Cerebrospinal Fluid Leak Research Articles

The use of dural sealant patches for reinforcement of durotomy repair: a systematic review.

Dural sealant patches (DSPs) are a useful adjunct when closing the dura during cranial or spinal surgery to avoid cerebrospinal fluid (CSF) leakage or infection. Authors of this paper systematically review the outcomes and incidence of CSF leakage and infection with the use of a DSP versus conventional practice. The MEDLINE, Embase, Cochrane Library, and Scopus databases were searched, and clinical trials and prospective or retrospective case-control and cohort studies with a low-risk of bias and involving any solid DSP used in adults for cranial or spinal cases were included. Studies that used a DSP in combination with another method of dural sealant closure, used a DSP as a dural substitute rather than an adjunctive closure device, or used hydrogel or polymer gel (i.e., nonsolid) dural sealant "patches" were excluded. A meta-analysis of comparative studies reporting outcomes relating to CSF leakage was performed together with a subgroup analysis for each DSP type. For comparative studies reporting outcomes relating to infection, a separate meta-analysis was conducted. Across the 7 noncomparative studies included, 669 patients received TachoComb (n = 421, 1 study), TachoSil (n = 8, 1 study), Liqoseal (n = 40, 1 study), TissuePatchDural (n = 144, 2 studies), or Hemopatch (n = 56, 2 studies). Across the 6 comparative studies included, 1013 patients received TachoSil (n = 784, 3 studies), TissuePatchDural (n = 147, 2 studies), or Hemopatch (n = 82, 1 study). When considering the rates of CSF leakage or infection, 2/6 comparative studies found DSPs to be significantly more effective than current practice, while the remaining 4/6 demonstrated noninferiority compared to current practice. All studies considered the DSPs to be safe. A meta-analysis revealed significant improvements in the incidence of CSF leakage with the use of a DSP overall, but the improvements in CSF leak rates for the TachoSil and TissuePatchDural subgroups did not reach statistical significance. The single study evaluating Hemopatch did find statistically significant improvements in CSF leak rates. There were no significant differences in infection between the DSP groups. There was a significant improvement in the incidence of CSF leaks with the use of DSPs. Comparisons among DSP types and evaluations of outcomes relating to infection should be the focus of further research in this area.

Dural and cranial reconstruction techniques in retrosigmoid craniotomy: key factors associated with CSF leaks in 225 patients.

This study evaluated the effectiveness of various dural closure and bone reconstruction techniques in preventing CSF leakage following retrosigmoid craniotomy for cerebellopontine angle (CPA) tumors. The goal was to identify whether newer combinations of reconstructive materials offer any advantage in reducing CSF leaks and improving surgical outcomes. The authors conducted a retrospective review of 225 patients who underwent a retrosigmoid craniotomy for CPA neoplasms between January 2018 and August 2024. Patient demographics, intraoperative reports, and postoperative complications were analyzed. Various reconstructive methods, including the use of TachoSil, HydroSet, autologous or heterologous dural patches, and bone flap repositioning, were compared. CSF-related complications such as CSF leakage, infections, and postoperative hydrocephalus were systematically evaluated. CSF leakage occurred in 31% of cases (n = 69), while CSF infections and postoperative hydrocephalus were noted in 6% and 7% of patients, respectively. HydroSet combined with bone flap repositioning significantly reduced CSF leakage (p = 0.008), as did the combination of HydroSet and heterologous dural patches (p = 0.007). TachoSil did not show a significant reduction in CSF leakage. Craniectomy with titanium mesh or heterologous cranioplasty was not associated with any CSF leaks. No other single or combined techniques showed significant associations with CSF leakage. HydroSet in combination with bone reconstruction and heterologous patches demonstrated superior outcomes in reducing CSF leaks. TachoSil did not significantly affect leakage rates, with less definite results. Refining surgical techniques and selecting appropriate materials for dural and bone reconstruction may help reduce complications and improve patient outcomes in CPA tumor surgeries using the retrosigmoid approach.

Does the crafted abdominal fat grafting technique completely eliminate risk of postoperative CSF leak in endonasal pituitary surgery? Technical note and preliminary clinical outcome.

