Incidence Of CSF Leak Research Articles

The Impact of Preoperative Spinal Injection Timing on the Postoperative Complications of Lumbar Fusion

ObjectiveTo determine the impact of ESIs on postoperative surgical complications. MethodsThis retrospective all-payer database analysis identified 202,181 adult patients undergoing one- to three-level transforaminal lumbar interbody fusion (TLIF) from 2010 to 2020. 1:1 exact matching on comorbidities and demographics was performed, creating two cohorts: (1) patients who received an ESI within 90 days of surgery and (2) patients who did not receive an ESI. The primary outcome was surgical complication rates between groups at 30 days postoperatively. For the secondary outcome, patients were stratified based on injection time before surgery: 1-30, 31-45, 46-60, 61-75, and 76-90 days. Logistic regression was performed between groups to identify temporal associations of complication rates. The p-value was set to 0.05 for the primary analysis, and the Bonferroni correction was utilized for the secondary outcome. ResultsExact matching produced 12,491 pairs for analysis. Groups were well-matched on demographics, comorbidities, and fusion levels. 30-day postoperative rates of surgical complications, hematomas, wound disruptions, or surgical site infections did not differ between groups (p>0.05). The rate of CSF leak was increased in the ESI group (0.19% vs. 0.09%, p=0.042). When temporally stratified, patients receiving an ESI within 30 days had significantly higher odds of CSF leak (OR: 4.24, 95% CI: 1.97-9.14). ConclusionsPatients who receive an ESI within 30 days of TLIF are at an increased risk for CSF leak. While the incidence of CSF leak remains small, it may be advisable to avoid ESIs at least 30 days before surgery for certain patients.

Short‐term urinary catheter usage in endoscopic skull base surgery and impact on urinary tract infection and reconstructive outcomes

AbstractObjectivesHospital‐acquired catheter‐associated urinary tract infections (UTIs) have been regarded as preventable adverse events, yet their risk in endoscopic skull base surgery (ESBS) has not been well described despite common use. We determine the incidence of UTI following ESBS and identify contributing clinical factors.MethodsRetrospective review was conducted for a cohort of 229 consecutive adult patients who underwent endoscopic endonasal surgery for treatment of any skull base pathology between July 2018 and June 2022 at a tertiary academic skull base surgery program. Postoperative UTI comprised the primary outcome. Independent variables included patient demographics, use and length of urinary catheterization, and pre‐existing genitourinary conditions.ResultsNosocomial UTIs were identified in 1.3% (3/229) of patients, occurring on postoperative days 2, 9, and 14, respectively; all were catheter‐associated. Overall, 86.0% (197/229) of patients received urinary catheters (mean duration 2.2 ± 1.8 days). Compared to those without, patients with UTI were older (70.0 ± 15.4 vs. 52.2 ± 16.8 years, p = 0.034), had lengthier stays (94.7 ± 126.8 vs. 5.9 ± 8.4 days, p < 0.001), and had prolonged catheterizations (9.3 ± 5.5 vs. 2.1 ± 1.5 days, p < 0.001). Preoperative genitourinary conditions were also associated with UTI development, namely, chronic urinary retention/obstruction (66.7% vs. 4.0%, p = 0.006), urinary incontinence (66.7% vs. 6.2%, p = 0.013), prostate disease (100.0% vs. 17.8%, p = 0.035), and renal dysfunction (100.0% vs. 9.7%, p = 0.001). Among intraoperative cerebrospinal fluid leak patients, postoperative CSF leak incidence was not associated with catheter use versus nonuse (3.3% vs. 12.5%, p = 0.276).ConclusionAlthough UTIs are uncommon in ESBS patients, advanced age, length of stay, duration of indwelling urinary catheterization, and comorbid genitourinary conditions may elevate risk.

Postoperative CSF Leak: Blood Patch-A New Avenue.

