Cerebrospinal Fluid Leak Research Articles

Nasoseptal Flap Enhancement on Early Postoperative MRI Does Not Predict 3-Month Enhancement nor Postoperative Cerebrospinal Fluid Leak Risk

BACKGROUND AND OBJECTIVES: The nasoseptal flap (NSF) has been a versatile reconstructive option for extended endonasal skull base surgery, significantly decreasing postoperative cerebrospinal fluid (CSF) leakage rates. One failure mechanism of concern is NSF necrosis. It has been postulated that immediate postoperative MRI flap enhancement can predict flap necrosis. This retrospective study analyzes NSF enhancement to assess for flap viability and CSF leakage. METHODS: Patients from 2012 to 2020 who underwent extended endoscopic endonasal surgery with NSF reconstruction were assessed. Immediate postoperative MRI and delayed 3-month MRI were compared for NSF enhancement. Enhancement was graded as no enhancement, partial, or complete enhancement. Patient demographics, tumor type, intraoperative CSF leak grade, and postoperative CSF leakage were assessed based on flap enhancement patterns. RESULTS: Of 713 patients who underwent endoscopic endonasal surgery, 64 required NSF reconstruction. On the immediate postoperative MRI, 45 patients (70%) had complete flap enhancement, 9 (14%) had partial, and 10 (16%) no enhancement. On the 3-month MRI, 59 patients (92%) had complete flap enhancement and 5 (8%) had partial enhancement. There was significant improvement of flap enhancement between immediate postoperative and 3-month MRI (P = .002). All patients with no initial enhancement had complete enhancement at 3 months. Of those with partial enhancement, 2 remained partial and 7 had complete enhancement at 3 months. Overall, 44 patients (69%) had no change between MRI scans, 17 (27%) improved, and 3 (5%) had decreased enhancement. There was no correlation between intraoperative CSF leak rates and flap enhancement. Four patients had postoperative CSF leaks, 2 having complete immediate enhancement, 1 partial, and 1 without enhancement (P = .85). CONCLUSION: Overall, immediate postoperative MRI NSF enhancement (or lack thereof) did not predict enhancement at the 3-month MRI and did not correlate with postoperative CSF leakage. Hence, one should not rely solely on postoperative flap enhancement to assess the viability of the dural reconstruction.

Sphenoid Sinus Fungal Ball and Reestablishing Sinus Function.

The aim was to assess the developmental attributes of sphenoid sinuses affected by fungal balls and describe a surgical approach which reestablishes gravity-dependent drainage to compensate for any mucociliary dysfunction. A within-patient case-control analysis was performed on sphenoid sinus dimensions from patients with sphenoid sinus fungal ball (SSFB). Radiological dimensions were assessed to determine the dominant or larger sinus by volume and width. Pneumatization in the sagittal and lateral extent was assessed. The influence of sinus size and pneumatization variants within a patient was analyzed. Patency and the presence of mucostasis from radical reshaping of the sinus cavity were documented at least 3 months after surgery. Complications (bleeding, cerebrospinal fluid leak, and cranial nerve palsy) were recorded. Twenty-three patients (59 ± 19 years, 86% female, 46 sphenoid sinuses) were assessed. Fungal ball was more common in the smaller (non-dominant) sinus, by width (78% vs. 22%, p < 0.01) and by proportion of total sphenoid volume (0.39 ± 0.16 vs. 0.61 ± 0.16, p < 0.01). Pneumatization variants did not influence the development of SSFB within a patient. All patients had patency and the absence of mucostasis or persistent inflammation at last follow-up. No complications were reported. The smaller or nondominant sphenoid sinus is more affected by SSFB. Surgical reshaping of the sphenoid to prevent mucostasis is favorable in managing the smaller affected sinus cavity. 4 Laryngoscope, 134:4888-4892, 2024.

