Relationship of CSF Leak to Skin Closure in Surgical Approaches Entering the Posterior Fossa

There are several methods for skin closure during surgical approaches that enter the posterior fossa, including running sutures and staples. It is not clear if one of these methods is superior. We sought to determine whether the use of staples led to a higher rate of CSF leakage. We conducted a retrospective review of case charts involving the posterior fossa entrance via transtemporal, far-lateral, and suboccipital craniotomy. Consecutive cases were selected from one skull base neurosurgeon's practice over a 5-year period. Some cases were performed jointly with the otolaryngology department. The type of skin closure (running suture vs. staples), CSF diversion perioperatively, case complexity (skull base approach vs. standard neurosurgical suboccipital approaches), and the subsequent development of CSF leakage (wound, rhinorrhea, or otorrhea) were recorded. Standard approaches were considered midline or lateral suboccipital craniotomies/craniectomies. These included craniotomy for cerebellar tumor/hemorrhage resection or posterior fossa decompression. Any further degree of drilling or exposure was considered a skull base approach (e.g., translabyrinthine and far-lateral approaches, occipitotemporal reconstructions). The rate of CSF leaks in the sutured group was 8.3%(2/24 cases) and in the stapled group was 5.3%(2/38 cases). The difference was not statistically significant (P = 0.96).

There is a bias toward suturing in skull base approaches; however, within the skull base approach group, there continued to be no difference in the CSF leak rate between the sutured (2/14 or 13%) and stapled groups (2/9 or 22%)(P = 0.95). There were no CSF leaks following standard suboccipital craniotomies in either the stapled (0/29) or sutured group (0/8). Considering the presence of perioperative CSF, diversion did not influence the results.

There are many surgical steps necessary to prevent postoperative CSF leakage. Such prevention depends on meticulous attention to closure of multiple layers and judicious use of perioperative CSF diversion. However, the exact manner of skin closure does not appear to influence the rate of postoperative CSF leakage. The main drawback of this conclusion is the small sample size; however, the conclusions are clinically relevant as they represent a consecutive series in one neurosurgeon's practice over a 5-year period.