Postoperative Cerebrospinal Fluid Fistula Research Articles

Incidence, Characteristics, and Outcomes of Pseudomeningocele and Cerebrospinal Fluid Fistula after Posterior Fossa Surgery

Posterior fossa approaches are common neurosurgical procedures. Rates of postoperative infection, pseudomeningocele, and cerebrospinal fluid (CSF) fistula are high; however, evidence regarding predisposing risk factors and treatment outcomes remain sparse. A retrospective cohort study was carried out of all posterior fossa surgeries conducted at a single institution between January 2015 and October 2019. Univariate statistical methods and stepwise logistic regression were used to assess which factors contributed most to risk of development of postoperative complications. A total of 269 patients were included; 18.6% experienced any postoperative complication, 13% developed either pseudomeningocele or CSF fistula, and 9.7% developed an infection. In multivariate analysis, development of a pseudomeningocele was significantly associated with previous cranial surgery (hazard ratio [HR], 3.15; 95% confidence interval [CI], 1.12-9.28; P= 0.0391). Development of a CSF fistula was significantly associated with index surgery for resection of neoplasm (HR, 7.65; 95% CI, 1.86-22.31; P= 0.0174). Development of an infection was significantly associated with concurrent CSF fistula (HR, 7.16; 95% CI, 1.91-23.19; P= 0.0041) and concurrent pseudomeningocele (HR, 3.41; 95% CI, 1.37-5.95; P=0.0082) and nonsignificantly associated with diabetes requiring treatment (HR, 2.42; 95% CI, 0.69-8.50; P= 0.168). Other hypothesized risk factors for these complications, such as nonmidline approaches to the posterior fossa, watertight duraplasty, use of dural fibrin sealant, and cranioplasty were not associated with these complications on multivariate analysis. Although many patients with pseudomeningocele were successfully managed with observation, only 38% of patients in whom CSF diversion was attempted avoided surgery. History of diabetes, cranioplasty, revision surgery, and surgery for tumor resection are identified as risk factors for the development of infection, pseudomeningocele, and CSF fistula, respectively.

Management of gunshot wounds to the spine at Parakou University Teaching Hospital In Benin Republics

Objective: Describe the clinical features and bullet removal in gunshot wound (GSW) to the spine. Patients and methods: From 2015 to 2021 we present Case series of consecutive five cases of GSW with spinal cord injury treated at a single center of parakou university neurosurgery department. Results: Patient ages ranged from 16 to 40 yr (mean: 27.4 yr). All the patients were male. Three had complete thoracic spinal cord injury (ASIA A), two had lumbar level injury with cauda equina syndrome in one case. Surgical and rehabilitation management, as well as the outcome, of a patient who with sustained spinal cord injury from a high velocity gunshot wound to the thoracic spine. Decompression and bullet removal were performed using an open surgery. The patient with thoracic spinal cord lesion associated with extended injuries related to bullet fragmentation have a poor prognosis. The patients with incomplete injuries had a good follow-up and neurologic recovery. There were no postoperative wound infections, cerebrospinal fluid (CSF) fistulas, or other complications related to the procedure. Conclusion: Surgical decompression and bullet removal is a safe technique that may help reduce the risk of postoperative infections and CSF fistulas in patients with GSW to the thoracic and lumbar spine.

Single Versus Double Hadad-Bassagasteguy Flap in Expanded Endoscopic Skull-Base Surgery.

The reconstruction of dural defects, after endoscopic removal of skull-base lesions, remains challenging when a large defect or a high flow intraoperative cerebrospinal fluid (CSF) leak is observed. The aim of this study is to describe our preliminary experience with a double Hadad-Bassagasteguy (H-B) flap technique for skull-base repair, comparing its efficacy with the use of a single H-B flap in our series. A retrospective chart review was conducted on patients who underwent exclusive endoscopic endonasal skull-base surgery at our Referral Skull Base Center from December 2014 to January 2018. Data on patient demographics, pathology, preoperative and postoperative imaging, intraoperative findings, surgical route, defect size, reconstruction techniques and repair materials, were analyzed. Patients were divided into double and single H-B flap groups. In the single and double H-B groups, the postoperative CSF leak rates were 37.5% (6 of 16 patients) and 4.5% (1 of 22 patients), respectively. The difference between the two groups was statistically significant (p = 0.0470). In patients with defects > 4cm or high-flow intraoperative CSF leakage related to the opening of the third ventricle, the double H-B flap was successfully placed with no occurrence of postoperative CSF leakage. The double H-B flap significantly reduced the postoperative CSF leakage rate after expanded transnasal skull-base surgery. Particularly in challenging cases, where a large skull-base defect or a high-flow intraoperative CSF leak was observed, this reconstructive method proved to be very effective, with no evidence of postoperative CSF fistulas.

