Multilayered Repair of High-Flow CSF Fistulae Following Endoscopic Skull Base Surgery without Nasal Packing or Lumbar Drains: Technical Refinements to Optimize Outcome

Background: The introduction of the nasoseptal flap (NSF) revolutionized endoscopic skull base surgery and facilitated the adoption of expanded approaches to extrasellar pathology.[1] However, the use of NSF following a high flow intra-operative CSF leak is often accompanied by the use of nasal packing and/or the insertion of a lumbar drain, both of which have significant shortcomings.[2] [3]

Objective: To review the results of a large series of endoscopic skull base cases with a high flow CSF leak, without adjunctive lumbar drainage or nasal packing and to assess the effect of modifications in technique on postoperative CSF leak rate.

Methods: A database of all skull base cases performed by the senior author over 10 years was reviewed. Data regarding patient demographics, underlying pathology, skull base repair techniques and postoperative complications were analyzed. Univariate analyses were performed to identify factors associated with postoperative CSF leak.

Results: Of 591 consecutive patients undergoing endoscopic endonasal approach to skull base pathology between 2012 and 2021, a total of 144 had a high flow intraoperative CSF leak. The most common pathologies were craniopharyngiomas (56/144, 39%), pituitary adenomas (34/144, 24%) and meningiomas (25/144, 17%). Initially, unstandardized techniques were used consisting of a variety of grafts including synthetic dural substitutes and/or fat graft, covered with a NSF and secured with a variety of dural sealants (collectively called Technique 1; [Fig. 1A]). Subsequently we used a four-layered technique consisting of an inlay layer of fascia lata, followed by an onlay layer of fascia lata, covered by a NSF and secured with BioGlue (Technique 2; [Fig. 1B]); recently this technique was modified to an inlay layer of fascia lata, covered by a NSF which in turn was supported with an onlay layer of fascia lata and secured with BioGlue (Technique 3, “The Dublin Technique”; [Fig. 1C]). In technique 3, by changing the order of layers, we avoided placing any tissue or material between the nasoseptal flap and the dural/bony tissue surrounding the skull base defect. The standardized approaches adopted in Techniques 2 and 3 were associated with a significantly lower rate of CSF leak than that observed with Technique 1 (5/106, 5% vs. 7/36, 19%, p = 0.006) ([Fig. 2]). Technique 3 was associated with a post-operative CSF leak rate of 0/41 (0%). No other factors were associated with a postoperative CSF leak. Lumbar drains and nasal packing were not used in any of the skull base repair techniques.

Conclusion: With iterative modifications and the adoption of a standardized multilayer closure technique for high flow intraoperative CSF leaks, it is possible to obtain a very low postoperative CSF leak rate, without the use of lumbar drains or nasal packing. Placement of materials in the extradural space between the nasoseptal flap and the dural/bony edges of the skull base defect may have a negative impact on the skull base repair.

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Publikationsverlauf

Artikel online veröffentlicht:
01. Februar 2023

• References

• 1 Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006;116(10):1882–1886
• 2 Ackerman PD, Spencer DA, Prabhu VC. The efficacy and safety of preoperative lumbar drain placement in anterior skull base surgery. J Neurol Surg Rep 2013;74(1):1–9
• 3 Lwu S, Edem I, Banton B, et al. Quality of life after transsphenoidal pituitary surgery: a qualitative study. Acta Neurochir (Wien) 2012;154(10):1917–1922