The endonasal transsphenoidal approach (ETA) developed over the years has become the standard of care for sellar and parasellar lesions. However, because it necessitates the removal of the skull base bone, it is often accompanied by CSF leakage. The authors aimed to provide technical nuances and analyze the results of their routine fat grafting technique after ETA. A consecutive patient cohort (2004-2024) of 168 patients who underwent ETA for sellar and parasellar lesions and the modified fat grafting technique for skull base repair were retrospectively reviewed. Overall, combined ETA and transcranial approach (TCA) was performed in 7 (4.2%) patients, and 4 (2.4%) patients had prior transsphenoidal surgery. The size of the lesion was < 10 mm in 24 (14.3%) patients, 10-30 mm in 93 (55.4%), and > 30 mm in 51 (30.4%). Histopathological diagnoses were as follows: 154 (91.7%) pituitary adenomas, of which 45 (26.8%) were secreting; 8 (4.8%) Rathke's cleft cysts; 2 (1.2%) inflammatory/autoimmune lesions; 2 (1.2%) craniopharyngiomas; 1 (0.6%) renal cell carcinoma metastasis; and 1 (0.6%) chordoma. Gross-total resection was achieved in 127 (75.6%) patients, near-total resection in 22 (13.1%), and subtotal resection/partial resection/biopsy in 19 (11.3%). Overall, 122 (72.6%) procedures had intraoperative CSF leakage. Postoperative CSF leakage was observed in 1 (0.6%) patient treated with a revision operation and regrafting with a slightly larger graft and lumbar drainage. Even slight modifications in contemporary surgical techniques and the addition of an innovative approach may improve the treatment of sellar and parasellar lesions via ETA and reduce the risk of CSF leakage. The authors have developed and described a modified fat grafting technique with gradual crafting and preprocessing of the abdominal fat tissue for skull base repair, and they have demonstrated its effectiveness in significantly reducing the CSF leak rate. This technique enables adequate reconstruction of skull base defects with low donor-site complication rates and obviates the need for external lumbar drainage.

Contribution of watertight dural closure to prevention of postoperative cerebrospinal fluid leakage in endoscopic transnasal surgery for intradural lesions.

The goal of this study was to evaluate the efficacy of watertight dural closure (WTDC) in preventing postoperative CSF leakage during extended endoscopic transnasal surgery (ETS) for skull base tumors, while preserving sinonasal quality by omitting the routine use of a nasoseptal flap. This retrospective study included 28 patients who underwent ETS and experienced Esposito grade 3 CSF leakage at a single institution between June 2022 and June 2024. WTDC was performed using fascia lata grafts and various suturing techniques. Surgical videos and electronic medical records were reviewed to assess suturing times and postoperative outcomes. The efficacy of WTDC in preventing CSF leakage was evaluated, and the technical aspects of the procedure were analyzed. Among the 28 patients (14 female, 14 male), WTDC was successfully achieved in 14 cases, with near-watertight closure in the remaining 14. The average suturing time decreased with experience, showing a trend of improved efficiency. No postoperative CSF leaks were observed, and 1 case of postoperative meningitis resolved without sequelae. Despite significant risk factors for CSF leakage, WTDC was effective in all patients without the routine use of lumbar drainage. WTDC in ETS is a reliable method for preventing postoperative CSF leakage, particularly in complex skull base surgeries with high-risk factors. This technique avoids the complications associated with nasoseptal flap use, preserves sinonasal quality, and reduces the need for lumbar drainage, making it a valuable option for skull base reconstruction.

Which type of duraplasty is best for Chiari type I malformation surgery?

This study investigated whether the selection of different dural substitutes and distinct dural repair techniques correlates with the incidence rate of postoperative CSF leak in a mixed population of adults and children with Chiari type I malformation (CM-I) who underwent posterior fossa decompression with enlargement duraplasty (PFDD) as the first surgical approach. A retrospective analysis was conducted on all patients admitted to the authors' institution between 2006 and 2023 for PFDD to treat syringomyelia and/or symptoms due to CM-I. Clinical, radiological, and surgical data were extracted from a prospectively maintained database. Demographic information was collected from medical records. Surgical procedures were also scrutinized, specifically focusing on the type of dural graft used for duraplasty, alongside perioperative complications and the necessity for subsequent surgeries. Lastly, during follow-up, the occurrence of a CSF leak was assessed and analyzed in relation to the type of dural graft used during surgery. The type of dural substitute chosen changed over the years to reduce CSF fistulas, while the technique of PFDD remained the same. Consequently, large sequential homogeneous groups differing only by dural substitutes were available for comparison. The data from 409 patients with CM-I undergoing PFDD were analyzed. A total of 368 cases had complete surgical data and were included. Thirty patients received autologous duraplasty. The remaining 338 cases with heterologous duraplasty from equine and bovine pericardium were considered for the comparative statistical analysis. The mean follow-up duration ranged from 39 months in adults to 45 months in children. The CSF complication rate requiring revision was 6.5% in the total cohort, with a higher incidence in children (10.5%) compared with adults (3.9%). There was no significant difference in adverse events (CSF leak, revision surgery, or ventriculoperitoneal shunt placement) between the different dural patches by univariate analysis if applied to the total cohort, although the trend neared significance (p = 0.06). In pediatric cases, this value was significant (p = 0.01) in favor of equine pericardium, particularly when combined with a collagen matrix inlay graft. This study on a large and homogeneous series of patients with CM-I undergoing PFDD with heterologous duraplasty demonstrated that CSF complications may be kept low. The dural substitutes derived from equine pericardium, particularly when combined with a collagen matrix inlay graft, exhibited a reduced rate of CSF leaks compared with substitutes derived from bovine pericardium.

