Objective: In posterior fossa surgery such as microvascular decompression (MVD), cerebrospinal fluid (CSF) leakage is a crucial problem. In this study, we explored the accurate diagnosis and effective non-surgical management of postoperative CSF leakage.Methods: We reviewed 749 patients who underwent MVD surgery from August 2018 to April 2022. Although we significantly reduced the CSF leakage problem by using the triple-layer closing technique (TLCT), CSF leakage was still a problem in a few cases. We managed these patients with the same diagnostic flow and treatment regimen using a lumbar drain (LD).Results: Among the 749 patients in the cohort, 11 (1.4%) had CSF leakage, and each of those cases presented with rhinorrhea. Five patients (45.5%) had the symptom on the first day, two patients (18.2%) on the second day, one patient (9.1%) on the third day, and three patients (27.3%) on the fifth day after surgery. After conservative treatment including CSF drainage via LD for 5.4 days on average, none of the patients had recurrent symptoms suggesting CSF leakage; thus, there was no need for wound repair surgery.Conclusion: Despite diligent attempts to prevent CSF leakage in open microsurgery, leaks inevitably occur in some cases and are more frequent in posterior fossa surgery. Although we cannot fully prevent leakage, we should limit the complication to ensure that it does not progress into other severe problems, such as meningitis. A closing technique such as TLCT is useful, but the early diagnosis and management of CSF leakage with LD is also important.
Sole vein offenders are rare and can be difficult to identify on preoperative magnetic resonance imaging (MRI) and intraoperative microscopy. The objective of this case review was to investigate factors resulting in successful decompression in venous offender cases. Among 234 cases of microvascular decompression surgery performed for hemifacial spasm from September 2020 to April 2022 at Konkuk University Medical Center, only two cases were identified as having a definite venous offender. We reviewed preoperative MRI and intraoperative microscopic findings and studied the correlation between decompression and lateral spread response (LSR) changes. Our two patients had possibility of a small venous offender on preoperative MRI, but it was ambiguous. A definite venous offender was identified on the operative microscopic findings and decompressed successfully, referring to the disappearance of the LSR waveform. Postoperatively, spasm disappeared or significantly improved. A venous offender is difficult to identify on preoperative MRI findings or even on intraoperative microscopic findings. In such cases, changes in the LSR waveform in response to decompressing the suspected vein can be a valuable reference for successful facial outcomes.
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