Introduction Cerebrospinal fluid leak (CSF) after a neurosurgical procedure is a known complication that may result in bad outcomes (1). The incidence of CSF leak varies based on the site involved; it ranges from 4 to 32% for transsphenoidal to posterior fossa procedures. The costs involved in treating postoperative CSF leaks increases exponentially that becomes a barrier in continuing optimum treatment. There are many studies that compare the different treatment modalities and even use of sealing agents but none give an algorithm of management. Our study aims at known technique that can help to treat these kinds of low-pressure CSF leaks. Materials and Methods This was a prospective study done over a period of 5 years from January 2014 to January 2019. All patients who underwent procedures in which durotomy was done were included in the study. Results A total of six patients were enrolled for the study. The duration of the study spanned 5 years from January 2014 to January 2019. All the patients after taking informed consent underwent the necessary investigations and a blood patch was done. Five of the patients the CSF stopped but in one patient it persisted. This patient again underwent investigation and under image guidance another blood patch was put after which the CSF leak stopped. Conclusion Blood patch under imaging guidance is a safe and simple technique. The success rates of cessation of CSF leaks are good. Also, it is a cost-effective method using an autograft (patient's blood).

CSF leak after pediatric endoscopic endonasal expanded approaches: a series review.

Endoscopic endonasal approaches in the pediatric population pose specific challenges. Management of postoperative cerebrospinal fluid [CSF] leak is probably the major concern. The purpose of the present investigation is to describe and analyze the incidence of postoperative CSF leaks in our pediatric series of endoscopic endonasal approaches. This is a retrospective analysis, case review of our institutional series. Descriptive statistical parameters and bivariate correlations are analyzed. Twenty-one patients have been operated through endoscopic approaches in our series. Four patients showed a postoperative CSF leak needing a revision surgery; these cases are described in further detail. Approaches expanded beyond the sellar area and non-sellar pneumatization of the sphenoid sinus were significantly associated with a higher risk of postoperative CSF leak. CSF leak incidence after endoscopic endonasal approaches is higher in pediatric patients than in adult series. Anatomic and pathologic factors add complexity to these approaches in children. Multilayer closure is advisable to prevent and treat this complication.

Endoscopic Endonasal Transplanum-Transtuberculum Approach for Pituitary Adenomas/PitNET: 25 Years of Experience.

The role of the endoscopic transplanum-transtuberculum approach (ETTA) in the treatment of pituitary adenomas/PitNETs (PAs) is sparsely analyzed in the literature, and its use is still debated in the current practice. The aim of this study was to report our experience with this approach. Our institutional registry was retrospectively reviewed, and patients who underwent ETTA for a PA from 1998 to 2022 were included. Fifty-seven cases were enrolled over a time span of 25 years, corresponding to 2.4% of our entire PA caseload. Radical resection was achieved in 57.9% of cases, with re-do surgery (p = 0.033) and vessel encasement/engulfment (p < 0.001) as predictors of partial resection. CSF leak incidence stood at 8.8%, with higher BMI (p = 0.038) as its only significant predictor. Partial or full improvement of the visual field deficits was achieved in 73.5% of cases. No surgical mortality was observed. According to our results, ETTA for the treatment of PAs is characterized by a satisfactory surgical outcome but with greater morbidity than the conventional endoscopic approach. Therefore, it should be reserved for the few selected cases otherwise unsuitable for the endoscopic trans-sphenoidal route, representing a valid alternative and an effective complementary route for the transcranial approach for these challenging PAs.

Anterior transpetrosal approach: experiences in 274 cases over 33 years. Technical variations, operated patients, and approach-related complications.