Suturing of the Arachnoid Membrane for Reconstruction of the Cisterna Magna: Technical Considerations

Postoperative cerebrospinal fluid (CSF) fistula following cranial or spinal surgery is associated with increased morbidity and mortality. To prevent CSF fistulas, various techniques have been described. Here, we describe the arachnoid membrane continuous-running suture technique in cisterna magna reconstruction for preventing postoperative CSF leakage. After craniotomy and dural opening, the incision of the arachnoid of the cisterna magna was performed using a diamond blade. To prevent the arachnoid from drying out and shrinking during surgery, it was periodically irrigated with warm saline solution. Posterior fossa surgery was performed. When closing the membranes, the arachnoid membrane was closed with the running-suture technique. After the first surgical knot was made in the cranial end of the arachnoid opening, continuous suturing with a 2-mm distance between the stitches was performed without stretching them. After every 3 stitches, the free end of the thread was pulled gently along the suturing axis, and the edges of the arachnoid were closed. After the arachnoid edges were approximated, the surgical knot was tied. Watertight closure was checked byperforming the Valsalva maneuver at the end of the surgery. No CSF leakages were observed after surgery. Arachnoid membrane suturing seems to be safe and effective in preventing postoperative CSF leakage and CSF-related complications. Using continuous running suturing alone, without any sealant, might beeffective in cases with untraumatized arachnoid membrane.

Perspective: Early diagnosis and treatment of postoperative recurrent cerebrospinal fluid fistulas/ dural tears to avoid adhesive arachnoiditis.

Background: Intraoperative traumatic cerebrospinal fluid (CSF) fistulas/dural tears (DT) occur in up to 8.7–9.5% of primary lumbar surgical procedures. Further, they recur secondarily in between 8.1% and 17% of cases. It is critical to diagnose and treat these recurrent lumbar DT early (i.e. within 3–4 weeks of the index surgery) to avoid the evolution of adhesive arachnoiditis (AA), and its’ permanent neurological sequelae.Methods: Postoperative lumbar CSF fistulas/DT should be diagnosed on postoperative MR scans, and confirmed on Myelo-CT studies if needed. They should be definitively treated/occluded early on (e.g. within 3–4 postoperative weeks) to avoid the evolution of AA which can be readily diagnosed on MR studies, and corroborated, if warranted, on Myelo-CT examinations. The most prominent MR/Myelo-CT findings include; nerve roots aggregated in the central thecal sac, nerve roots peripherally scarred/adherent to the surrrounding meningeal wall (“empty thecal sac sign”), soft tissue masses in the subarachnoid space, and/or multiple loculated/scarred compartments.Results: Percutaneous interventional procedures (i.e. epidural blood patches, injection of fibrin glue (FG)/fibrin sealants (FS)) are rarely effective for treating postoperative recurrent lumbar CSF fistulas. Rather, direct surgical occlusion is frequently warranted including the use of; an operating microscope, adequate surgical exposure, 7-0 Gore-Tex sutures, muscle/dural patch grafts or suture anchors, followed by the application of microfibrillar collagen, and fibrin sealant/glue.Conclusion: Lumbar AA most commonly results from the early failure to diagnose and treat recurrent postoperative CSF fistulas. Since the clinical course of lumbar AA is typically one of progressive neurological deterioration, avoiding its’ initial onset is key.

A Novel Classification and Its Clinical Significance in Spinal Schwannoma Based on the Membranous Hierarchy.