Expert consensus on diagnosis and treatment of spontaneous intracranial hypotension(2024)

Spontaneous intracranial hypotension is a disease characterized by orthostatic headache caused by spinal cerebrospinal fluid leakage. Patients have to remain bedridden, which significantly affects their quality of life. In severe cases, complications such as subdural hematomas may occur. Clinical practice reveals a high rate of misdiagnosis and insufficient implementation of diagnostic and treatment measures. To improve clinical physicians' understanding of spontaneous intracranial hypotension and to standardize the diagnosis and treatment, the Neurologist Branch of the Chinese Medical Doctor Association and the Headache and Sensory Disorders Committee of the Chinese Research Hospital Association organized experts to develop a total of 30 recommendations on the clinical identification, examination processes, diagnostic criteria, treatment, and follow-up of spontaneous intracranial hypotension based on domestic and international clinical practices and recent literature evidence after extensive discussions.

Spontaneous Intracranial Hypotension and Dural Ectasia in Marfan Syndrome: An Illustrative Case Successfully Treated with Steroid Therapy and Literature Review

Background: Spontaneous intracranial hypotension (SIH) is a rare and frequently misdiagnosed disorder characterized by a low volume of cerebrospinal fluid (CSF) caused by the leakage of CSF through the spinal dural membrane. Patients with Marfan Syndrome (MS) and other connective tissue disorders are at an increased risk for dural ectasia, which may predispose them to spontaneous CSF leaks due to the structural weakness of their dural membranes. The management of SIH in MS patients is debated. Conservative measures, an epidural blood patch (EBP), and surgical treatments are the options generally provided. Methods: Herein, we report on the case of a 52-year-old female affected by MS, genetically confirmed, with a two-month history of sudden-onset, “thunderclap” headache, worsened in an upright position and horizontal diplopia. A Computed Tomography (CT) scan of the brain showed a bilateral chronic subdural hematoma, slit ventricles, and a caudal descent of the brainstem without overt tonsillar herniation. The Magnetic Resonance Imaging (MRI) scan of the whole spine revealed dural ectasia in the lumbosacral area and presacral perineural cyst without extradural CSF collection. The case was successfully managed with bed rest and high-dose corticosteroid therapy. Then, we discuss the pertinent literature, consisting of 25 papers dealing with the treatment of SIH in patients affected by MS. Results: The literature review yielded 25 papers dealing with SIH management in patients with MS, including 28 patients overall; 21 patients underwent EBP, of whom 7 patients had multiple procedures. Overall, in 23 cases (82%), the symptoms improved. In three cases, the patients were managed conservatively with bed rest. In three of these cases, there was an improvement. In one case, the surgical fenestration of two lumbar intradural spinal meningeal cysts was performed and the patient improved after the procedure. Our patient underwent 15 days of steroid therapy (dexamethasone iv 12 mg/day for 7 days, then reduced to 4 mg/day) and intravenous hydration (Ringer lactate 1500 mL/day). In ten days, the symptoms disappeared. At the 6-month follow-up, the patient was in good clinical condition, and a CT scan showed an almost complete regression of the bilateral subdural hematoma. Conclusions: The management of SIH in MS patients is still challenging. Patients with connective tissue disorders such as MS are at an increased risk for SIH. Few studies have assessed the management of these patients and different strategies. Our case and the available literature provide further data for this type of case.

Clinical study of percutaneous endoscopic thoracic spine surgery via trench technique for thoracic spinal cord ventral decompression