The anterior transpetrosal approach (ATPA) was initially reported in 1985. The authors' institution has 274 case records of surgery performed with the ATPA during the period from 1984 to 2017. Although many technical advances and modifications in the ATPA have occurred over those 33 years, to the authors' knowledge no articles to date have reported a detailed analysis of variations and complications of the ATPA. In this study, the authors analyzed their patient series to elucidate improvements over time in ATPA methodology while highlighting unresolved problems and evaluating how to avoid surgical complications. All surgical cases (274 patients) using the ATPA at the authors' institution during the period from 1984 to 2017 were analyzed retrospectively using charts, clinical summaries, operative records, and operative videos. Obtained parameters were patient age and sex, diagnosis, size of tumors, location of disease, operative date, neurological symptoms before and after surgery, radiographically identified brain injury, and other surgical complications. The most common diagnosis was petroclival meningioma (n = 158), followed by trigeminal schwannoma (n = 32), chordoma (n = 25), epidermoid tumor (n = 21), other tumor (n = 27), aneurysm (n = 6), and other (n = 5). The original ATPA was performed in 239 cases. In an additional 35 cases, a modified ATPA was performed. Zygomatic osteotomy with ATPA was a common modification that was used in 19 of the 35 cases to decrease retraction damage to the temporal lobe for high-positioned tumors. Brain injury by temporal lobe retraction without venous hemorrhage still occurred in 8 of the 19 cases (3.1%) with surgical death in 1 of these cases (0.4%) of reoperation with sacrifice of the petrosal vein. Symptomatic CSF leak was the most frequent complication noted and was observed in 35 cases (13.5%). In most of these cases the patients were cured by observation or lumbar drain, but in 6 cases (17.1%) reoperation was needed. Facial nerve damage related to surgical approach decreased from 6.2% to 3.5% after 2010; however, the incidence of CSF leaks (13.5%) has not improved. There have been several modifications and advancements made in the ATPA to increase tumor removal and decrease surgical complications. However, complications related to surgical approach occurred, such as venous occlusion-related brain injury and facial nerve damage at pyramid resection. CSF leak remained an unsolved problem related to the ATPA procedures. Preoperative assessment of venous variation of the middle fossa, pneumatization of the temporal bone, and intraoperative monitoring of cranial nerves are important procedures to decrease these complications.

Endoscopic transsphenoidal surgery reconstruction using the fibrin sealant patch Tachosil®

Introduction The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil® is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil® to repair intraoperative defects during an endoscopic transsphenoidal approach. Materials and methods All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil® at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil® was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak. Results A total of 52 primary procedures where Tachosil® was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% (n = 4), with all cases having had a Tachosil® overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil® patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil®. Conclusions We believe this to be the largest case series evaluating the endoscopic use of Tachosil® in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil® may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks.

Tisseel® versus Hemopatch® for dural sealing in neurosurgery. A prospective study in a tertiary center

BackgroundDural repair is a potential source of complications in neurosurgery. We make a comparison in pseudomeningocele and CSF leak incidence with the sealants Tisseel® and Hemopatch®. MethodsWe collected 147 patients from September 2017 to December 2018 in a prospective observational study. Inclusion criteria were adult patients with an intradural cranial or spinal surgery whose dura was closed with a fibrin sealant. Primary endpoints were the incidence of pseudo meningocele and CSF leak. Secondary endpoints were the surgical-site infection, epidural hematoma, and the influence of previous surgery. ResultsIn 65 and 82 patients Tisseel® and Hemopatch® were used as sealants respectively. The incidence of CSF leak presented a significant statistical relation with the use of Tisseel® in a univariate and multivariate analysis. Infratentorial surgery presented a higher incidence of pseudomeningocele and CSF leak, but the approach used was not a significant factor in multivariate analysis. Patients who were operated previously had a higher risk present a postoperative complication. ConclusionsThe incidence of pseudomeningocele and CSF leak was higher with Tisseel® compared with Hemopatch® with a statistic significant relation in case of CSF fistulae. The procedure done may be a confusion factor in our study. There was no report of adverse effects or a higher incidence of complications. However, it is recommended to plan randomized trials with larger samples to get stronger evidence.

Cerebrospinal Fluid Leak after Repair of Congenital Spinal Pathologies, Incidence and Management

Objective: To know the incidence of CSF leak and role of tincture benzoyl in the management of CSF leak after the repair of congenital spinal deformities like myelomeningocele, meningocele and tethered cord syndrome.Materials and Methods: All patients who were operated for congenital spinal surgeries in the form of MMC, Meningocele and TCS by a single surgeon were followed for a minimum of 3 months. Patients with already CSF leak/ruptured MMC prior to surgery were not part of the study. The particulars like gender and type of surgery, days since first surgery, associated infection, hydrocephalus and type of management were noted on a proforma.Results: A total of 73 patients with spinal dysraphism were operated during the study period and of them about 13 patients returned with problems of the CSF leak. The mean duration and duration since the CSF leak was from 6 days to 16 days. Among them, 10 patients had an MMC repair and one patient had TCS release, while 2 patients were having meningocele repair. The patients were stitched and one patient was re-operated two times for repair of CSF leak. Two patients had a CSF leak along with post op signs of HCP that settled by placing a shunt along with primary repair of the wound reinforced with tincture benzoyl in a single setting. Conclusion: CSF leak is a common complication following repair of spinal dysraphism and most patients can be managed with the application of tincture benzoyl alone or after simple skin reinforcement.