Spinal schwannoma is a common benign tumor. However, the high recurrence rate and incidence of surgical complications are unsolved problems. To propose a morphological classification of spinal schwannoma based on tumor-membrane relationships to increase the gross total resection (GTR) rate and to decrease the incidence of surgical complications. Histological techniques were used to study 7 adult cadavers. Following picrosirius staining, the membranes around the nerve root were observed under a microscope. Data from 101 patients with spinal schwannoma were also collected for clinical analysis. The sleeve around the spinal nerve root consisted of dura and arachnoid tissues. The space between them gradually narrowed and fused at the proximal pole of the nerve root ganglion. Spinal schwannomas were divided into 4 types based on membranous structure: intrapial (type I), subarachnoidal (type II), intra- and extradural (type III), and extradural growth (type IV). Types II and III were further subdivided into 2 subtypes. GTR was achieved in all patients (100%), with no tumor recurrence during follow-up. Overall functional status significantly improved postoperatively. A total of 59 patients (92%) showed improvement or significant improvement postoperatively. There was no difference in surgical outcomes among the tumor classifications (P=.618). No intraoperative vertebral artery injuries or postoperative cerebrospinal fluid fistula occurred. Spinal schwannoma classification based on a membranous hierarchy provides an intuitive platform for preoperative planning and intraoperative safety. This classification scheme may help surgeons better define surgical goals and anticipate or even avoid complications from resection.

Cervical meningioma resection including the inner dura through an open-door laminoplasty using hydroxyapatite spacers: A case report

Background: The ideal surgery for spinal cord tumors is complete resection to prevent recurrence. However, it should be accomplished safely/effectively without risking increased morbidity. Here, we report a cervical meningioma that was totally resected, including the inner dura, through a laminoplasty performed with hydroxyapatite (HA) spacers.Case Description: A 61-year-old Asian male presented with a symptomatic intradural extramedullary C4-C6 cervical meningioma. At surgery, this required resection of the inner dural layer through an open-door laminoplasty. Preservation of the outer dural layer facilitated a watertight closure and the avoidance of a postoperative cerebrospinal fluid (CSF) fistula. Notably, the laminoplasty utilized HA spacers which were magnetic resonance (MR) compatible allowing for future follow-up studies to evaluate for tumor recurrence. At 5-year follow-up, the tumor had not recurred, the patient was asymptomatic, and alignment was maintained.Conclusion: Gross total resection of an intradural extramedullary C4-C6 cervical meningioma was performed with removal of just the inner dural layer. Preservation of the outer dural layer allowed for a watertight closure and the avoidance of a postoperative CSF leak. Further, laminoplasty using HA spacers allowed for successful tumor resection, adequate fusion/stabilization, while not interfering with future MR studies (e.g., HA MR compatible).

Minimally Invasive Management of Civilian Gunshot Wounds to the Lumbar Spine: A Case Series and Technical Report.

Treatment of penetrating gunshot wounds (GSW) to the spine remains controversial. The decision to operate is often based on surgeon preference and experience. We present a case series of 7 patients who underwent minimally invasive thoracolumbar/sacral decompression and bullet removal at a level 1 trauma center. To describe the use of minimally invasive techniques to achieve decompression and bullet removal for GSW to the spine. From 2010 to 2017, 7 patients with spinal GSW underwent minimally invasive decompression and bullet removal at an academic level 1 trauma center. Patient ages ranged from 20 to 55 yr (mean: 31 yr). The mechanisms of injury were GSW to the abdomen/pelvis (n=6) and direct GSW to the spine (n=1). Based on the neurological examination, the injuries were characterized as complete (n=1) or incomplete (n=6). Decompression and bullet removal were performed using a tubular retractor system. All patients with incomplete injuries who had postdischarge follow-up demonstrated some neurologic recovery. There were no postoperative wound infections, cerebrospinal fluid (CSF) fistulas, or other complications related to the procedure. Minimally invasive decompression and bullet removal is a safe technique that may help reduce the risk of postoperative infections and CSF fistulas in patients with GSW to the lumbar spine compared to the standard open technique. This approach appears to be particularly beneficial in patients with incomplete injuries and neuropathic pain refractory to medical treatment.

Development of cerebrospinal fluid fistula after incidental durotomy in spinal decompression surgery.

