Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review

Abstract

Following the introduction of fully endoscopic techniques for the resection of pituitary tumors, there was a rapid expansion of the indications for endonasal endoscopic surgery to include extrasellar tumors of the skull base. These techniques offer significant advantages over traditional open surgical approaches to the skull base, including improved tumor resection, and better post-operative neurological outcomes. Following their introduction, however, the initial rate of post-operative CSF leak was unacceptably high. Post-operative CSF leak following skull base surgery is a major source of morbidity, and can lead to the development of life-threatening intracranial infection. The use of vascularized naso-septal flaps transformed the management of these patients, significantly reducing the rate of post-operative CSF leak and increasing the number of patients that could benefit from this less invasive treatment modality. Adequate repair of iatrogenic defects in the skull base is of crucial importance for patients with skull base tumors, as the development of a post-operative CSF leak, and the associated complications can significantly delay the administration of the adjunctive oncological therapies these patients require. In this review, we provide an overview of the latest evidence regarding skull base reconstruction following endoscopic skull base surgery, and describe the skull base repair technique in use at our institution.

Skull base repair following endonasal pituitary and skull base tumour resection: a systematic review

“…Several reviews (qualitative and quantitative) exploring the available repair techniques in iatrogenic skull base neurosurgery exist. In terms of narrative reviews, Hannan et al explored methods of skull base repair with historical reference and technical details [ 13 ]. Reye et al focused on pedicled and free flaps through narrative discussion, exploring the indications and complication profile for vascularised repair options available [ 20 ].…”

“…fat grafts, nasoseptal flaps) and supportive measures (e.g. lumbar drains) [ 11 , 13 ]. These repair choices may be influenced by numerous factors, including approach (TSA or EEA), presence or grade of intraoperative CSF leak (ioCSFL) [ 14 ], patient characteristics (e.g.…”

“…elevated BMI) and surgeon experience [ 11 , 15 , 16 ]. However, there is a paucity of high-quality evidence or consensus on skull base repair methodology, and surgical practice is resultantly heterogenous [ 11 , 13 , 16 ].…”

Surgical Management of Sinonasal Cancers: A Comprehensive Review

“…Vascularized flaps can also be used to cover the duraplasty and accelerate the healing process, especially if post-operative radiotherapy is planned. The nasoseptal flap can be harvested easily in most situations, but other flaps may be considered if the tumor invades the septum or the pedicle of the nasoseptal flap [60]. The decrease in the CSF leak rate has reduced the need for lumbar drainage, the low complication rate, the shorter hospital stay and has accelerated the dissemination of the technique [60].…”

Endoscopic endonasal surgery for anterior skull base meningiomas

“…In our experience, lumbar drainage is not necessary to ensure effective reconstruction [31] . Should a nasoseptal flap not be available, other vascularized flaps may be considered such as a pedicled middle or inferior turbinate flap or pericranial flap tunneled through a nasionectomy [33,34] . In cases with no available vascularized options, multilayered avascular reconstructions with autologous fat, fascia lata and synthetic materials reinforced with Merocel (Medtronic, Dublin, Ireland) sponges may be required, although CSF leak rates tend to be higher compared to vascularized reconstruction techniques [35] .…”