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Castelnuovo P, Valentini M, Sileo G, Battaglia P, Bignami M, Turri-Zanoni M. Management of recurrent cerebrospinal fluid leak, current practices and open challenges. A systematic literature review. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:S14-S27. [PMID: 37698096 PMCID: PMC10159643 DOI: 10.14639/0392-100x-suppl.1-43-2023-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 09/13/2023]
Abstract
Cerebrospinal fluid leak (CSFL) is a rare pathological condition which requires prompt and adequate management due to the high rate of associated major complications. At present, CSFL can be successfully treated through endoscopic endonasal approaches with success rates higher than 90%. Despite this, CSFL recurrence may occur, and its management is critical and still represents a matter of debate. A systematic review of the literature on the management of recurrent CSFL was conducted. It included a cohort of 1,083 cases of CSFL treated with surgical or conservative approaches; 112 cases of recurrence were reported for an overall recurrence rate of 10.3%. Most of the leaks were localised in the anterior skull base (68.3%) and identification of recurrent CSFL may be troublesome. Therefore, the entire skull base must be meticulously examined and long-term follow-up is mandatory. The risk for CSFL recurrence is higher in patients affected by idiopathic intracranial hypertension (IIH), but its role in CSFL recurrence is yet to be understood. Recurrent CSFL must be repaired as soon as possible in order to reduce the risk of intracranial complications. The use of early post-operative CSF diversion by lumbar drain (LD) is currently a matter of debate even in case of CSFL recurrences.
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Affiliation(s)
- Paolo Castelnuovo
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Marco Valentini
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Giorgio Sileo
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Paolo Battaglia
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Maurizio Bignami
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Lariana, Como, Italy
| | - Mario Turri-Zanoni
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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Labeyrie MA, Bedarida V, Vever U, Guedon A, Herman P, Verillaud B, Houdart E. Venous sinus stenting after repair of skull base spontaneous cerebrospinal fluid leaks: A single-center retrospective cohort series with case-control analysis. J Neuroradiol 2021; 49:164-168. [PMID: 34273358 DOI: 10.1016/j.neurad.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/24/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Management of idiopathic intracranial hypertension (IIH) is recommended after surgical repair of spontaneous cerebrospinal fluid leaks (sCSF-leaks) of the skull base for prevention of recurrence. PURPOSE To assess the feasibility of venous sinus stenting, a treatment commonly used for the treatment of IIH associated with intracranial venous sinus stenosis (VSS), after sCSF-leaks closure. MATERIALS AND METHODS A single-center cohort series of consecutive patients who underwent sCSF-leak closure was retrospectively analyzed. Stenting was considered either for leak recurrence or in prophylactic manner after repair in patients with VSS as confirmed by cerebral venous imaging. Leak recurrence, need for new repair or adjunctive treatment of IIH, meningitis, and stenting complications were determined at the last follow-up. Cases who had prophylactic stenting were compared to historical controls before stenting option. RESULTS Twenty-two patients had intracranial venous stenting after sCSF-leak closure. Their median age was 58 years (Q1=45; Q3=68), BMI=31 kg.m-2 (Q1=27; Q3=36), and female rate=85%. The overall rate of successful repair after stenting was 95% (95% CI = 87-100%) at a median follow-up of 2.4 years (Q1=1.2; Q3=3.3). Adjunctive treatment for IIH was needed in 4 patients (4/22, 18%) including 2 patients without leak recurrence. No meningitis, permanent morbidity or mortality was observed after stenting. Compared to 18 controls, cases had significantly less recurrence (P = 0.03), and a trend for less adjunctive treatment for IIH (P = 0.06). CONCLUSIONS Our study suggests that stenting might be a valid option for prevention of sCSF-leak recurrences after repair in patients with intracranial venous sinus stenosis.
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Affiliation(s)
- Marc-Antoine Labeyrie
- Interventional Neuroradiology department, Hôpital Lariboisière, Université de Paris, France.