To evaluate the feasibility, safety, and early effectiveness of percutaneous endoscopic thoracic spine surgery via the trench technique for ventral decompression in central calcified thoracic disc herniation (CCTDH) and thoracic ossification of the posterior longitudinal ligament (T-OPLL). Seven patients with single-segment CCTDH or T-OPLL admitted between June 2017 and May 2020 and meeting the selection criteria were retrospectively analyzed. There were 3 males and 4 females with an average age of 51.7 years ranging from 41 to 62 years. There were 2 patients with T-OPLL (T 1, 2 in 2 cases) and 5 patients with CCTDH (T 1, 2 in 1 case, T 7, 8 in 1 case, T 10, 11 in 2 cases, T 11, 12 in 1 case). Five patients with thoracic axial pain and intercostal neuralgia had a preoperative visual analogue scale (VAS) score of 6.0 (5.0, 6.5), and 7 patients had a preoperative Japanese Orthopaedic Association (JOA) score of 21 (21.0, 22.0). Transforaminal approach was used in 4 cases and transpedicular approach in 3 cases. Ventral decompression of thoracic spinal cord was performed by thoracic endoscopy combined with trench technique. The operation time, intraoperative blood loss, postoperative hospital stay, and postoperative complications were recorded. Thoracic spine CT and MRI were performed preoperatively and postoperatively to evaluate the surgical decompression, VAS score was used to evaluate the pain of thoracic back and lower limbs, and JOA score was used to evaluate the functional recovery. Modified MacNab criteria was used to evaluate the effectiveness. All surgeries were successfully completed. The operation time ranged from 60 to 100 minutes, with an average of 80.4 minutes; the intraoperative blood loss ranged from 40 to 75 mL, with an average of 57.1 mL; the postoperative hospital stay ranged from 4 to 7 days, with an average of 5.4 days. CT and MRI examinations indicated that the decompression was adequate. All 7 patients were followed up 3-22 months, with an average of 13.3 months. One case developed postoperative wound infection, and 1 case developed pneumonia; the remaining patients did not have any complications such as wound infection or cerebrospinal fluid leakage. Five patients with thoracic axial pain and intercostal neuralgia had VAS scores of 2.0 (1.5, 2.5) at 1 day after operation and 2.0 (1.0, 2.0) at last follow-up, both of which were significantly lower than the preoperative scores ( P<0.05). At 1 day after operation, the JOA scores for all 7 patients were 22.0 (21.0, 24.0), which showed no significant difference compared to the preoperative score ( P>0.05); however, at last follow-up, the score improved to 24.0 (24.0, 26.0), which was significant compared to the preoperative scores ( P<0.05). At last follow-up, the effectiveness was assessed using the modified MacNab criteria, the results were excellent in 2 cases, good in 3 cases, fair in 2 cases, and the excellent and good rate was 71.4%. Using the trench technique, percutaneous endoscopic thoracic spine surgery can achieve the ventral decompression in CCTDH and T-OPLL, providing a new approach for surgical treatment of CCTDH and T-OPLL.

The drainage volume control by elevation of drainage height versus head down tilt in supine position for management of cerebrospinal fluid leakage following lumbar posterior surgery.

To compare the clinical outcomes of control of drainage volume through either elevating the drainage height or tilting the head down in a supine position for the management of cerebrospinal fluid leakage (CSFL) following posterior lumbar surgery. A retrospective analysis was conducted to review the data of patients who underwent lumbar spine surgery at a single hospital over a 4-year period from January 2020 to December 2023. Postoperative CSFL and complications were recorded. All patients with CSFL were managed with bed rest, a 20-30° head-down tilt position, or a drainage system elevated by 10cm, along with subfascial drains, for a duration of 3days. The clinical outcomes of drainage volume control were compared between the elevation of the drainage system and the head-down tilt position in the supine posture. The incidence of CSFL after lumbar surgeries was 1.2% (84 out of 7,284 cases). None of the CSFL patients experienced significant complications or required reoperation. When compared to the traditional Trendelenburg position, elevating the drainage height reduced the incidence of headache and dizziness, as well as shortened the time to ambulation, postoperative defecation time, and postoperative hospital stay, with statistically significant differences (p < 0.05). Postoperative drainage volume control using the Trendelenburg position or elevation of the drainage height is both safe and effective for the management of CSFL. The method involving a 10cm elevation of the drainage system appears to be an easier and more clinically acceptable approach for the nursing care of CSFL following posterior lumbar surgery.