Transnasal Transsphenoidal Approach for Pituitary Tumors: An ENT Perspective.

Endoscopic transnasal transsphenoidal (ETNTS) approach was first described in 1992 and is standard approach for the resection of benign pituitary adenomas. This prospective study aims in incidence and preoperative assessment of extent of the pituitary adenoma, peroperative findings of transnasal transsphenoidal excision, techniques of skull base repair, complications and its management in a tertiary centre. A prospective analysis from Jan 2017 to May 2019, of patients undergoing ETNTS approach of pituitary adenomas was made in terms of incidence in various age-groups, type of adenoma, operative findings including CSF leak, repair of the skull base defect, complications encountered and its management was done in a tertiary care centre and compared with the present literature. A total of 141 patients underwent ETNTS, with highest number of cases found in 41-50years age-group with mean age of 42.6years. Male: Female ratio was 1.6. Macroadenoma was in 123 patients while 18 had microadenoma, of these 63.74% were functional adenoma, highest of GH secreting, while 36.26% were non-functional. Mean surgical time was 98.4min ± 21.2min. Peroperative CSF leak was in 30.5% cases in various grades. Closure techniques included use of fat, multilayer techniques, Hadad's flap and gasket technique as per the type of CSF leak. Neurological and rhinological complications were 6.38% each. This study is focused on the ENT perspective of the endoscopic transnasal trans-sphenoidal approach for pituitary adenomas. The reduced rate of morbidity and complications is encouraging. The endoscopic skull base defect closure is challenging and requires skill, meticulous approach and synchronised team work in order to achieve a favourable outcome. The incidence of CSF leak can be minimised and if encountered has to be dealt in an organised manner, thus contributing to a reduced rate of complications. The complications encountered must be foreseen and managed with a proficient approach.

Combined endoscopic approach in the management of suprasellar craniopharyngioma.

Craniopharyngiomas are dysontogenic tumors with benign histology but aggressive behavior. The surgical challenges posed by the tumor are well recognized. Neuroendoscopy has recently contributed to its surgical management. This study focuses on our experience in managing craniopharyngiomas in recent years, highlighting the role of combined endoscopic trans-ventricular and endonasal approach. Ninety-two patients have been treated for craniopharyngioma from 2000 to 2016 by the senior author. A total of 125 procedures, microsurgical (58) and endoscopic (67), were undertaken. Combined endoscopic approach was carried out in 18 of these patients, 16 children and 2 young adults. All of these patients presented with a large cystic suprasellar mass associated with hydrocephalus. In the first instance, they were treated with a transventricular endoscopic procedure to decompress the cystic component. This was followed by an endonasal transsphenoidal procedure for excision within the next 2 to 6 days. All these patients improved after the initial cyst decompression with relief of hydrocephalus while awaiting remaining tumor removal in a more elective setting. Gross total resection could be done in 84% of these patients. Diabetes insipidus was the most common postsurgical complication seen in 61% patients in the immediate period but was persistent in only two patients at 1-year follow-up. None of the children in this group developed morbid obesity. There was one case of CSF leak requiring repair after initial surgery. Peri-operative mortality was seen in one patient secondary to ventriculitis. The patients who benefit most from the combined approach are those who present with raised intracranial pressure secondary to a large tumor with cyst causing hydrocephalus. Intraventricular endoscopic cyst drainage allows resolution of hydrocephalus with restoration of normal intracranial pressure, gives time for proper preoperative work up, and has reduced incidence of CSF leak after transnasal surgery. Combined endoscopic approach thus gives a unique opportunity to remove these lesions more radically with less morbidity.

Dynamics of postoperative serum cortisol after transsphenoidal surgery for Cushing's disease: implications for immediate reoperation and remission.