Incidental durotomy (ID) during spinal surgery is a risk factor for the development of cerebrospinal fluid (CSF) fistula. The rates of ID with or without consecutive CSF fistula vary according to the extent of the surgical procedure. Revision surgery has the highest rates of dural tears. However, not every case of ID leads to CSF fistula requiring revision surgery. The objective of this study was to analyze the predictors for the development of CSF fistula after ID. This retrospective study included 6024 consecutive patients who had been surgically treated for degenerative spinal disease at our clinic over the past 15 years. Patients who had undergone surgical revision for CSF fistula were assigned to the CSF fistula group. A matched 3:1 control group (ID group) was formed of patients with ID but without CSF fistula. Charts, surgical reports, and radiographic data were reviewed and statistically analyzed for demographics, duration of symptoms, comorbidities, surgical strategy, and pre- and postoperative neurological performance. The 15-year incidence of CSF fistula in the overall population was 0.36% (N.=22). The following locations were affected: N.=18 lumbar (81.8%), N.=2 cervical (9.1%), and N.=2 thoracic (9.1%). The extent of ID was similar in both groups. The two groups did not significantly differ with regard to the intraoperative management of dural repair with primary suturing (P=0.345), dural patches, sealant, or collagen matrix (P=0.228; P=0.081; P=0.081). In the postoperative period, bed rest in supine position for 48 hours (P=0.037) and laxative therapy (P=0.034) were the most beneficial treatment modalities for preventing CSF fistula. Patients with CSF fistula were hospitalized significantly longer (21 days vs. 10 days in the control group; P<0.001). This large test group showed a low incidence of postoperative CSF fistula after intraoperative ID. Bed rest and laxative treatment were important approaches to preventing CSF fistula.

Middle Cranial Fossa Encephalocele and Cerebrospinal Fluid Leakage: Etiology, Approach, Outcomes.

Objective To compare outcome data for surgical approaches in the management of a middle cranial fossa encephalocele or cerebrospinal fluid (CSF) leak and, secondarily, to evaluate the role of obesity and the etiology of the defect. Design Retrospective Setting Quaternary referral center Participants The study included 73 patients who underwent surgical repair of middle cranial fossa tegmen defects, two of which underwent bilateral repair. Outcome Measures Demographic characteristics, clinical presentation, etiology, imaging, audiometry, surgical findings, method and material for repair, and postoperative course. Results Fifty cases were spontaneous in origin, 2 were iatrogenic, and 23 were because of chronic otitis media. Of the 50, 18 underwent middle fossa craniotomy, 29 underwent a transmastoid approach, and 28 underwent a combined approach for repair. A postoperative CSF leak was seen in five patients: one who had undergone a transmastoid approach and four after a combined approach. There was no significant difference between the three approaches and risk of postoperative CSF fistulae. Two of the CSF fistulae resolved after a lumbar drain, and the remaining three patients required revision surgery. Conclusions Middle cranial fossa tegmen defects are most commonly seen in obese females and are spontaneous in origin. The most common location was the tegmen mastoideum, and these defects were most commonly repaired through the transmastoid approach, with no greater risk of recurrence.

Clinical Experience with Hemopatch® as a Dural Sealant in Cranial Neurosurgery.

Background: Herein, we report our clinical experience with the novel polyethylene glycol-covered matrix dural onlay, Hemopatch® (Baxter Deutschland GmbH, Unterschleißheim, Germany) for the prevention of postoperative cerebrospinal fluid (CSF) fistulas.Methods: Retrospectively, 22 consecutive patients (11 females, 11 males, mean age: 49.8 years, range: 15–77 years) with oncological and vascular intracranial lesions were included in this study. In all patients, the Hemopatch was applied as the dural onlay. The accuracy of the primary dural sutures was distinguished into 1) no visible gaps, 2) small gaps < 3 mm, and 3) large gaps > 3 mm. We evaluated the patient charts, surgical reports, and postoperative images. The median follow-up was three months. We recorded any wound healing disorder, such as infection or CSF fistula, and postoperative hemorrhage resulting in surgical revision.Results: Supratentorial, infratentorial, and transsphenoidal approaches were conducted in 17, four, and one patient, respectively. Accurate sutures without visible gaps, small gaps, and large gaps were covered with the Hemopatch in 11, eight, and three patients. One patient developed a CSF fistula (4.5%), one patient had a wound infection (4.5%), and in one patient, a remote cerebellar hemorrhage occurred (unrelated to the dural closure) (4.5%). Thus, the surgical revision rate due to wound healing disorders was 9% (2/22).Conclusion: It is safe and feasible to use the Hemopatch as a dural sealant. The rate of postoperative wound healing disorders in our population was in the lower range of reported surgical revision rates after supra-/infratentorial craniotomies. However, prospective and controlled clinical trials are still warranted.