COMPLEXITY OF PITUITARY ADENOMA SURGERY

Introduction Pituitary adenomas are the most common intraselllar tumors, representing 16% of all intracranial lesions. Although the symptomatology is very complex, it requires a multimodal treatment plan, in order to cover all corners of this combined pathology. Mostly the treatment is surgical, hormonal or combined. The transnazosphenoidal corridor offers a optimal visualitation of the anatomic location (via microscope or endoscope) but also comes with a variety of morbidities, one of the most important being the cerebrospinalfluid fistula (CSF leak). Objective We effectuated a retrospective cohort study in which we included patients with pituitary adenoma who were operated in the Clinic of Neurosurgery from Targu-Mures Emergency County Hospital between January 2018 and April 2024 with full documentation, including complications (apoplexy, infections, CSF fistula etc.). Results A total of 45 patients passed the inclusion criteria with a predominance of female patients (60%, n=27) with a mean age of 55.77 years. Analizing the clinical and paraclinical data, there were 39 patients with macroadenoma (vs. microadenoma n=6), with the dominant symptomatology being headache (86.66%) and visual disturbances (66.66%). In 32 cases the transnazosphenoidal (TSS) approach was used (1 case endoscopic and 31 cases microscopic), in 10 cases pure transcranian with modified pterional or subfrontal craniotomy and in 3 cases there was a combined approach. Postoperative complications were encountered in 8 cases (17.77%), and death in 1 case. 6 patients presented postoperative CSF fistula. In 16 cases we encountered postoperative Diabetes Insipidus with a significant difference in the tumor volume favoring this manifestation (p=0.0001). There was no significance found between the volume of the tumor and postoperative CSF leak (p=0.665). In 31 cases (68.88%) the TSS approach was used and the closing of the sphenoid sinus and cranial base was effectuated in a classic manner with fat, fascia and muscle; in additional cases specified glues were used. Conclusions Our study wants to reflect on the importance of anterior/middle cranial base closure, taking into account the possible postoperative complications. It is important to be aware of the technique of different nasoseptal flaps in order to prevent CSF fistula and reduce postoperative complications.

NEW TECHNOLOGIES AVAILABLE FOR MICRONEUROSURGICAL REMOVAL OF ACOUSTIC NEUROMAS

Introduction The aim of this study was to analyze the results of microsurgery removal of acoustic neuromas (AN) using new technologies: flexible hand-held laser fiber, Sonopet Ultrasound Aspirator, Facial Nerve “detector” monopolar stimulation (for localize position and course of facial nerve), BAER’s with level specific (LS) CE-Chirp stimulus for hearing preservation, endoscope for IAC final check, and injectable bone substitute for closure. We report a retrospective nonrandomized clinical study on 300 cases consecutively operated on. Material and Methods From July, 2010 to December, 2023, 350 consecutive patients suffering from AN have been operated on with microneurosurgical technique by key-hole retrosigmoid approach. In majority of cases tumor resection was performed with the aid of a handheld flexible laser fiber. In the same period, Sonopet Ultrasound aspirator was used for tumor debulking and/or opening of the internal auditory meatus and canal. From May 2015, hearing preservation by means LS CE-Chirp BAER was attempted in patients with preoperative socially useful hearing (AAO-HNS class A and B). In addition, we check the removal of tumor inside the internal auditory canal (IAC) by using the flexible and/or rigid endoscope, for completing tumor removal near the fundus. Results Overall time from incision to skin suture changed in relation to size of tumor (from 165 to 575 minutes) and was not affected by the use of hand-held laser. Facial nerve function was clinically assessed with the House-Brackmann (HB) scale preoperatively, in the early postoperative period (after 1 week), and at 6-month follow-up. In 3 cases a preoperative facial nerve palsy was observed (HB III and HB IV, respectively). In the remaining cases, 6 months after surgery facial nerve preservation rate (HB I) was 92%, Hearing preservation rate (AAO-HNS A and B, pre- and postoperatively) was 52% in eligible cases. Total and “nearly total” removal of tumor was possible in about 80% of cases. Dura closure was performed with underlaying autologous pericranium. Injectable bone substitute in the gaps after bone flap repositioning minimized postoperative CSF leakage and improved the aesthetic result. Conclusions The use of new technologies (handheld flexible laser fibers, Sonopet Ultrasound Aspirator, fluoreceine, Nimbus facial nerve continuous monitoring, LS CE-Chirp BAER, endoscope for IAC final check) in AN microsurgery seems to be safe and efficacious and facilitates tumor resection, especially in ‘‘difficult’’ conditions (e.g., large size, highly vascularized, or hard tumors). The good functional outcome following conventional microsurgery seems to be further improved and the extent of tumor removal could be increased with the proper use of the new technologies available in the neurosurgical armamentarium.

The Challenges of Patients with Spinal CSF Leaks in Canada: A Cross-Sectional Online Survey.