OBJECTIVESuccessful transsphenoidal surgery for adrenocorticotropin hormone (ACTH)-producing pituitary tumors is associated with subnormal postoperative serum cortisol levels, which may guide decisions regarding immediate reoperation. However, little is known about the detailed temporal course of changes in serum cortisol in the immediate postoperative period, and the relationship of postoperative cortisol dynamics to remission and late recurrence.METHODSA single-center retrospective cohort analysis was performed for all patients undergoing pituitary surgery from 2007 through 2015. Standardized diagnostic and treatment algorithms were applied to all patients with potential Cushing's disease (CD), including microsurgical transsphenoidal adenomectomy (TSA) by a single surgeon. All patients had serum cortisol levels drawn at 6-hour intervals for 72 hours after surgery, and were offered reoperation within 3 days for normal or supranormal postoperative cortisol levels. Primary outcomes were 6-month remission and late recurrence; secondary outcomes were persistent postoperative hypocortisolism and surgical morbidity. Discriminatory levels of postoperative serum cortisol for predicting remission were calculated at various intervals after surgery using receiver operating characteristic (ROC) curves.RESULTSAmong 89 patients diagnosed with CD, 81 underwent initial TSA for a potentially curable lesion; 23 patients (25.8%) underwent an immediate second TSA. For the entire cohort, 6-month remission was achieved in 77.8% and late recurrences occurred in 9.5%, at a mean of 43.5 months. Compared with patients with a single surgery, those with an immediate second TSA had similar rates of remission (78.3% vs 77.6%) and late recurrence (5.6% vs 11.1%). The rate of hypocortisolism for patients with 2 surgeries (12/23, 52.2%) was significantly greater than that for patients with single surgeries (13/58, 22.4%; p < 0.001). There was no difference in the incidence of CSF leaks between the first and second operations. Remission was achieved in 58 (92.1%) of 64 patients who completed the 2-surgery protocol. The temporal course of postoperative serum cortisol levels among patients varied considerably, with subnormal nadir levels < 2 μg/dl occurring between 12 hours and 66 hours. Patients achieving remission had significantly lower mean serum cortisol levels at every time point after surgery (p < 0.01). By ROC curve analysis, nadir cortisol levels < 2.1 μg/dl were predictive of 6-month remission for the entire cohort over 3 days (positive predictive value [PPV] = 94%); discriminating cortisol levels for predicting remission on postoperative day (POD) 2 were < 5.4 μg/dl (PPV = 97%), although patients with remission after postoperative cortisol levels of 2-5 μg/dl had a significantly higher rate of late recurrence.CONCLUSIONSThere is substantial variation in the temporal course of serum cortisol levels over the first 72 hours after TSA for CD, with nadir levels predictive for remission occurring as late as POD 3. Although a cortisol level of 2.1 μg/dl at any point was an accurate predictor of 6-month remission, levels less than 5.4 μg/dl on POD 2 were reasonably accurate. These data may enable decisions regarding the efficacy of an immediate second surgical procedure performed during the same hospitalization; immediate reoperation is associated with excellent remission rates and low recurrence rates in patients otherwise unlikely to achieve remission, but carries a higher risk of permanent hypocortisolism.

The learning curve for endoscopic trans-sphenoidal resection of pituitary macroadenomas. A single institution experience, Leeds, UK.

The object of this study was to assess whether increasing operative experience results in greater endoscopic trans-sphenoidal resection of pituitary macroadenomas and lower complications. A retrospective single institution cohort study was performed. Subjects underwent endoscopic trans-sphenoidal resection of pituitary macroadenoma between July 2009 and July 2016 by three neurosurgeons. Following data collection, statistical analysis compared percentage of tumor resection and length of hospital stay (LOS) with experience. Complications including CSF leak are reported. In total, 142 patients (87 male, 55 female) mean age 55.1 were included. Surgeon 1 performed 106 cases; surgeon 2 performed 23 cases; and surgeon 3 performed 13 cases. Mean pre-operative tumor volumes were 8.18cm3, 6.52cm3, and 3.47cm3 and post-operative volumes were 2.21, 1.74, and 1.93cm3 for surgeons 1, 2, and 3, respectively. Respective percentage resections were 74.3, 77.2, and 52.1%. Analysis demonstrated no difference in tumor resection with increasing experience for all three surgeons (p=0.11, p=0.17, and p=0.26). Tumor consistency and cavernous sinus involvement did not appear to affect tumor resection. Mean LOS was 5days, 4days, and 3days, respectively, with no significant correlation with experience for all three surgeons. Intraoperative CSF leak incidence was 19/106 (18%) for surgeon 1, 6/23(26%) for surgeon 2, and 2/13(15%) for surgeon 3. Primary closure rate was 96.3% and only three other complications occurred. This study demonstrates that in our institution there is no statistically significant learning curve for the endoscopic resection of pituitary macroadenoma. However, there is a trend of improvement in tumor resection with experience for one surgeon. These findings suggest that the surgeons in our institution were capable of performing this procedure effectively with a low complication rate since adoption of the endoscopic technique in 2009.

Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients.

OBJECTIVE Cerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors' institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations. METHODS The authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted. RESULTS A total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke's cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%. CONCLUSIONS In this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

Letter to the Editor: Reduced incidence of CSF leak following complete calvarial reconstruction of craniectomies

Letter to the Editor: Reduced incidence of CSF leak following complete calvarial reconstruction of craniectomies

Treatment of Giant Arachnoid Cysts on Spinal Cord - Relevant Surgical Aspects

Objectives The aim of the present study was to demonstrate that microsurgical resection of the posterior portion of giant spinal arachnoid cyst can be effective in the treatment of patients. Methods We selected three cases that consecutively underwent spinal surgery with microsurgical technique who were admitted to our institution. They were treated and followed-up, rehabilitation being performed weekly and quarterly medical consultation. The three patients were informed about the research and ethical aspects and agreed to participate with the exposure of their complete medical history. All cases were approved by the Institutional Review Board. These three cases were used to illustrate the surgical treatment used by our team to discuss the best treatment option. Results Three patients underwent microsurgical resection of the posterior portion of giant spinal arachnoid cyst. This surgical technique had its use justified by the possibility of reducing the incidence of CSF leak, since lesions were extradural. The treated patients presented clinical improvement, which was maintained for more than twelve months. Conclusion Although some authors state that complete resection of the cyst is the best surgical option, we believe that, specifically on giant spinal arachnoid cysts, the resection of the posterior portion of the cysts may decrease postoperative CSF leak incidence. Furthermore, our series suggests that the adopted surgical treatment may lead to better functional outcomes while this treatment is performed for spinal decompression using a less invasive technique and, thus, leading to an earlier clinical improvement.

Skull Base Reconstruction with Titanium Mesh for Benign Complex Anterior Skull Base Tumors: Case Series and Review of the Literature

Aim: The aim of the study was to evaluate the role of titanium mesh used in combination with other synthetic materials in providing a rigid support for reconstruction of anterior skull base defect and preventing CSF leak. Material and methods: All Cases of complex benign anterior skull base lesions operated between December 2008 and December 2013 (5 years) which had titanium mesh for reconstruction were reviewed. Six operations were performed on five patients for large anterior skull base meningioma (3 cases) and fibrous dysplasia (2 cases). The main complaint was exophthalamous in 4 patients, and one presented with nasal blockage due to ethmoidal and nasal invasion. The reconstructions were performed by using titanium mesh with pericranial flaps, synthetic dural grafts, and surgical glue. Routine lumbar drain was not used. Three patients had previous surgeries. Three patients were female, and the age range was 4 to 55. We had a minimum of 12 months follow up. The incidence of CSF leak, infections, and other surgical morbidity related to the reconstruction were recorded. The status of exophthalamous post operatively was also observed. Results: We had no incidence of CSF leak or infection. One case of recurrent psuedomeningocele was encountered and it required repeated aspiration, then lumbar drain, and finally insertion of subgalial-peritoneal shunt. Exophthalamous improved in 3 patients and remain the same in one. Conclusion: Use of titanium mesh with local flaps or synthetic dural graft and surgical glue is safe, simple, and effective for reconstruction of anterior skull base defects caused by benign tumor or fibrous dysplasia.

Management of CSF leak following spinal surgery.