Utilizing real-time contrast medium to detect the fistula of giant spinal arachnoid cyst and treat with minimal invasive surgery

BackgroundSpinal arachnoid cysts are rare and have varied clinical manifestations depending on the affected spinal region and nerve roots. A complete cyst excision with fistula closure is the first choice of treatment. However, it might be difficult to localize the specific position of the fistula because previous images have no enhancements or the fistula is too tiny to be detected.Case presentationThis case is a giant lumbar extradural arachnoid cyst. We administered a lumbar injection with contrast medium into subarachnoid space under digital subtraction angiography (DSA) and disclosed the fistula. Confirming the location of fistula enabled us to perform minimally invasive surgery to ligate the fistula. Surgical intervention for a spinal arachnoid cyst might encounter the problem of the formation of a postoperative cerebrospinal fluid (CSF) fistula. We propose the option of detecting the fistula preoperatively for minimal invasive surgery. Recurrence depends on the long-term follow-up, and more cases are needed to further evaluate our technique.ConclusionsThe real-time contrast medium technique for spinal arachnoid cysts contributes to the complete ligation with minimally invasive surgery.

Endonasal endoscopic surgery in pituitary adenomas: Surgical results in a series of 86 consecutive patients

IntroductionThe endoscopic endonasal approach has become the gold standard for the surgical treatment of pituitary adenomas. ObjectivesThe aim of this study is to present the results obtained in our hospital in purely endoscopic surgery of pituitary adenomas. MethodsFrom February 2011 to August 2016, we conducted a prospective study on a series of 86 patients with pituitary adenoma, all of whom underwent surgery with a purely endoscopic endonasal approach. The ‘four hands-two nostrils’ technique was performed in all cases by a surgical team composed of an ENT surgeon and a neurosurgeon. Mean follow-up was 32 months. All patients were evaluated according to clinical, radiological and endocrinological criteria. ResultsIn our series, 53% were women and 47% men. The age ranged from 14 to 84 years of age, with a mean of 54 years of age. The most common initial symptom was visual deficit (42%), followed by hormonal hyperfunction (21%), with acromegaly being the most common clinical syndrome. The most common tumours were non-functioning tumours (73%), while GH-secreting tumours (65%) were the most common functioning adenoma. Regarding tumour size, 76% were macroadenomas, 11% microadenomas and 13% giant adenomas. Approximately 63% of the adenomas exhibited suprasellar extension and 37% involved invasion of the cavernous sinus (Knosp grade ≥3). Total excision was achieved in 77% of the cases. After the intervention, visual improvement was achieved in 91% and remission of endocrine hyperfunction in up to a 73% of cases. The most common complication was anterior pituitary insufficiency of at least one axis (9%). There were no cases of postoperative cerebrospinal fluid fistula. ConclusionsIn terms of surgical quality, our results are similar to those of published series, and demonstrate the efficacy and safety of the endoscopic endonasal approach as the surgical treatment of choice for pituitary adenomas. However, further studies with a higher sample size are necessary to obtain clinically significant results.

Risk Factors and Management of Incidental Durotomy in Lumbar Interbody Fusion Surgery.

This is a retrospective study analysis. In this retrospective study we evaluated risk factors for incidental durotomy and its impact on the postoperative course. Lumbar interbody fusion (LIF) is increasingly applied for the treatment of degenerative instability. A known complication is incidental durotomy. A cohort of 541 patients who underwent primary LIF surgery between 2005 and 2015 was analyzed. Previous lumbar surgery, age, surgeon's experience, intraoperative use of a microscope, and the number of operated levels were assessed and the risk for incidental durotomy was estimated using the Log-likelihood test and Wald test, respectively. The association of incidental durotomy and outcome parameters was analyzed using the quantile regression model. In 77 (14.2%) patients intraoperative cerebrospinal fluid (CSF) fistula was observed. Previous lumbar surgery (P<0.001), number of operated levels (P=0.03), and surgeon's experience (P=0.01) were significantly associated with incidental durotomy. Incidental durotomy was significantly associated with a prolonged bed rest (P<0.001), hospital stay (P=0.041), and an increased use of postoperative antibiotics (P<0.001). Eleven of 77 patients with incidental durotomy (14.3%) developed postoperative CSF fistula of whom 10 (91%) needed revision surgery for dural repair. We could identify important risk factors for incidental durotomy in LIF surgery. In patients who had undergone previous lumbar surgery and those with multilevel disease particular precaution is required. Furthermore, we were able to verify the morbidity associated with CSF fistula as shown by increased immobilization and follow-up surgeries for postoperative CSF fistula which emphasizes the importance to develop strategies to minimize the risk for incidental durotomy.