Spinal CSF leak can cause disabling headaches and neurological symptoms. Lack of awareness, diagnostic delay and treatment inconsistencies affect the quality of CSF leak care globally. This is the first study aiming to identify and assess these challenges in Canada. A cross-sectional online survey of Canadian patients with spinal CSF leak was designed in collaboration with Spinal CSF Leak Canada, including questions on demographics, headache condition, investigations, treatments, quality of life, financial consequences and out-of-country care. The survey captured 103 respondents with confirmed spinal CSF leak diagnosis, of whom 56% were still suffering. The majority were female (80%), most being highly educated, with a mean age of 41.8 (SD: 10.37) years at the time of diagnosis. Inconsistencies in care resulted in variable durations for obtaining diagnosis and treatment. The majority of respondents (88%) had seen multiple physicians, and only 50% had seen a CSF leak specialist. Invasive imaging was not performed in 43%. CSF leak relapse after initial successful treatment occurred frequently (43%). The incidence of rebound intracranial hypertension was high (52.5%), and the treatment was difficult to access (77%). Out-of-country care was common (28%), and the impact on financial health was omnipresent (81.5%). The survey demonstrates significant gaps in spinal CSF leak care in Canada, similar to global observations. Lack of awareness and access, delayed care, and inconsistencies in investigations and management are common. Spinal CSF leak significantly impacts patients' physical, mental and financial well-being. Increased awareness, referral pathways and standardized treatment algorithms are key factors in optimizing patient care in Canada.

Dorsolateral Transdural Surgical Management of Spontaneous Intracranial Hypotension From Ventral Dural Cerebrospinal Fluid Leaks: Case Series and Technical Report

BACKGROUND and OBJECTIVES: Spontaneous intracranial hypotension is an uncommon but debilitating condition that commonly involves positional headaches and vertigo. One cause is cerebrospinal fluid (CSF) leakage from ventral dural defects from calcified spinal discs. Patients can undergo epidural blood or fibrin glue patches as treatment; however, in cases where the leak does not resolve, surgical repair of the dural tear may be warranted. We aim to describe a case series and technical notes for these patients. METHODS: Patients with spontaneous intracranial hypotension because of myelography-confirmed ventral dural defect from calcified thoracic disc, who were treated surgically between June 2020 and March 2024, were included in the study cohort. Demographic information, clinical course, and postoperative outcomes were collected. The surgical technique was also described based on an illustrative case. RESULTS: Twelve consecutive patients underwent surgery between June 2020 and March 2024 with postoperative records. The median age at the time of surgery was 41.5 years (range: 28-58 years). Male patients comprised 50% of the cohort. Dural defects were spread throughout the thoracic spine in the cohort. While all patients reported positional headaches, other symptoms included vertigo, pulsatile tinnitus, and neck pain. Median length of follow-up time was 6.5 weeks. There were no surgical complications or permanent neurologic deficits. All patients had radiologic cure of their leaks with absence of extradural CSF on postoperative MR imaging. Ten patients (83.3%) had complete resolution of spontaneous intracranial hypotension-related symptoms. Two patients did suffer from rebound headaches postoperatively. CONCLUSION: The dorsolateral transdural surgical approach is a safe and effective method to repair type 1 CSF leaks caused by ventral dural defects. Our case series of 12 patients did not involve any surgical or immediate postoperative complications, and all patients had radiologic resolution of their leaks with relief of positional headaches. Two patients experienced continued headaches after treatment.

Operative treatment and postoperative complications of a frontal sinus fracture: a case report

Frontal sinus fractures are significant injuries; they represent approximately 5-15% of all maxillofacial trauma cases. These fractures can cause complications and present important challenges. The type of surgical technique used, such as sinus reconstruction or obliteration, depends on the severity of the trauma and the general condition of the patient. The surgical treatment for frontal sinus fractures may include a coronal approach. The outcomes associated with frontal sinus fractures can range from mild headaches to severe complications, including cerebrospinal fluid (CSF) leakage; in cases of ineffective conservative treatment, surgical intervention may be necessary. TachoSil is used as a sealing agent during surgery to mitigate potential complications.