Postoperative CSF leak is a known complication of spinal surgery especially after surgery for neural tube defects (NTD). The problem can metamorphose into a severe infection. This article hopes to shed some light on the management of these problems and suggests precautions so as to reduce their occurrence. A retrospective analysis of 102 children, between the ages of 1 day and 12 years, operated for various spinal pathologies, over the past 2.5 years by the same surgeon (CB) was done. The various methods of dural closure were noted. The methods of management of postoperative CSF leaks were analysed, and the patients were followed till discharge. The incidence of CSF leak was found to be 12.7%. The methods of management included lumbar drain only (n = 7), lumbar drain with re-exploration (n = 3), lumbar drain followed by lumboperitoneal shunt (n = 2) and only lumboperitoneal shunt (n = 1). The use of fibrin glue did not seem to significantly prevent the incidence of CSF leak in cases. Primary and meticulous dural closure is sine qua non in preventing postoperative CSF leak. A lumbar drain is a convenient and economical method of managing the problem initially failing which more invasive methods like re-exploration may be employed.

The incidence of complications in elective cranial neurosurgery associated with dural closure material

Dural closure with synthetic grafts has been suggested to contribute to the incidence of infection and CSF leak. The objective of this study was to assess the contribution of choice of dural closure material, as well as other factors, to the incidence of infection and CSF leak. A retrospective, consecutive cohort study of adult patients undergoing elective craniotomy was established between April 2010 and March 2011 at a single center. Exclusion criteria consisted of trauma, bur hole placement alone, and temporary CSF fluid diversion. Three hundred ninety-nine patients were included (mean follow-up 396.6 days). Nonautologous (synthetic) dural substitute was more likely to be used (n = 106) in cases of reoperation (p = 0.001). Seventeen patients developed a surgical site infection and 12 patients developed a CSF leak. Multivariate logistic regression modeling identified estimated blood loss (OR 1.002, 95% CI 1.001-1.003; p < 0.001) and cigarette smoking (OR 2.198, 95% CI 1.109-4.238; p = 0.019) as significant predictors of infection. Synthetic dural graft was not a predictor of infection in multivariate analysis. Infratentorial surgery (OR 4.348, 95% CI 1.234-16.722; p = 0.024) and more than 8 days of postoperative corticosteroid treatment (OR 3.886, 95% CI 1.052-16.607; p = 0.048) were significant predictors for the development of CSF leak. Synthetic dural graft was associated with a lower likelihood of CSF leak (OR 0.072, 95% CI 0.003-0.552; p = 0.036). The use of synthetic dural closure material is not associated with surgical site infection and is associated with a reduced incidence of CSF leak. Modifiable risk factors exist for craniotomy complications that warrant vigilance and further study.

Prevention of postoperative cerebrospinal fluid leaks with multilayered reconstruction using titanium mesh–hydroxyapatite cement cranioplasty after translabyrinthine resection of acoustic neuroma

Several prophylactic surgical methods have been tried to prevent CSF leakage after translabyrinthine resection of acoustic neuroma (TLAN). The authors report an improvised technique for multilayer watertight closure using titanium mesh-hydroxyapatite cement (HAC) cranioplasty in addition to dural substitute and abdominal fat graft after TLAN. The study was limited to 42 patients who underwent TLAN at University Hospitals Case Medical Center using this new technique from 2006 to 2012. Systematic closure of the surgical wound in layers using temporalis fascia, dural substitute, dural sealant, adipose graft, titanium mesh, and then HAC was performed in each case. Temporalis muscle and eustachian tube obliteration were not used. The main variables studied were patient age, tumor size, tumor location, cosmetic outcome, length of hospitalization, and the incidence of CSF leak, pseudomeningocele, and infection. Excellent cosmetic outcome was achieved in all patients. There were no cases of postoperative CSF rhinorrhea, incisional CSF leak, or meningitis. Cosmetic results were comparable to those achieved using HAC alone. This cost-effective technique used only a third of the HAC required for traditional closure in which the entire mastoid defect is filled with cement, predisposing to infection. Postoperative CT and MRI showed excellent bony contouring and dural reconstitution, respectively. The authors report on successful use of titanium mesh-HAC cranioplasty in preventing postoperative CSF leak after TLAN in all cases in their series. The titanium mesh provides a well-defined anatomical dissection plane that would make reoperation easier than working through scarred soft tissue. The mesh bolsters the fat graft and keeps HAC out of direct contact with mastoid air cells, thereby reducing the risk of infection. The cement cranioplasty does not preclude subsequent implantation of a bone-anchored hearing aid.