Complications of Extended Endoscopic Endonasal Surgery in Elderly Patients.

Extended endoscopic endonasal procedures are not unique among surgical interventions in carrying increased risk in the elderly population. There are, however, components of the procedure, namely high-flow cerebrospinal fluid leaks, that do result in the potential for increased perioperative morbidity for these patients. We present the case of a 77-year-old male with a large invasive pituitary macroadenoma resected through a transplanum-transtuberculum-transsellar endonasal approach. A gross total resection was obtained with resolution of the patient's preoperative ophthalmologic deficits. One month postoperatively, the patient developed progressive lethargy and cranial imaging demonstrated a left convexity subacute subdural hematoma. This was evacuated through a twist drill craniostomy. Despite measures to limit the operative time of the initial endonasal procedure as well as the absence of a postoperative cerebrospinal fluid fistula, the patient still developed this complication. Along with more typical potential causes of postoperative decline following extended endonasal procedures, problems from high-flow intraoperative cerebrospinal fluid leaks alone can result in morbidity in the elderly population. This should be acknowledged preoperatively and a high suspicion should exist for the presence of intracranial hemorrhage in these patients with any postoperative deficits. Additional intraoperative measures can be utilized to minimize such risks. The link to the video can be found at: https://youtu.be/EkLmt2T8_UE .

O uso de selante de fibrina em cirurgia de lesões do ângulo pontocerebelar e da fossa posterior

A cola de fibrin é um adesivo biológico tópico, constituído de concentrdo humano de fibrinogênio que é ativado pela adição de trombina e cloreto de cálcio. O cágulo resultante mimetiza o estágio final da coagulação plasmática, não apresentando reação como corpo estranho ou fibrose excessiva. A cola de fibrina é útil para vários propósitos em enurocirurgia, como: tratamento e prevenção de fístulas liquóricas, hemostasia após a resseção de tumores cerebrais e malformações arteriovenosas, selagem de anastomoses vasculares, como reforço após clipagem de aneurismas, e anastomoses de nervos substituindo a sutura e para cranioplastias. De maio a junho de 1999, a cola biológica (Beriplast P® - Centeon Fermacêutica Ltda. São Paulo) foi usada para prevenção de fístula liquórica em oito pacientes com tumores de fossa posterior, sendo quatro schwanomas do acústico, dois paragangliomas do forame e dois maningiomas petrocliviais. Não foram observadas complicações relacionadas ao uso da cola de fibrina e não houve formação de fístula no pós-operatório. Segundo nossa experiência atual e précida, a cola de fibrina é um valioso adjuvante a vários procedimentos microneurocirúrgicos.

Incidental Durotomy in Open Versus Tubular Revision Microdiscectomy: A Retrospective Controlled Study on Incidence, Management, and Outcome.

Retrospective case-control study. To compare the incidence, management, and outcome of incidental durotomy in revision microdiscectomy with open and minimal-access surgery. Incidental durotomy occurs with a variable incidence of 3%-27% in spine surgery. The highest rate occurs in revision microdiscectomy. The intraoperative and postoperative management of dural tears varies in the literature and the definite impact on clinical outcome has to be clarified. This is a retrospective study of medical records of 135 patients who underwent revision microdiscectomy, divided into 2 subgroups: OPEN (n=82) versus minimal-access surgery (MINI, n=53). Occurrence of intraoperative dural tears, intraoperative and postoperative management of durotomy, and clinical outcomes, according to MacNab criteria, were retrospectively examined. Statistical comparisons for categorical values between groups were accomplished using the 2-tailed Fisher exact test. P-values <0.05 were considered to be statistically significant. The incidence of durotomy in group OPEN was 19.5% (n=16/82) and in group MINI 17.0% (n=9/53) (P=0.822). The majority of durotomies (23/25) were repaired with an absorbable fibrin sealant patch alone. Postoperative cerebrospinal fluid fistula occurred only in 1 case of the OPEN group and was treated with lumbar drainage without the need for a reoperation. Patients with durotomy of the MINI group tended to have better outcome compared with those of the OPEN group without being statistically significant. The incidence of durotomy and postoperative cerebrospinal fluid fistula in lumbar revision microdiscectomy does not significantly differ between minimal-access and standard open procedures. The application of a fibrin sealant patch alone is an effective strategy for dural repair in revision lumbar microdiscectomy.