Nasoseptal Flap Reuse for Reconstruction in Revision Endoscopic Skull Base Surgery

Abstract Introduction The nasoseptal flap (NSF) is the “workhorse” for reconstruction in endoscopic skull base surgery. It creates a reliable, watertight closure to prevent cerebrospinal fluid (CSF) leaks. The flap's robust vascular pedicle allows for it to be taken down and reused in subsequent reconstructive surgeries if needed. Previous literature has demonstrated successful reuse of the flap up to 24 months after initial surgery. The present study analyzes a cohort of patients with NSFs that were reused up to 12 years following the initial surgery. Methods A retrospective analysis was performed on patients who underwent revision endoscopic skull base surgery for recurrent tumor at a tertiary academic skull base center. Patient demographics, tumor type, length of time between first and second surgery, and outcomes were evaluated. Results A total of 15 patients were identified between 2012 and 2022 who underwent revision endoscopic skull base surgery with previous NSFs that were reused for reconstruction. The time interval between surgeries ranged from 9 months to 12 years. There were 12 pituitary adenomas, 2 Rathke's cleft cysts, and 1 craniopharyngioma. One patient developed a CSF leak 5 days postoperatively, which was repaired with an abdominal fat graft, synthetic dural substitute, and a middle turbinate flap. The operative technique for the take-down and reuse of the NSF will be demonstrated. Conclusion The NSF can be taken down and reused in revision endoscopic skull base cases, even several years after the initial surgery, with excellent coverage of the defect and low incidence of postoperative CSF leak.

Pneumatization pattern of the temporal bone with volumetric assessment and its impact on the frequency of cerebrospinal fluid leak in patients undergoing vestibular schwannoma surgery via the retrosigmoid approach

IntroductionVestibular schwannomas are benign tumors that account for 8% of all intracranial tumors. Due to their location in the cerebellopontine angle and internal auditory canal, access to these lesions requires disruption of the temporal bone. The pneumatization of this bone varies between individuals, and literature reports suggest that it may influence the frequency of cerebrospinal fluid leaks. In our study, we assessed whether the pneumatization of the temporal bone differs in individuals with or without cerebrospinal fluid leak.MethodsWe conducted a retrospective analysis that initially included 143 individuals, of whom 103 were ultimately qualified for the study. We analyzed the clinical data of the patients and the radiological characteristics of the pneumatization of the temporal bone using volumetric methods, additionally relying on classifications of temporal bone pneumatization.ResultsPneumatization of the temporal bone in patients operated on for vestibular schwannoma with cerebrospinal fluid leakage was significantly higher compared to the group without leakage (Right: 11.15 [IQR 8.93–12.83] vs. 13.25 [IQR 10.15–15.53]; p = 0.040; Left: 10.95 [IQR 9.5–12.26] vs. 14.4 [IQR 13.03–15.7]; p = 0.012). Additionally, a higher degree of pneumatization of the petrous apex was significantly more frequent in the group with cerebrospinal fluid leak in both left (p &amp;lt; 0.001) and right (p &amp;lt; 0.001) side.DiscussionThe analyzed data suggest that greater pneumatization of the temporal bone and a higher degree of petrous apex pneumatization in the classification of temporal bone pneumatization may be associated with an increased risk of cerebrospinal fluid leak. To draw causal inferences, prospective studies in this area are necessary.

Spontaneous cerebrospinal fluid rhinorrhoea: a case report and literature review

BackgroundCerebrospinal fluid rhinorrhea is a rare condition characterized by the abnormal leakage of cerebrospinal fluid from the intracranial space into the sinonasal cavity. It includes various etiologies, including traumatic, iatrogenic, and spontaneous causes, each with distinct epidemiological and clinical characteristics.Case presentationA 40-year-old Asian female presented with a three-month history of watery discharge from her left nostril and dull headaches localized to the left side of her head. Despite the initial diagnosis of allergic rhinitis, symptoms persisted, leading to further evaluation and eventual diagnosis of cerebrospinal fluid rhinorrhea. Detailed history, physical examination, and diagnostic tests including fluid analysis and imaging confirmed the diagnosis. The patient underwent a successful surgical repair after failed conservative management, highlighting the importance of timely intervention.ConclusionCerebrospinal fluid rhinorrhea poses significant risks if left untreated, including meningitis. Prompt recognition, accurate diagnosis, and individualized treatment strategies are crucial in mitigating complications and improving patient outcomes. A multidisciplinary approach, incorporating both conservative and surgical interventions tailored to the underlying cause, is essential for the successful management of cerebrospinal fluid rhinorrhea.

Clinical Comparison of Endoscopic Posterior Lumbar Interbody Fusion and Open Posterior Lumbar Interbody Fusion for Treating Lumbar Spondylolisthesis.