Trends in Medicare procedural and reimbursement rates for spinal CSF leak repair (2000-2021).

CSF leaks are a common complication of spinal surgery, occurring in 3%-16% of elective cases and up to 12% of operatively managed traumatic spinal injuries. They can also occur following lumbar puncture. However, there are limited data on utilization and reimbursement trends within Medicare for CSF leak repairs. Characterizing the economic burden and market of spinal CSF leak repair has implications for optimizing effective management strategies. This study evaluates reimbursement and utilization trends for both surgical repair and epidural blood patch (EBP) management of spinal CSF leaks between the years 2000 and 2021. The 2000-2021 provider utilization and payment files from the Centers for Medicare & Medicaid Services was queried to identify all spinal CSF leak repair procedures billed to Medicare part B. For each management strategy, the number of procedures, total charges submitted by providers, and total Medicare reimbursements were extracted. Monetary data were adjusted to 2021 US dollars using changes to the Consumer Price Index. Spearman rank correlation coefficients were used to analyze trends in reimbursement and utilization. From 2000 to 2021, 62,826 open surgical repairs were reported with $37,082,407 paid in reimbursement (45.9% repaired without additional laminectomy, 28.8% with laminectomy, and 25.3% requiring a spinal dural graft). An additional 63,227 EBPs were reported for CSF leak repair with $7,567,776 in reimbursement. Reimbursement for CSF leak repair without laminectomy totaled $15,707,094; repairs with laminectomy, $12,429,690; and use of spinal dural grafts, $8,945,444. Both a significant 162% increase in the utilization of spinal dural grafts (333 to 872, p < 0.001) and a decrease in reimbursement ($671 to $496, p = 0.02) was observed from 2000 to 2021. There was a significant 31% decrease in reimbursement for EBP ($148 to $102, p < 0.001). Significant variability exists in the management strategy and rates of utilization and reimbursement for treating spinal durotomy. Despite increasing utilization of spinal dural grafts, reimbursement has declined between the years 2000 and 2021. Further studies are required to optimize both the cost effectiveness and efficacy of spinal durotomy repair techniques.

Modified graded skull base reconstruction for intraoperative CSF leak repair in endoscopic endonasal surgeries: a single-surgeon experience in initial years of practice and nuances in the early learning curve.

The purpose of this study was to evaluate the outcome of a modified graded reconstruction technique based on the size of intraoperative CSF leaks in patients undergoing endoscopic endonasal surgery performed by a single surgeon in the early years of his practice. The database of patients who underwent endoscopic endonasal approaches (EEAs) between September 2020 and August 2024 was included. Surgical complexity was categorized into levels II, III, and IV. Intraoperative CSF leak was categorized into 4 grades (0-3). Patients were divided into 2 timeline groups (those undergoing an EEA between 2020 and 2022 [group A] and between 2023 and 2024 [group B]) to assess the trends in surgical complexity and repair outcomes. A total of 69 patients with a mean age of 56 ± 16.9 years (range 12-83 years) were identified; 34 (49.3%) were female. The median body mass index was 31 (> 25 in 82.6%). The most common pathology was nonsecretory macroadenoma (57.9%). The EEA at complexity levels II, III, and IV was performed in 36.2%, 46.4%, and 17.4% of the patients, respectively. Intraoperative CSF leaks grades 1, 2, and 3 were encountered in 39.1%, 7.2%, and 17.4% of the patients, whereas 36.2% did not develop leaks (grade 0). Fat grafts and collagen matrix were used for all patients with grades 1-3. Patients with complexity level II only developed grade 1 and 2 leaks, and none of level III developed grade 3. A nasoseptal flap was used in 4 patients (5.8%), with all having level IV surgery and grade 3 intraoperative leak. Only 1 patient (1.4%) developed a postoperative CSF leak, and a lumbar drain was only used for this patient (1.4%) at the revision surgery. The rate of grades 2 and 3 leaks in group B was significantly lower than in group A (8.3% vs 33.3%, p = 0.022). Temporary nasal packing usage was also significantly lower in group B (8.3%) than in group A (28.9%) (p = 0.049), whereas high-complexity EEA rates and pedicled flap usage were not correlated with the year of surgery. A graded endoscopic endonasal repair protocol, combined with the judicious use of lumbar drains and nasoseptal flaps rather than a reflexive approach, helps in minimizing postoperative CSF leak rates. Cross-training of neurosurgery graduates focusing on skull base practice is highly recommended for maximizing good outcomes in their early years of practice. With growing experience, intraoperative leak rates tend to decrease, and the reconstruction relies on a tailored multilayer strategy rather than bulky synthetic materials.