Clinical study on microsurgical treatment of lumbar disc herniation assisted by METRx system

Objective To explore the techniques and curative effect of microsurgical procedures assisted by minimal exposure tubular retractor system (METRx) in the treatment of lumbar disc herniation (LDH). Methods A total of 51 LDH patients, including 24 patients with L 4-5 herniation and 27 patients with L 5 -S 1 herniation, underwent discectomy assisted by METRx system. The operation time, intraoperative blood loss, postoperative complications and hospital stay were recorded. Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) were used to evaluate the degree of low back pain before operation, one week, 3 months after operation, and in the last follow-up. Lumbar MRI was used to evaluate the decompression of spinal canal. Results The success rate of operations in 51 cases was 98.04% (50/51). The average operation time was 125 min, the average intraoperative blood loss was 50 ml, the mean hospital stay was 5 d, all patients were followed up for 6-48 months (average 24 months). Compared with preoperation, both VAS and ODI scores decreased significantly one week after operation ( P = 0.036, 0.029), 3 months after operation ( P = 0.018, 0.023) and in the last follow-up ( P = 0.007, 0.013). The improvement rate of ODI was 35.37% in the last follow-up. No infection, postoperative cerebrospinal fluid (CSF) fistula, neurological defects or incision infection was found. One patient presented acute abdominalgia on the 2nd day after operation, and was diagnosed as annexitis. One patient showed nerve root irritation symptoms after operation caused by thick nerve root during the surgery. They were cured after symptomatic treatment. Conclusions Microsurgical procedures for treating LDH assisted by METRx system can effectively relieve nerve root compression, protect the dural sac and nerve roots, and reduce surgical complications. DOI: 10.3969/j.issn.1672-6731.2016.04.008

Far lateral approach: Is condylar resection required?

We report our experience with the far lateral approach (FLA) and its modifications in the surgical resection of tumors of craniocervical junction (CCJ). We retrospectively reviewed data of 36 patients with CCJ lesions who underwent surgical excision. Data are presented as frequency/percentages. Tumor locations were classified by anatomical relation around the CCJ (on axial plane). For anterior and laterally placed tumors, we preferred the FLA and its modification. A postoperative complication was defined as a new neurological deficit without subsequent recovery. The perioperative mortality was defined as death within 30 days of surgery. The mean age of the study population was 48.8 years (5-64 years) with 15 women. Simpson's Scale Grade 2 resection was achieved in 18 out of 19 patients with meningiomas. Overall, transient complications were observed in eight patients (22%); none of the patients developed postoperative cerebrospinal fluid fistula. The permanent morbidity rate was 5.6%. One patient died on the 6th postoperative day. The mean follow-up period was 4.1 years (range, 3 months-12 years). Tumor recurrence was observed in two patients who were advised radiotherapy. Twenty patients (96%) were independent for activities of daily living. The FLA is a versatile approach and is useful for a variety of lesions located ventrolateral to the brainstem and upper cervical cord. It allows adequate exposure with minimal retraction. Most of the foramen magnum meningiomas can be excised either without or with only partial resection of the condyle. The transjugular process approach to the jugular foramen (JF) is effective for JF tumors without the necessity of facial nerve transposition.

Endoscopic combined "transseptal/transnasal" approach for pituitary adenoma: reconstruction of skull base using pedicled nasoseptal flap in 91 consecutive cases.

The purpose of this study was to describe the endoscopic combined "transseptal/transnasal" approach with a pedicled nasoseptal flap for pituitary adenoma and skull base reconstruction, especially with respect to cerebrospinal fluid (CSF) fistula. Ninety-one consecutive patients with pituitary adenomas were retrospectively reviewed. All patients underwent the endoscopic combined "transseptal/transnasal" approach by the single team including the otorhinolaryngologists and neurosurgeons. Postoperative complications related to the flap were analyzed. Intra- and postoperative CSF fistulae were observed in 36 (40%) and 4 (4.4%) patients, respectively. Among the 4 patients, lumbar drainage and bed rest healed the CSF fistula in 3 patients and reoperation for revision was necessary in one patient. Other flap-related complications included nasal bleeding in 3 patients (3.3%). The endoscopic combined "transseptal/transnasal" approach is most suitable for a two-surgeon technique and a pedicled nasoseptal flap is a reliable technique for preventing postoperative CSF fistula in pituitary surgery.