A retrospective case-control study. To compare the clinical efficacy of endoscopic (Endo) and open posterior lumbar interbody fusion (PLIF) in treating lumbar spondylolisthesis. Endo-PLIF has emerged as a new technique for treating lumbar spondylolisthesis. We propose Endo-PLIF as an alternative method. Sixty-four patients with single-segment lumbar spondylolisthesis underwent Endo-PLIF (n = 39) or open PLIF (n = 25) treatment. Demographic data, perioperative parameters, and radiographic parameters were recorded. Clinical results were evaluated by Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores. The fusion rate was evaluated by computed tomography at 12 months postoperatively. In addition, a case-control process was included to ensure unbiased comparisons. The average operation time was longer in the Endo-PLIF group. Endo-PLIF showed advantages in reducing blood loss, shortening hospital stay, and early ambulation, but with a longer x-ray exposure time. Both VAS and ODI scores significantly improved in both groups, but the VAS for back pain was lower in the Endo-PLIF group. The radiographic results were similar in both groups. Three patients in the Endo-PLIF group had minor complications. Two patients in the open PLIF group experienced cerebrospinal fluid leakage. Both VAS and ODI scores significantly improved in both groups compared with preoperative scores, but the Endo-PLIF group showed more significant improvement at early follow-up (P < 0.05). There was no significant difference in interbody fusion rate between the two groups. Both Endo-PLIF and open PLIF are effective for treating single-segment lumbar spondylolisthesis. Endo-PLIF shows advantages in reducing blood loss, shortening hospital stays, and promoting early ambulation, with comparable fusion rates and patient satisfaction to open PLIF. Despite minor complications in the Endo-PLIF group and cerebrospinal fluid leakage in the open PLIF group, both procedures lead to significant improvements in pain and disability scores, with Endo-PLIF demonstrating more significant early improvements.

QOL-25. DIGITAL PHENOTYPING OF PERIOPERATIVE MOBILITY METRICS IN PATIENTS UNDERGOING SURGICAL RESECTION OF SKULL BASE TUMORS

Abstract Current methods to assess quality of life and recovery after surgery for skull base tumors are limited and often biased by subjective patient-reported assessments, while objective, in-situ assessments are lacking. Smartphone-based digital phenotyping has been increasingly studied across pathologies, utilizing built-in technologies to measure behavioral patterns pertaining to sleep, physical mobility, social interactions, and cognitive functioning, among others. Here, we report our initial experience with smartphone-based digital phenotyping in patients who underwent resection of skull base lesions. Patients seen at our multi-disciplinary skull base center were enrolled under an institutional board-approved protocol and installed the Beiwe application, which passively collected GPS data 20 days pre- and up to 140 days post-surgery. Variables measured included time spent at home, number of separate significant places visited outside home, daily walking time, and daily number of steps taken. 26 patients were enrolled, comprised of 14 pituitary adenomas, 8 meningiomas, and 4 vestibular schwannomas. All patients demonstrated increased time spent at home, fewer number of significant locations visited, decreased walking time, and decreased total steps in the immediate post-operative period. For pituitaries, mean return to baseline for these variables was 25.7, 24.3, 80.2, and 88.9 days, respectively. For meningiomas, return to baseline was 56.5, 214.4, 45.0, and 45.6 days, respectively. For vestibular schwannomas, return to baseline was 219, 39.9, 35.1, and 36.4 days, respectively. This study demonstrates initial efficacy of digital phenotyping for a cohort of patients undergoing surgical resection of skull base lesions, based on passively collected smartphone GPS data during the peri-operative period. This is part of a larger, ongoing study enrolling surgical patients as well as non-operative controls for comparison. Such peri-operative mobility metrics may potentially be refined to predict postoperative outcomes following surgery such as improvement of neurological symptoms, postoperative CSF leak, infection, dysnatremia, and hospital length of stay.

Paroxysmal dysarthria caused by cerebrospinal fluid rhinorrhea.