Management of incisional cerebrospinal fluid leak in open cranial surgeries and the "folding technique" in duraplasty.

The aim of this study was to review a series of patients who underwent open cranial surgeries to evaluate the incidence of iatrogenic incisional CSF leaks and discuss its prevention and management. The authors also discuss the utility of the "folding technique" used in duraplasty as an alternative to conventional dural reconstruction techniques. All patients undergoing open cranial surgery were reviewed, and those with incisional CSF leak were included in this study. CSF leakage was managed using either conservative nonsurgical methods or surgical interventions. When the conservative nonsurgical methods failed to curb the leak, surgical procedures such as lumbar external drainage (LED) using lumbar subarachnoid drainage, external ventricular drainage (EVD), a lumboperitoneal or ventriculoperitoneal shunt (VPS), and reexploration of the surgical site were considered. Between 2019 and 2024, 2149 patients underwent open cranial surgeries at our hospital for any cranial pathology; 39 (1.8%) of these patients experienced postoperative incisional CSF leakage. The majority of the pathologies requiring surgeries were located in the supratentorial region (76.9%). Patients were classified according to the type of dural closure technique used. Primary stitching, the patient's fascia, or synthetic dura (resorbable, nonresorbable, or both) were used for dural reconstruction. The median interval between the surgery and the start of the leakage was 19 (IQR 1-79) days in patients with no history of radiotherapy; however, this duration was longer in patients who received radiotherapy (median 45 [IQR 10-540] days). The surgical interventions for CSF leakage were classified as wound resuturing (combined with other conservative approaches such as tightened dressing and elevating the head end of the bed), LED or EVD, or surgical reexploration. The folding technique in duraplasty is a simple way to achieve watertight duraplasty even with autograft or synthetic material. Incisional CSF leakage is a potentially preventable complication with high morbidity. Such cases could be managed via conservative approaches including wound resuturing, LED or EVD, and surgical reexploration. However, the management strategy is beyond any strict algorithm. This folding technique for duraplasty is a worthy replacement for conventional primary suturing for dural repair or reconstruction in cranial and even spinal defects. This study highlights the importance of regaining the watertight nature of the dura in the primary surgery to prevent any further intervention and lower the overall morbidity.

Frontal sinus mucosa suture closure technique for prevention of cerebrospinal fluid rhinorrhea after bifrontal craniotomy: long-term follow-up results.

Bifrontal craniotomy often involves the bony opening and mucosal disruption of the frontal sinus (FS), which can lead to cerebrospinal fluid (CSF) leakage and meningitis. These complications are particularly associated with surgical treatments for skull base tumors and anterior cerebral artery aneurysms. The authors initially reported on the basic technique in 2014 with 51 cases. This study presents a detailed description of their technique and postoperative management for sealing the exposed FS during bifrontal craniotomy, including long-term follow-up results and outcomes. To objectively evaluate the effectiveness of suturing FS mucosa in preventing CSF leakage during bilateral frontal craniotomy, the authors focused only on anterior cerebral artery aneurysms. This limitation was necessary as other conditions, like extensive tumors or trauma, might lack intact FS mucosa or require its removal due to infection. The records of 34 consecutive patients (median age 62.0 years, mean 60.4 years, range 33-78 years) who underwent bifrontal craniotomy for anterior cerebral artery aneurysms between January 2014 and December 2023 were retrospectively analyzed. All patients had bony opening and mucosal injury of the FS (with exposure to the nasal cavity) that required mucosal suturing. This technique for sealing the exposed FS involves careful dissection of the mucosa from the entire sinus, sterilization with iodine-soaked surgical cotton, and preparation for closure. After the microsurgical procedure is completed, the exposed mucosa is sealed with 6-0 nylon sutures and further secured with fibrin glue-soaked Gelfoam. The bony exposure is covered with an autologous bone flap created from the inner table of the craniotomy bone flap. Finally, the frontal periosteal flap is sutured to the frontal base dura mater. Patients were instructed not to blow their noses for 2 months postoperatively. Two patients experienced transient non-CSF leakage from the nasal cavity, likely due to irrigation fluid, which resolved within 2 days postoperatively. No recurrence was observed during a mean follow-up period of 52.8 ± 41.7 months (median 49 months, range 3-127 months). No cases of meningitis or other intracranial infections were reported. The long-term results demonstrate the sustained effectiveness of this technique in preventing postoperative complications related to FS exposure during bifrontal craniotomy.

Use of TachoSil for durotomy repair in spine surgery: a single-center retrospective review.

