Use of Calcium Phosphate Bone Cement in Retrosigmoid Craniotomies Reduces Rates of Craniotomy Site CSF Leak and Pseudomeningocele: A Cohort Study and Meta-Analysis

Background: Postoperative cerebrospinal fluid (CSF) leak through the surgical incision, often preceded by pseudomeningocele, is a potential complication following skull base surgery that can lead to infection and possibly require further surgical intervention. The use of calcium phosphate bone cement (CPC) has been previously described as a strategy to reduce the rates of pseudomeningocele and postoperative CSF leak following skull base surgery. Here, we present our experience with CPC use in retrosigmoid craniotomies and perform a systematic review of the literature to determine the effectiveness of CPC in reducing postoperative complications, including pseudomeningoceles and craniotomy site CSF leaks.

Methods: Single-institution cohort study and systematic literature review and meta-analysis of CPC use in retrosigmoid craniotomies were performed. Univariate analysis via logistic regression was used to determine risk factors associated with postoperative wound complications including pseudomeningocele/CSF leak at the craniotomy site.

Results: A total of 287 patients underwent retrosigmoid craniotomies at our institution between 2017 and 2023 with a mean follow-up of 17 months (range: 2–68 months). 157 (55%) patients were female and mean age at diagnosis was 54 (range: 18–81). At the time of surgery, 12 (4%) patients were active smokers, 53 (18%) were former smokers, and 222 (77%) were never smokers. Mean BMI was 29 kg/m² (range: 17–49 kg/m²). The most common pathology was vestibular schwannoma (68%) followed by meningioma (21%). Bone flap closure with calcium phosphate bone cement (CPC) was utilized in 40 (14%) cases. Within the CPC cohort, 6 patients additionally received cranioplasty with titanium mesh. No pseudomeningoceles or CSF leaks occurred at the craniotomy site within the CPC cohort compared to 18 (7%) patients in the non-CPC cohort (p = 0.078). Of the 18 patients who experienced pseudomeningoceles, 12 required reoperation. Additionally, no patients in the CPC experienced wound infection, dehiscence, or breakdown compared to 10 (4%) patients in the non-CPC cohort (p = 0.195). In univariate analysis, only increased BMI was significantly associated with CSF leak at the craniotomy site (OR: 1.10, 95% CI: 1.02–1.19, p = 0.017). The systematic literature review identified 19 studies discussing the use of CPC in skull base surgery, of which 5 examined retrosigmoid craniotomies. Including the patients in our cohort, there were a total 1313 patients with 607 receiving CPC. In the pooled analysis, CPC was significantly associated with lower risk of pseudomeningocele/CSF leak at the craniotomy site (RR: 0.21, 95% CI: 0.15–0.30, p < 0.0001) and infection (RR: 0.27, 95% CI: 0.17–0.41, p < 0.0001).

Discussion: The use of CPC in retrosigmoid craniotomies serves as a safe and effective strategy to reduce the incidence of pseudomeningoceles and craniotomy site CSF leaks, leading to lower rates of wound related complications and infection.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024