Cerebrospinal fluid (CSF) rhinorrhea causes the loss of CSF, resulting in a decrease in intracranial pressure and a lack of CSF protection in brain tissue. CSF rhinorrhea may cause impairment of posterior cranial nerves resulting in facial paralysis and vertigo. However, dysarthria caused by involvement of glossopharyngeal nerves and vagus nerves has seldom been reported. Here, we reported a 69-year-old woman who had paroxysmal slurred speech due to CSF rhinorrhea together with paroxysmal facial paralysis.

Headache disorders in patients with Ehlers-Danlos syndromes and hypermobility spectrum disorders

Extra-articular symptoms, including headaches, are frequently encountered in patients with Ehlers-Danlos syndrome (EDS) and hypermobility spectrum disorders (HSD), and may be the presenting complaint. Migraine is reported in up to three quarters of patients with symptomatic joint hypermobility, have a higher headache frequency, and an earlier age of onset compared to the general population. Orthostatic headache is an important presentation, and should raise suspicion of an underlying spinal cerebrospinal fluid leak, dysautonomia, and craniocervical pathology, which are all associated with heritable connective tissue disorders (HCTD) including EDS. Any proposed invasive procedure should be scrupulously balanced against its potential risks, taking into account the type of EDS (e.g., vascular EDS) and its systemic manifestations. This is particularly pertinent when suspecting craniocervical instability since it remains a controversial diagnosis with a limited treatment evidence-base. This article reviews the commonly encountered headache disorders in patients with joint hypermobility-related conditions with a focus on EDS and HSD, describes their diverse presentations, and an overview of the recommended management strategies. It also emphasises the need for increased awareness of comorbid conditions in EDS and HSD among clinicians treating headaches to ensure a patient-tailored approach and facilitate a multidisciplinary approach in managing often complex cases.

The Impact of Venous Stenting for Patients with Idiopathic Intracranial Hypertension and Spontaneous Cerebrospinal Fluid Leak on Symptoms and Quality of Life

BACKGROUND: Elevated intracranial pressure can cause skull base defects and a spontaneous cerebrospinal fluid leak (CSF). Venous sinus stenting (VSS) has emerged as a promising treatment option for patients with a CSF leak in the setting of idiopathic intracranial hypertension (IIH). There is a lack of literature on symptomatology and quality of life (QOL) after VSS for IIH patients with a CSF leak. This study explores the effects of VSS on symptoms and QOL in IIH patients with a CSF leak. METHODS: This is a retrospective study on patients who have IIH complicated by a CSF leak and underwent VSS. A QOL questionnaire was developed from the migraine disability assessment test and the PROMIS-PI was given to patients included in this study. RESULTS: Ten patients were included in this study. Nine patients underwent endoscopic closure of CSF prior to stent placement and one patient was treated with VSS only. There was no evidence of CSF leak recurrence in this population following VSS. Headaches improved in 5/8, tinnitus in 5/6, and visual disturbance in 4/5 patients. Diamox was discontinued in 7 out of 8 patients after VSS. There was an improvement in headache (p=0.0140) specific questions and overall QOL (p=0.0061) on the QOL questionnaire. DISCUSSION: This preliminary study demonstrates that VSS is effective in alleviating many symptoms in IIH patients with a CSF leak, especially headaches. Diamox may be able to be discontinued in many patients following VSS. No CSF leak recurrence was noted in this patient population.

Minimally Invasive Approaches to Spinal Cerebrospinal Fluid Leak Repair: Current Strategies and a Novel Technique

Spinal cerebrospinal fluid (CSF) leaks can be caused by tears in the dura and are challenging to treat. Traditional methods of treating spinal CSF leakage include nonsurgical management, epidural blood patches (EBP), and direct surgical repair. Minimally invasive surgery (MIS) is rapidly progressing within neurosurgery due to its advantages for patient safety and comfort. Existing MIS techniques to spine surgery utilize a rigid endoscope, which has limitations when reaching smaller areas requiring greater degrees of visualization. The simultaneous use of a flexible endoscope and wearable heads-up display (wHUD) improves access and visualization in these small areas while allowing the surgeon to maintain optimal ergonomics. In this article, we review minimally invasive approaches to spine surgery and the management of spinal CSF leaks. We also demonstrate a novel minimally invasive technique utilizing flexible endoscopy and a wHUD to treat a case of recurrent CSF leak. We describe the successful utilization of this technology and provide the groundwork for future practitioners to incorporate this approach into their practice.