A significant complication of spine surgery is persistent postoperative CSF leak secondary to intentional or incidental durotomy. Traditionally, the gold standard for repair of simple durotomy has been primary surgical repair; however, this technique alone may not be possible for more complex durotomy and is often supplemented with sealants or fibrin glues. The authors add to the literature the largest series of spine surgery patients treated with TachoSil, a synthetic collagen patch containing human fibrinogen and human thrombin, for the management of incidental or intentional durotomy. The authors identified all patients who underwent a spinal operation and were billed for operative use of TachoSil at their institution between January 1, 2023, and November 3, 2023. Demographic, clinical, and outcome variables were collected and analyzed using standard statistical methods. Categorical variables were reported as number (%), and continuous variables were reported as median (range). The authors retrieved 55 patients meeting their inclusion criteria. The population consisted of 29 (52.7%) females, had a median age of 52 years, and had a median BMI of 28.3 kg/m2. Of the repaired durotomies, 37 (67.3%) were intentional to the operation and 18 (32.7%) were incidental or secondary to trauma. Abnormal residual fluid collections were appreciated in 1 (1.8%) patient. Wound breakdown was observed in 2 (3.6%) patients. Thirty-day readmission was observed in 6 (10.9%) patients, and 30-day reoperation was necessary in 2 (3.6%) patients. Ninety-day readmission was observed in 7 (12.7%) patients and 90-day reoperation was necessary in 3 (5.5%) patients. One (1.8%) case of 30-day readmission was related to CSF leak, and no cases of 30-day or 90-day reoperation were related to dural closure failure. This study is a brief examination of the demographic characteristics, surgical variables, and outcomes of durotomy repair in spine surgery with TachoSil and provides encouraging results for the continued use of the material in this context. This study provides the impetus for examination of TachoSil in larger, multi-institutional studies to establish it as a standard of care in spinal dural repair.

Multicenter study on 2-year outcomes of dual application of hydroxyapatite cranioplasty and a nasoseptal flap following endoscopic endonasal surgery for tuberculum sellae meningiomas or craniopharyngiomas.

The authors evaluated the intermediate-term outcomes of a skull base reconstruction technique using hydroxyapatite cranioplasty combined with a nasoseptal flap following endoscopic endonasal surgery (EES) for suprasellar tumors. Specifically, the evaluation focused on the avoidance of lumbar CSF drainage, prevention of CSF leakage, and incidence of postoperative complications, including meningitis and nasoseptal flap necrosis, during a minimum follow-up of 2 years. This multicenter study included patients who met the following criteria: 1) underwent EES for tuberculum sellae meningiomas or craniopharyngiomas, 2) received dual application of hydroxyapatite cranioplasty and reconstruction using a nasoseptal flap, 3) had a follow-up duration of at least 2 years, and 4) did not undergo lumbar drainage of CSF postoperatively. The success rate of reconstruction was determined based on postoperative CSF leakage, associated complications, meningitis, postoperative hospital length of stay (LOS), and would dehiscence. A total of 198 patients from three institutions diagnosed with tuberculum sellae meningioma (86 patients) or craniopharyngioma (112 patients) were included in this study. The median follow-up duration was 39 months. No patient underwent postoperative lumbar drainage of CSF. Postoperatively, only 3 patients (1.5%) experienced CSF leaks requiring reoperation. The median hospital LOS after surgery was 5 days. Other postoperative complications included atypical meningitis in 5 patients and wound dehiscence in 3 patients during the follow-up period. All patients with nonbacterial meningitis were treated with intravenous antibiotics and dexamethasone medication for 2 weeks. The combination of hydroxyapatite cranioplasty and a nasoseptal flap in reconstruction following EES decreased the requirement for postoperative lumbar CSF drainage and shortened hospital LOSs with minimal morbidities. Nevertheless, careful attention to the risks of meningitis and central necrosis of a nasoseptal flap is crucial for optimizing patient outcomes.

Clival dural reconstruction via transnasal approaches: fat graft fixation technique.

CSF fistulas are the weak spots of transnasal endoscopic and microsurgical skull base approaches. An autologous fat graft is considered the best substrate for clival dural reconstruction via transnasal approaches. However, potential gravitational displacement of the graft may result in CSF leakage. The authors have developed and described herein the fat graft fixation (FGF) technique to secure the fat graft against dislocation after transclival resection of chordomas invading the dura. Seventy-five patients with cranial chordomas underwent surgical treatment at the authors' institution from September 2006 through June 2023. Of these, the authors collected demographic, clinical, radiological, surgical, and outcome data from 34 patients who underwent an endoscope-assisted microsurgical transclival approach via a transnasal, sublabial, or sublabial transmaxillary extended corridor. The FGF reconstruction technique was progressively implemented to improve clival reconstruction, with a focus on the results. With a custom-made 8-mm 3/8 round atraumatic surgical suture needle, a 4/0 Vicryl stitch was placed through the adjacent dural borders. An abdominal autologous fat graft was then placed over the dural defect. One triple knot was tied to secure the graft and prevent its delayed gravitational displacement. The primary outcome was to determine if the FGF group had a higher rate of early or late oronasal CSF fistula compared to the unlocked free graft group. Secondary outcomes included tension pneumocephalus, surgical site infection, and meningitis. The fat graft was not used in 8 (23.5%) of the 34 patients because the dura was intraoperatively intact. The unlocked free graft and FGF techniques were used in 20 (58.8%) and 6 (17.6%) patients, respectively. Of the 34 patients, no fistulas were observed in the group treated with the FGF technique, while 4 fistulas were found in the unlocked free graft group (p < 0.05), with 2 of these cases involving meningitis. Patients with a CSF fistula underwent a total of 7 surgical procedures: 3 revision surgical procedures, 2 lumboperitoneal shunts, and 2 ventriculoperitoneal shunts. In the authors' preliminary experience, the FGF technique has shown promise in eliminating the risk of CSF fistula and other related complications after the transclival approach for clival chordomas involving the dura.

