Multi-layered repair of high-flow CSF fistulae following endoscopic skull base surgery without nasal packing or lumbar drains: technical refinements to optimise outcome

Abstract

Aims Post-operative CSF leak remains a significant problem following endoscopic skull base surgery, particularly when there is a high-flow intra-operative CSF leak. Most skull base repair techniques are accompanied by the insertion of a lumbar drain and/or the use of nasal packing which have significant shortcomings. Our aim was to review the results of a large series of endoscopic skull base cases where a high-flow intra-operative CSF leak rate was encountered and repaired to assess if modifications in technique could reduce the post-operative CSF leak rate. Methods A retrospective review of a prospectively maintained database of skull base cases performed by a single surgeon over a 10-year period was performed. Data regarding patient demographics, underlying pathology, skull base repair techniques and post-operative complications were analysed. Results One hundred forty-two cases with high-flow intra-operative CSF leak were included in the study. The most common pathologies were craniopharyngiomas (55/142, 39%), pituitary adenomas (34/142, 24%) and meningiomas (24/142, 17%). The CSF leak rate was 7/36 (19%) when a non-standardised skull base repair technique was used. However, with the adoption of a standardised, multi-layer repair technique, the post-operative CSF leak rate decreased significantly (4/106, 4% vs. 7/36, 19%, p = 0.006). This improvement in the rate of post-operative CSF leak was achieved without nasal packing or lumbar drains. Conclusion With iterative modifications to a multi-layered closure technique for high-flow intra-operative CSF leaks, it is possible to obtain a very low rate of post-operative CSF leak, without lumbar drains or nasal packing.

The impact of obesity on rates of post-operative CSF leak following endoscopic skull base surgery: results from a prospective international multi-centre cohort study

“…The introduction of the vascularised nasoseptal flap (NSF), pedicled on the sphenopalatine artery, was transformative in the reduction of the incidence of post-operative CSF leak following EEA, which were in excess of 30% in early series ( 40 , 42 , 43 ). In the intervening period following the introduction of the NSF further adjuncts to skull base repair following EEA have been advocated, including the use of tissue sealants, multiple layers of autologous fascia lata, autologous fat graft and nasal packing, although none have demonstrated such a dramatic impact on the rate of post-operative CSF leak as the use of the NSF ( 44 – 46 ). In an effort to further reduce the incidence of post-operative CSF leak, the use of prophylactic lumbar drainage has been advocated: a single centre randomised controlled trial (RCT) of post-operative lumbar drainage demonstrated a significant reduction in the rate of post-operative CSF leak when compared to the cohort randomised to no prophylactic lumbar drainage (8% vs 21%) ( 7 ).…”