Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery

Abstract

OBJECTIVE The aim in this paper was to determine risk factors for the development of a postoperative CSF leak after an endoscopic endonasal approach (EEA) for resection of skull base tumors. METHODS A retrospective review of patients who underwent EEA for the resection of intradural pathology between January 1997 and June 2012 was performed. Basic demographic data were collected, along with patient body mass index (BMI), tumor pathology, reconstruction technique, lumbar drainage, and outcomes. RESULTS Of the 615 patients studied, 103 developed a postoperative CSF leak (16.7%). Sex and perioperative lumbar drainage did not affect CSF leakage rates. Posterior fossa tumors had the highest rate of CSF leakage (32.6%), followed by anterior skull base lesions (21.0%) and sellar/suprasellar lesions (9.9%) (p < 0.0001). There was a higher leakage rate for overweight and obese patients (BMI > 25 kg/m) than for those with a healthy-weight BMI (18.7% vs 11.5%; p = 0.04). Patients in whom a pedicled vascularized flap was used for reconstruction had a lower leakage rate than those in whom a free graft was used (13.5% vs 27.8%; p = 0.0015). In patients with a BMI > 25 kg/m, the use of a pedicled flap reduced the rate of CSF leakage from 29.5% to 15.0% (p = 0.001); in patients of normal weight, this reduction did not reach statistical significance (21.9% [pedicled flap] vs 9.2% [free graft]; p = 0.09). CONCLUSIONS Preoperative BMI > 25 kg/m and tumor location in the posterior fossa were associated with higher rates of postoperative CSF leak. Use of a pedicled vascularized flap may be associated with reduced risk of a CSF leak, particularly in overweight patients.

ICAR: endoscopic skull‐base surgery

“…Over the last decade, the EEA has gradually become the predominant method for pituitary adenoma removal and related parasellar tumors in many centers around the world . After tumor removal, an effective skull‐base reconstruction is essential to avoid a postoperative CSF leak and related complications such as meningitis, pneumocephalus, and reoperation . Although many varied techniques for skull‐base reconstruction and CSF leak have been proposed in both the microscopic and endoscopic eras of pituitary surgery, the majority of publications follow similar principles and methodology.…”

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.…”

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

“…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 . However, in patients at high risk for a postoperative CSF leak, such as those with large anterior or posterior cranial base defects, LD use may be associated with decreased risk of CSF leak.…”