Recent experience with calcium phosphate cement cranioplasty after lateral supraorbital keyhole approach to the anterior cranial fossa.

Through an eyebrow incision, the lateral supraorbital (LSO) keyhole approach provides access to various lesions in the anterior cranial fossa and affords many of the advantages of minimal access and minimally invasive surgery. The LSO approach and other minimal access approaches including various endonasal approaches to the anterior cranial fossa, however, have been associated with nonnegligible rates of CSF leaks postoperatively. The authors report their recent experience using calcium phosphate cement cranioplasty as a method of preventing CSF leakage after LSO keyhole craniectomy. A retrospective medical records review was performed for 9 consecutive patients undergoing operations by the senior authors using the LSO keyhole approach with skull defect repair using calcium phosphate cement cranioplasty alone between 2022 and 2024. Review of the medical records included clinic notes, imaging studies, and operative notes as well as details regarding the length of hospital stay, complications, and rate of tumor recurrence. Eight of 9 patients underwent resection of meningiomas, while 1 underwent resection of a cavernous malformation. The cohort consisted of 7 females (78%) and 2 males (22%) with a mean age of 55.2 years. The mean tumor volume among the 8 meningiomas was 18.09 cm3, and peritumoral edema was present in 8 of the 9 cases (89%). Gross-total resection was achieved in 7 of 8 meningioma cases (87.5%). Among the 9 patients, the mean length of hospital stay was 2.4 days. Two patients (22%) experienced complications. No patients experienced a CSF leak postoperatively. At a mean follow-up of 13.8 months, 1 patient (12.5%) experienced tumor recurrence. Based on this and prior experience, the use of calcium phosphate cement cranioplasty alone following an LSO keyhole approach to the anterior cranial fossa is a safe alternative to traditional closure techniques, which rely on replacement of bone flap with plates and screws, and it might reduce the rate of postoperative CSF leakage. Larger studies are required to confirm these findings.

Fibrin-coated collagen fleece "sandwich" closure technique for cranial and spinal dural reconstruction and closure.

Persistent CSF leakage and symptomatic pseudomeningocele formation are a primary concern following intradural posterior fossa and spinal surgeries, with rates approaching 23.7% and 10%, respectively. These complications occur at a higher rate in cases in which a watertight primary closure cannot be attained. In such cases, various dural substitutes and sealants are at the surgeon's disposal and often require suturing a dural substitute to the existing dura. Herein, the authors describe a novel sutureless inlay-onlay fibrin-coated collagen fleece (TachoSil) "sandwich" closure technique for dural reconstruction and closure. The authors retrospectively reviewed posterior fossa and intradural spinal cases performed by the senior author from January 1, 2021, to August 30, 2024, which used the described novel closure technique when primary closure without expansion could not be attained. Primary outcomes were rates of postoperative CSF leakage, symptomatic pseudomeningocele formation, CSF diversion, infection, and revision surgery. A total of 13 patients (8 craniotomies, 2 craniectomies, and 3 spinal cases) were identified with a mean age of 61.3 ± 14.0 years. Surgical indications included intra-axial and extra-axial tumors, acute cerebellar infarcts, an unruptured aneurysm, and a ruptured arteriovenous malformation. One patient (7.7%) who underwent emergency craniectomy for acute cerebellar infarct developed a postoperative CSF leak and symptomatic pseudomeningocele with suspicion of pseudotumor cerebri, ultimately requiring CSF diversion. There were no complications among patients receiving craniotomy or intradural spinal surgery. No postoperative infections or revision surgeries occurred. The TachoSil sandwich technique represents an effective means of cranial and spinal dural reconstruction and closure in cases in which watertight primary dural closure cannot be achieved.

Massive pneumocephalus after Valsalva maneuver in sphenoidal meningocele.