| | - Vincent Bedarida
- Otorhinolaryngology department, Hôpital Lariboisière, Inserm U1141, Université de Paris, France
| | - Ursulla Vever
- Neurology department, Hôpital Lariboisière, Université de Paris, France
| | - Alexis Guedon
- Interventional Neuroradiology department, Hôpital Lariboisière, Université de Paris, France
| | - Philippe Herman
- Otorhinolaryngology department, Hôpital Lariboisière, Inserm U1141, Université de Paris, France
| | - Benjamin Verillaud
- Otorhinolaryngology department, Hôpital Lariboisière, Inserm U1141, Université de Paris, France
| | - Emmanuel Houdart
- Interventional Neuroradiology department, Hôpital Lariboisière, Université de Paris, France
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Nguyen DT, Helleringer M, Klein O, Jankowski R, Rumeau C. The relationship between spontaneous cerebrospinal fluid leak and idiopathic intracranial hypertension. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 138:177-182. [PMID: 33257267 DOI: 10.1016/j.anorl.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Surgical treatment of spontaneous cerebrospinal fluid (CSF) leak is now performed by ENT surgeons, endonasal endoscopy being preferred to craniotomy as less invasive. However, it is often the symptom of underlying idiopathic intracranial hypertension, which lies outside the traditional sphere of ENT competence. Surgery is a necessary step, but should not obscure the need to treat the underlying pathology. This treatment is complex, and requires multidisciplinary team-work between otorhinolaryngologist, ophthalmologist, neurologist, neurosurgeon, radiologist, dietician, endocrinologist and psychotherapist. The present update details this multidisciplinary management to which the ENT surgeons must be attentive before and after spontaneous CSF leak repair.
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Affiliation(s)
- D-T Nguyen
- Service d'ORL et chirurgie cervico-faciale, hôpitaux de Brabois, CHRU de Nancy, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France.
| | - M Helleringer
- Service de neurochirurgie, CHRU de Nancy, hôpital Central, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - O Klein
- Service de neurochirurgie, CHRU de Nancy, hôpital Central, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - R Jankowski
- Service d'ORL et chirurgie cervico-faciale, hôpitaux de Brabois, CHRU de Nancy, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France
| | - C Rumeau
- Service d'ORL et chirurgie cervico-faciale, hôpitaux de Brabois, CHRU de Nancy, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France; EA3450 DevAH, développement adaptation et handicap, université de Lorraine, 9, avenue de la Forêt-de-Haye, 54505 Lorraine, France
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Dallan I, Cambi C, Emanuelli E, Cazzador D, Canevari FR, Borsetto D, Tysome JR, Donnelly NP, Rigante M, Georgalas C, Alobid I, Molteni G, Marchioni D, Shahzada AK, Scarano M, Seccia V, Pasquini E. Multiple spontaneous skull base cerebrospinal fluid leaks: some insights from an international retrospective collaborative study. Eur Arch Otorhinolaryngol 2020; 277:3357-3363. [PMID: 32725273 DOI: 10.1007/s00405-020-06227-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Spontaneous skull base cerebrospinal fluid leaks occurring without any apparent cause are rare. But those patients that present such leaks simultaneously, or successively, in multiple locations are even rarer. Given the rarity of this condition, we collected data from other groups in a multicentre study to reach an adequate number of patients and draw some preliminary considerations. METHODS We carried out a multicentre retrospective study on a cohort of patients treated at third level hospitals in Italy, Spain, United Kingdom and Greece for multiple spontaneous-CSF leaks and we compared them with a control group of patients treated for recurrent spontaneous-CSF leaks. Data regarding clinical aspects, radiological findings, surgical techniques and outcome were collected and preliminary considerations on the results were discussed. RESULTS A total of 25 patients presented multiple simultaneous spontaneous CSF leaks while 18 patients fit with the criteria of recurrent spontaneous CSF leaks. Data analysis was conducted separately. CONCLUSIONS Our understanding of the pathogenesis of this condition is currently very limited. A causative role of IIH may be present but the differences that emerged from the comparison with patients with recurrent fistulas seem to promote the possible role of other cofactors. A longer follow-up period is needed, and, in our opinion, prospective and multicentre studies are the only solution to seriously deal with such a complex topic.
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Affiliation(s)
- Iacopo Dallan
- ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Via Paradisa, 2, 56126, Pisa, Italy
| | - Christina Cambi
- ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Via Paradisa, 2, 56126, Pisa, Italy.
