Abstract

BackgroundThe semi-sitting position in neurosurgical procedures is still under debate due to possible complications such as venous air embolism (VAE) or postoperative pneumocephalus (PP). Studies reporting a high frequency of the latter raise the question about the clinical relevance (i.e., the incidence of tension pneumocephalus) and the efficacy of a treatment by an air replacement procedure.MethodsThis retrospective study enrolled 540 patients harboring vestibular schwannomas who underwent posterior fossa surgery in a supine (n = 111) or semi-sitting (n = 429) position. The extent of the PP was evaluated by voxel-based volumetry (VBV) and related to clinical predictive factors (i.e., age, gender, position, duration of surgery, and tumor size).ResultsPP with a mean volume of 32 ± 33 ml (range: 0–179.1 ml) was detected in 517/540 (96%) patients. The semi-sitting position was associated with a significantly higher PP volume than the supine position (40.3 ± 33.0 ml [0–179.1] and 0.8 ± 1.4 [0–10.2], p < 0.001). Tension pneumocephalus was observed in only 14/429 (3.3%) of the semi-sitting cases, while no tension pneumocephalus occurred in the supine position. Positive predictors for PP were higher age, male gender, and longer surgery duration, while large (T4) tumor size was established as a negative predictor. Air exchange via a twist-drill was only necessary in 14 cases with an intracranial air volume > 60 ml. Air replacement procedures did not add any complications or prolong the ICU stay.ConclusionAlthough pneumocephalus is frequently observed following posterior fossa surgery in semi-sitting position, relevant clinical symptoms (i.e., a tension pneumocephalus) occur in only very few cases. These cases are well-treated by an air evacuation procedure. This study indicates that the risk of postoperative pneumocephalus is not a contraindication for semi-sitting positioning.

Highlights

  • IntroductionWhile the semi-sitting position facilitates surgery by providing a clean surgical field and enabling a bimanual preparation [9, 16, 17, 24, 28], there is a general reservation due to potential complications such as venous air embolism (VAE), intraoperative hypotension, or postoperative pneumocephalus (PP) [1, 13, 21]

  • The use of semi-sitting position in neurosurgery is still under debate [21, 24]

  • We hypothesize that the opening of the basal cisterns in suboccipital craniotomy with cerebrospinal fluid (CSF) loss may be a strong source of postoperative pneumocephalus

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Summary

Introduction

While the semi-sitting position facilitates surgery by providing a clean surgical field and enabling a bimanual preparation [9, 16, 17, 24, 28], there is a general reservation due to potential complications such as venous air embolism (VAE), intraoperative hypotension, or postoperative pneumocephalus (PP) [1, 13, 21]. As the loss of CSF is a gravity-dependent phenomenon, postoperative pneumocephalus is more frequently found following neurosurgical procedures under semi-sitting position in comparison with the supine position [30]. In order to systematically address to this issue, two groups of patients who underwent retrosigmoid craniotomy under semi-sitting position (group 1) or supine position (group 2) were compared in regard to the appearance of postoperative pneumocephalus. The semi-sitting position in neurosurgical procedures is still under debate due to possible complications such as venous air embolism (VAE) or postoperative pneumocephalus (PP). Studies reporting a high frequency of the latter raise the question about the clinical relevance (i.e., the incidence of tension pneumocephalus) and the efficacy of a treatment by an air replacement procedure

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