Pneumocephalus, defined as the presence of gas within the intracranial space, typically results from head trauma, surgery, or diagnostic/therapeutic procedures that disrupt the dura. However, spontaneous or non-traumatic pneumocephalus is rare. This video article presents a case report of a 64-year-old woman referred to the Department of Otolaryngology with a severe frontal headache and clear nasal discharge (rhinorrhea) after performing the Valsalva maneuver to relieve ear fullness. The patient had previously been diagnosed with sphenoidal meningocele and was awaiting skull base reconstruction surgery. A computed tomography (CT) scan of the brain and paranasal sinuses revealed significant pneumocephalus, with a defect in the sellar floor and cerebrospinal fluid (CSF) pooling in the sphenoid sinus. An endoscopic trans-sphenoidal repair of the CSF leak was promptly performed, and a post-operative CT scan showed complete resolution of the pneumocephalus. At the 2-month follow-up, the defect had healed optimally, with no intracranial complications observed. Pneumocephalus is a rare clinical condition, and prompt, accurate diagnosis, along with early intervention, is crucial to prevent neurological complications.

Results of a German national survey to assess early mobilization versus bed rest in the postoperative management of incidental durotomy during lumbar surgery and the need for a randomized clinical trial.

Incidental durotomy during degenerative lumbar spine surgeries poses a complex medical challenge. Despite its relatively common occurrence, consensus on its management remains elusive due to the absence of robust, high-level evidence, resulting in significant variations in practice across medical institutions. The aim of this survey was to assess the current practices in Germany regarding early mobilization versus bed rest in the postoperative management of incidental durotomy during lumbar surgery to estimate the need for a randomized clinical trial. A digital survey titled "Postoperative management of incidental durotomy in lumbar spine surgery" was conducted among 119 neurosurgical departments in Germany. Key questions included the use of bed rest postsurgery, timing of mobilization, and whether the practice depended on the complexity of the surgery or the quality of the dural tear repair. The survey also explored the role of lumbar drains in management and respondents' potential participation in a multicenter study on the benefits of bed rest. Invitations were sent in November 2023, and responses were collected during November and December 2023. A total of 89 (75%) departments completed the survey. Among them, 75% reported using bed rest in the postoperative management of incidental durotomy. For 57%, this practice depends on the complexity of the surgical procedure or the quality of the surgical repair of the dural tear, while 18% apply it independently. Twenty-nine of the 89 departments (33%) answered that mobilization is allowed 24 hours after surgery, 13 departments (15%) allow mobilization after 48 hours, and 19 departments (21%) allow it after 72 hours. Additionally, 34% reported using a lumbar drain in cases of persistent postoperative CSF leakage, 36% use it for secondary surgical revision, and 30% do not use it in either case. Furthermore, 55 departments (62%) expressed potential interest in participating in a multicenter randomized trial addressing the postoperative management of incidental durotomy. The postoperative management of incidental durotomy during lumbar surgery exhibits significant variation across neurosurgical departments in Germany. Postoperative bed rest remains a common practice. To evaluate the true benefits of bed rest, a randomized multicenter study is recommended. A summary proposal for such a study is presented to address this need.

Comparison of surgical approaches and outcome for symptomatic pineal cysts: microscopic/endoscopic fenestration vs. stereotactic catheter implantation

PurposeTreatment strategies for space-occupying/symptomatic pineal cysts (PC) are still up for debate. In this study we present PC management, outcome data and risk factors for recurrence after surgery, focusing on microscopic/endoscopic procedures vs. stereotactic catheter implantation as alternative treatment concept to permanently drain PC into ventricles/cisterns.MethodsThis monocentric retrospective analysis included clinical data from all consecutive PC patients treated surgically between 2000 and 2022. Postoperative neurological and functional outcomes, along with perioperative complications, as well as time to PC recurrence and MR-morphological data were evaluated.Results39 patients (median age 32.6 years, range: 5.1–71.6 years) were analyzed. Main presenting symptoms were headaches, visual impairment, and epileptic seizures. In 18 patients (46.2%) an enlarged ventricular system was preoperatively found with 7 patients (18.0%) suffering from occlusive hydrocephalus. 14 patients underwent microscopic/endosocopic surgery, in 25 cases stereotaxy was preferred. No complication was seen in the microsurgery/endoscopy group compared to one intracystic postoperative bleeding (2.6%) and two CSF leaks (5.1%) after stereotaxy (p = 0.5). Overall, clinical improvement and significant cyst volume reduction (p < 0.0001) was seen in all patients. Recurrent PC were seen in 23.1%, independent of surgical procedure (p = 0.2). In cases of recurrence, TTR was 25.2 ± 31.2 months. Male gender (p = 0.01), longer surgery time (p = 0.03) and preoperatively increased Evans index (EI) (p = 0.007) were significant risk factors for PC recurrence in multivariate analysis.ConclusionIn patients suffering from PC, microsurgical and stereotactic approaches can improve clinical symptoms at low procedural risk, with equal extent of volume reduction. However, preoperative ventricular enlargement and EI values should be considered for optimal treatment planning to reduce recurrence.

