrhea. Data Sources A comprehensive search was performed with the following databases: Ovid MEDLINE (1947 to November 2015), EMBASE (1974 to November 2015), Cochrane Review, and PubMed (1990 to November 2015). Review Method A meta-analysis was performed according to PRISMA guidelines. Results A total of 1314 nonduplicate studies were identified in our search. Twelve articles comprising 508 cases met inclusion criteria. Overall, use of LDs was not associated with significantly lower postoperative CSF leak recurrence rates following endoscopic repair of CSF rhinorrhea (odds ratio: 0.89, 95% confidence interval: 0.40-1.95) as compared with cases performed without LDs. Subgroup analysis of only CSF leaks associated with anterior skull base resections (6 studies, 153 cases) also demonstrated that lumbar drainage did not significantly affect rates of successful repair (odds ratio: 2.67, 95% confidence interval: 0.64-11.10). Conclusions There is insufficient evidence to support that adjunctive lumbar drainage significantly reduces postoperative CSF leak recurrence in patients undergoing endoscopic CSF leak repair. Subgroup analysis examining only those patients whose CSF leaks were associated with anterior skull base resections demonstrated similar results. More level 1 and 2 studies are needed to further investigate the efficacy of LDs, particularly in the setting of patients at high risk for CSF leak recurrence.

ICAR: endoscopic skull‐base surgery

“…Perioperative LD following endoscopic endonasal repair remains a controversial topic. A recent meta‐analysis by Ahmed et al . reviewed 12 studies examining the use of lumbar drains in the perioperative period following endoscopic endonasal repairs of CSF leaks of varying etiologies.…”

“…At some centers, it is used routinely with good success, predominantly for larger high‐grade leaks, whereas in others it may be associated with a higher failure and meningitis rate . Two recent meta‐analyses and a review article failed to find benefit of perioperative lumbar drain placement in patients with pituitary adenomas and other skull‐base tumors, and 1 emphasized potential risk of major complications including meningitis and ventriculitis . However, there is also conflicting data showing that use of intraoperative LD may reduce the risk of intraoperative CSF leak .…”

Perioperative management in endoscopic endonasal skull‐base surgery: a survey of the North American Skull Base Society

“…Complications after EESBS such as CSF leak can lead to costly readmissions and disrupt patient recovery, yet routine intraoperative practices such as the use of LDs and reconstructive techniques have not yet been standardized. Meta‐analyses have not shown any significant decrease in postoperative CSF leak when an LD was used in routine pituitary surgery . Similarly, a more recent large retrospective review showed no decrease in perioperative CSF leak rates in those patients undergoing lumbar drainage .…”

Continuous lumbar drainage and the postoperative complication rate of open anterior skull base surgery

“…With changing trends toward endoscopic approaches for skull base surgery, the elective use of LD in such operations has been widely investigated . Recently, a prospective study found that elective LD placement is related to lower rate of postoperative CSF leaks in endoscopic skull base operations, whereas a meta‐analysis found no difference in the postoperative CSF leak rates or successful repair rates for endoscopic CSF leak repair with elective LD placement …”

“…6 With changing trends toward endoscopic approaches for skull base surgery, the elective use of LD in such operations has been widely investigated. 14,[16][17][18][19] Recently, a prospective study found that elective LD placement is related to lower rate of postoperative CSF leaks in endoscopic skull base operations, 20 whereas a meta-analysis found no difference in the postoperative CSF leak rates or successful repair rates for endoscopic CSF leak repair with elective LD placement. 21 Our current investigation revealed that patients who underwent elective perioperative LD insertion had a higher rate of malignancy as well as a higher rate of dural and intracranial extension of their lesions, and that they were treated more often with adjuvant therapy and had a longer postoperative hospitalization period.…”