Late Onset of CSF Rhinorrhea in a Postoperative Transsphenoidal Surgery Patient Following Robotic-Assisted Abdominal Hysterectomy.

Justin T Dowdy,Marcus W Moody,Christopher P Cifarelli

doi:10.1177/2324709614520982

Abstract

Cerebrospinal fluid (CSF) leak is the most commonly encountered perioperative complication in transsphenoidal surgery for pituitary lesions. Direct closure with a combination of autologous fat, local bone, and/or synthetic grafts remains the standard of care for leaks encountered at the time of surgery as well as postoperatively. The development of the vascularized nasoseptal flap as a closure technique has increased the surgeon’s capacity to correct even larger openings in the dura of the sella as well as widely exposed anterior skull base defects. Yet these advances in the technical nuances for management of post-transsphenoidal CSF leak are useless without the ability to recognize a CSF leak by physical examination, clinical history, biochemical testing, or radiographic assessment. Here, we report a case of a patient who developed a CSF leak 28 years after transsphenoidal surgery, precipitated by a robotic-assisted hysterectomy during which increased intra-abdominal pressure and steep Trendelenberg positioning were both factors. Given the remote nature of the patient’s transsphenoidal surgery and relative paucity of data regarding such a complication, the condition went unrecognized for several months. We review the available literature regarding risk and pathophysiology of CSF leak following abdominal surgery and propose the need for increased vigilance in identification of such occurrences with the increasing acceptance and popularity of minimally invasive abdominal and pelvic surgeries as standards in the field.

Highlights

Cerebrospinal fluid (CSF) rhinorrhea is a well-documented complication of transsphenoidal surgery (TSS) for pituitary and parasellar lesions.[1,2,3,4,5,6,7,8,9,10,11] The risk of postoperative CSF leak ranges from 2.3% to 13% in larger series,[1,2,8,9] with advanced technical experience of the surgeon further reducing the incidence to approximately 2%.2 Associated sequelae of untreated CSF leaks may include tension pneumocephaly, prolonged hospitalization, and meningitis, which may be life-threatening.[1,2,5,9] Both repeat transsphenoidal surgery (RTSS) for recurrent disease and the occurrence of CSF flow within the surgical field requiring immediate surgical repair are independent factors for the development of subsequent CSF rhinorrhea.[5,6,7,8] Such leaks commonly present within 1 week of initial surgery; CSF rhinorrhea has been reported to occur up to 10 years after TSS.[6,11]In this report, we describe the case of a patient who developed a CSF leak and subsequent meningitis after undergoing a robotic-assisted hysterectomy
The risk of postoperative Cerebrospinal fluid (CSF) leak ranges from 2.3% to 13% in larger series,[1,2,8,9] with advanced technical experience of the surgeon further reducing the incidence to approximately 2%
We describe the case of a patient who developed a CSF leak and subsequent meningitis after undergoing a robotic-assisted hysterectomy

Summary

Introduction

Cerebrospinal fluid (CSF) rhinorrhea is a well-documented complication of transsphenoidal surgery (TSS) for pituitary and parasellar lesions.[1,2,3,4,5,6,7,8,9,10,11] The risk of postoperative CSF leak ranges from 2.3% to 13% in larger series,[1,2,8,9] with advanced technical experience of the surgeon further reducing the incidence to approximately 2%.2 Associated sequelae of untreated CSF leaks may include tension pneumocephaly, prolonged hospitalization, and meningitis, which may be life-threatening.[1,2,5,9] Both repeat transsphenoidal surgery (RTSS) for recurrent disease and the occurrence of CSF flow within the surgical field requiring immediate surgical repair are independent factors for the development of subsequent CSF rhinorrhea.[5,6,7,8] Such leaks commonly present within 1 week of initial surgery; CSF rhinorrhea has been reported to occur up to 10 years after TSS.[6,11]In this report, we describe the case of a patient who developed a CSF leak and subsequent meningitis after undergoing a robotic-assisted hysterectomy.

Results

Conclusion