CSF-Venous Fistulas Arising Intraosseously within Bone Remodeled by Meningeal Diverticula.

CSF-venous fistulas (CVFs) are a common and increasingly recognized type of spinal CSF leak. Most of these fistulas occur in the setting of spontaneous intracranial hypotension, though nonspontaneous cases have been described as well. In most instances, CVFs arise from the dome or neck of nerve root sleeve diverticula (also called meningeal diverticula). Venous drainage typically involves some combination of the internal epidural venous plexus and external vertebral venous plexus. Not uncommonly, venous drainage into the basivertebral venous plexus or other intraosseous veins can be seen. However, the drainage is usually a secondary finding related to normal communication between intraosseous and extraosseous veins. We have recently observed unique cases in which CVFs arise directly within the vertebral elements, resulting in primarily intraosseous drainage. It is possible that this phenomenon is secondary to prominent meningeal diverticula remodeling the adjacent vertebral elements. In this clinical report, we reviewed a multi-institutional series of CVFs exhibiting primary intraosseous drainage, with the goal of illustrating the imaging findings, treatment strategies, and outcomes of the patients. Nine cases were identified demonstrating this phenomenon. We show that intraosseous CVFs can arise in virtually any part of the vertebrae and describe how this feature affects treatment.

Complication Rates Following Endoscopic Sinus Surgery for Chronic Sinusitis.

Endoscopic sinus surgery (ESS) is a minimally invasive procedure indicated for medically refractory chronic sinusitis (CRS). As with any surgical procedure, there are potential risks and complications. The purpose of this study is to report skull base, orbital, and hemorrhagic-associated complication rates following ESS. A retrospective query on the TriNetX platform identified patients diagnosed with CRS who subsequently underwent ESS in the last 20 years. Outcomes analyses were performed to determine the incidence of skull base (cerebrospinal fluid rhinorrhea, bacterial meningitis, dural tear), orbital (diplopia, optic nerve injury, blindness, epiphora, orbital hemorrhage, canthotomy/canthoplasty), and hemorrhagic (epistaxis, carotid artery injury, blood transfusion) complications within 30 days postoperatively. Kaplan-Meier Analysis estimated survival probability from each complication type. Outcome rates were also compared between female and male patients. A total of 116 669 patients from 55 healthcare organizations fit the study criteria. The average age at surgery was 47.9 ± 17.9 years. The gender distribution of the cohort was 50% female and 48% male. The risk of skull base, orbital, and hemorrhagic complications within 30 days of the surgery was found to be 0.212%, 0.741%, and 3.00%, respectively. Kaplan-Meier Analysis revealed that survival probability from each complication type was 99.783%, 99.260%, and 96.903%, respectively. Comparison of outcome risks stratified by gender revealed no major differences for skull base and orbital complications; however, males exhibited a significantly higher risk of hemorrhagic complications (3.2% vs 2.8%, P < .0001). The study supports ESS as a safe procedure for the management of CRS. Though rare, hemorrhagic complications are more common than orbital and skull base complications. Hemorrhagic complications are also more common in men than women. These findings provide insights for counseling patients about ESS risks and benefits.

Congenital scoliosis presenting in teenage years outcomes without hemivertebra excision.

In congenital scoliosis, the surgical strategy approach of hemivertebra excision, with or without instrumentation and fusion, is a common approach to correction of scoliosis. However, hemivertebra excisions are technically challenging, with potential complications including spinal cord injury, nerve root injury and cerebrospinal fluid leak. The purpose of this study was to determine whether correction of congenital scoliosis can be achieved using a posterior instrumentation/fusion-only approach without the need for hemivertebra excision. 35 patients with congenital scoliosis and hemivertebra operated between 2007 and 2024 were matched to 35 AIS patients by BMI, levels fused, and preoperative Cobb. Wilcoxonrank-sum tests, chi-square tests, and Fisher's Exact tests were utilized. Age (p = 0.22), BMI (p = 0.25) and preoperative Cobb (p = 0.79) were similar between hemivertebra and AIS patients. Cobb correction (HV: 71.8% vs. AIS: 70.4%; p = 0.92) and EBL (500cc vs. 400cc; p = 1.0) were similar. Operative time (310.0min vs. 242.0min; p < 0.001) and length of stay (7.0days vs. 5.0days; p < 0.001) were statistically different. Patients operated on after 2018, when the Rapid Recovery Protocol was implemented, had a similar length of stay (4.5 vs. 5.0; p = 0.92). Patients in both cohorts had similar SRS-22 scores. Choosing fusion levels in congenital patients, on similar principles to AIS, leads to avoidance of hemivertebra excision, including lumbosacral hemivertebrae. This approach is safer than hemivertebra excision and has similar, or better, curve correction than previously reported.