Role of Lumbar Drains in Contemporary Endonasal Skull Base Surgery: Meta-Analysis and Systematic Review

D’Anza, Brian; Tien, Dessie; Stokken, Janalee K.; Recinos, Pablo F.; Woodard, Troy; Sindwani, Raj

doi:10.2500/ajra.2016.30.4377

Cited by 61 publications

(50 citation statements)

References 44 publications

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“…16 Perioperative CSF lumbar drainage represents one way of potentially mitigating this risk. 20,35 With CSF leak rate reduction through use of vascularized pedicled flaps in reconstruction, there has been a reported reduction of LD usage with emphasis on placement in response to specific reconstruction, flow of CSF leak, and surgeon preference. 23,36 Our survey indicated more respondents place LDs preoperatively as the perceived risk of postoperative CSF leak increases.…”

Section: Discussionmentioning

confidence: 99%

“…23,36 Our survey indicated more respondents place LDs preoperatively as the perceived risk of postoperative CSF leak increases. Contradicting this logic is the recent meta-analysis by D'Anza et al, 35 which found that LD use was not associated with a reduced odds ratio for postoperative CSF leak. When postoperative CSF leak occurs, our respondents attempt conservative management with lumbar drainage an average of 2.5 days, consistent with published recommendations.…”

Section: Discussionmentioning

confidence: 99%

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Survey of endoscopic skull base surgery practice patterns among otolaryngologists

Wannemuehler

Rabbani

Burgeson

et al. 2018

Laryngoscope Investig Oto

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BackgroundEndoscopic skull base surgery (ESBS) is a rapidly expanding field. Despite divergent reported preferences for reconstructive techniques and perioperative management, limited data exist regarding contemporary practice patterns among otolaryngologists performing ESBS. This study aims to elucidate current practice patterns, primarily the volumes of cases performed and secondarily a variety of other perioperative preferences.MethodsAn anonymous 32‐item electronic survey examining perioperative ESBS preferences was distributed to the American Rhinologic Society membership. Statistical significance between variables was determined utilizing Student t, chi‐square, and Fisher exact tests.ResultsSeventy otolaryngologists completed the survey. The effective response rate was approximately 22.5%. Sixty percent of respondents were in full‐time academic practice and 70% had completed rhinology/skull base fellowships. Annually, 43.3 mean ESBS cases were performed (29.1 private practice vs. 52.9 academic practice, P = .009). Academic practice averaged 24.1 expanded cases versus only 11 in private practice (P = .01). Of respondents, 55.7% stood on the same side as the neurosurgeon and 72.9% remained present for the entire case. Current procedural terminology coding and antibiotic regimens were widely divergent; 31.4% never placed lumbar drains preoperatively, while 41.4% did so for anticipated high‐flow cerebrospinal fluid leaks. While considerable variation in reconstructive techniques were noted, intradural defect repairs utilized vascularized flaps 86.3% of the time versus only 51.3% for extradural repairs (P < 0.001). Major complications were rare. Postoperative restrictions varied considerably, with most activity limitations between 2–8 weeks and positive airway pressure use for 2–6 weeks. Most respondents started saline irrigations 0–2 weeks postoperatively.ConclusionsBased on responses from fellowship‐ and non‐fellowship‐trained otolaryngologists in various practice settings, there remains considerable variation in the perioperative management of patients undergoing ESBS.Level of Evidence5

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Survey of endoscopic skull base surgery practice patterns among otolaryngologists

Wannemuehler

Rabbani

Burgeson

et al. 2018

Laryngoscope Investig Oto

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“…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 .…”

Section: Intradural Tumorsmentioning

confidence: 99%

ICAR: endoscopic skull‐base surgery

Wang

Zanation

Gardner

et al. 2019

Int Forum Allergy Rhinol

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279

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Background Endoscopic skull‐base surgery (ESBS) is employed in the management of diverse skull‐base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull‐base surgery have produced the International Consensus Statement on Endoscopic Skull‐Base Surgery (ICAR:ESBS). Methods Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence‐based review or evidence‐based review with recommendations format. Subsequently, each topic was written and then reviewed by skull‐base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. Results The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull‐base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. Conclusion A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence‐based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull‐base community to embrace these opportunities and collaboratively address these shortcomings.

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“…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 .…”

Section: Discussionmentioning

confidence: 95%

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

Roxbury

Lobo

Kshettry

et al. 2017

Int Forum Allergy Rhinol

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Background:The objective of this work was to be er understand variations in perioperative management in endoscopic endonasal skull-base surgery (EESBS) and to identify trends in management based upon the practice pa erns of North American Skull Base Society (NASBS) members. Methods:A 29-question survey evaluating perioperative EESBS management was sent to all NASBS members. Responses were analyzed with descriptive statistics. Subgroup analysis was performed based on participant demographics. A Bonferroni correction was performed and a p value <0.01 was considered statistically significant for subgroup analysis.Results: Of 651 invitees, 116 responded (17.8%). Participants were primarily from the United States (81.0%), and practiced in academic centers (83.6%). The majority were neurosurgeons (55.2%) or rhinologists (27.6%). Most surgeons (83.6%) advocated use of preoperative intravenous antibiotics (96.6%) and image guidance in all cases (83.6%). Lumbar drains were not recommended for cases in which an intraoperative cerebrospinal fluid (CSF) leak was not anticipated (94.8%). Nasoseptal flaps (NSFs) were not recommended in cases without intraoperative CSF leak (84.5%), but were recommended in cases of high-flow intraoperative CSF leak (97.4%). While postoperative restrictions were highly variable, most providers recommended CSF leak precautions (89.7%), flying restrictions (94.0%), and driving restrictions (95.6%) regardless of intraoperative CSF leak status. Most experts also recommended that continuous positive airway pressure (CPAP) be avoided for at least 2 weeks when an intraoperative CSF leak is encountered (81.9%). Conclusion:Despite variation in perioperative management of EESBS patients, important trends were identified by this study. Further investigation is needed to standardize perioperative practice pa erns in EESBS. C 2017 ARS-AAOA, LLC.

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Role of Lumbar Drains in Contemporary Endonasal Skull Base Surgery: Meta-Analysis and Systematic Review

Abstract: Available evidence for the use of LDs in skull base surgery is of poor quality. Analysis of the literature revealed heterogenous and varied reporting in the primary literature. Further studies that include randomized controlled trials are needed.

Cited by 61 publications

References 44 publications

Survey of endoscopic skull base surgery practice patterns among otolaryngologists

Survey of endoscopic skull base surgery practice patterns among otolaryngologists

ICAR: endoscopic skull‐base surgery

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

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