| | | | | | - Frank Rikki Canevari
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Daniele Borsetto
- Department of Skull Base Surgery, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - James R Tysome
- Department of Skull Base Surgery, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Neil P Donnelly
- Department of Skull Base Surgery, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Mario Rigante
- ENT Department, University of Perugia, Perugia, Italy
| | - Christos Georgalas
- Rhinology and Endoscopic Skull Base Unit, Hygeia Hospital, Athens, Greece
| | - Isam Alobid
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clínic, Barcelona, Spain
| | - Gabriele Molteni
- Otorhinolaryngology-Head and Neck Surgery, Department of Surgery, University Hospital of Verona, Verona, Italy
| | - Daniele Marchioni
- Otorhinolaryngology-Head and Neck Surgery, Department of Surgery, University Hospital of Verona, Verona, Italy
| | | | - Mariella Scarano
- ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Via Paradisa, 2, 56126, Pisa, Italy
| | - Veronica Seccia
- ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Via Paradisa, 2, 56126, Pisa, Italy
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Gravbrot N, Jahnke H, White WL, Little AS. Resumption of Positive-Pressure Ventilation Devices for Obstructive Sleep Apnea following Transsphenoidal Surgery: An Institutional Experience of a Surgical Cohort. J Neurol Surg B Skull Base 2020; 81:237-243. [PMID: 32499997 DOI: 10.1055/s-0039-1688795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/26/2019] [Indexed: 10/26/2022] Open
Abstract
Objectives Transsphenoidal surgery creates a skull base defect that may cause postoperative cerebrospinal fluid (CSF) leakage or pneumocephalus. This study reviewed the institutional experience of a pituitary center in managing patients who use positive-pressure ventilation (PPV) devices for obstructive sleep apnea (OSA) after transsphenoidal surgery, which risks disturbing the skull base repair. Design Retrospective review. Setting Pituitary referral center in a major metropolitan medical center. Methods PPV was resumed at the discretion of the treatment team based on intraoperative findings and OSA severity. Perioperative complications related to resuming and withholding PPV were recorded. Participants Transsphenoidal surgery patients with OSA using PPV devices. Main Outcome Measures Intracranial complications before and after resuming PPV. Results A total of 42 patients met the study criteria. Intraoperative CSF leakage was encountered and repaired in 20 (48%) patients. Overall, 38 patients resumed PPV (median: 3.5 weeks postsurgery; range: 0.14-52 weeks) and 4 patients did not resume PPV. Postoperatively, no patient experienced CSF leakage or pneumocephalus before or after resuming PPV. Four (10%) patients required temporary nocturnal supplemental oxygen at home, one patient was reintubated after a myocardial infarction, and one patient had a prolonged hospital stay due to chronic obstructive pulmonary disease exacerbation. Conclusions Resuming PPV use after transsphenoidal surgery did not result in intracranial complications. However, delay in resuming PPV resulted in four patients requiring oxygen at home. We propose a preliminary PPV device management algorithm based on the size of the intraoperative CSF leak to facilitate future studies.
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Affiliation(s)
- Nicholas Gravbrot
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Heidi Jahnke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - William L White
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
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Abstract
OBJECTIVE Determine if patients with increased opening pressure (OP) on lumbar puncture (LP) have thinner calvaria and skull bases. STUDY DESIGN Retrospective cohort study. SETTING Tertiary referral center. PATIENTS Patients (≥18 yr of age) who had a recorded OP on LP and high-resolution computed tomography imaging of the head. Patient age, sex, body mass index were calculated. Intracranial hypertension (IH) was defined with an OP≥25 cm-H2O and low intracranial pressure with an OP<15 cm-H2O. INTERVENTION Measurement of calvarial, zygoma, and skull base thickness when blinded to OP with three-dimensional slicer and radiologic calipers. MAIN OUTCOME MEASURES Association of calvarial, skull base, and zygoma thickness with OP and age. RESULTS Fifty-eight patients were included with a mean (SD) age of 53.1 (16.2) years and average (SD) body mass index of 30.1 (9.1) kg/m. Patients with IH had thinner mean (SD) calvaria (3.01 [0.81] versus 2.70 [0.58] mm; p = 0.036) and skull bases (5.17 [1.22] versus 4.60 [1.42] mm; p = 0.043) when compared with patients without IH. The mean (SD) extracranial zygoma thickness was similar between the two groups (5.09 [0.76] versus 5.00 [0.73] mm; p = 0.56). General linear model regression demonstrated advancing age was associated with increasing calvarial thickness in patients without IH and calvarial thinning in patients with IH (p = 0.038). CONCLUSION IH is independently associated with intracranial bone (calvaria and skull base) thinning and not extracranial (zygoma) thinning. Skull thinning occurs with IH and advancing age. These findings support a possible role of increased ICP in the pathophysiologic development of spontaneous cerebrospinal fluid leaks.
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Long-term management and outcomes after repair of cerebrospinal fluid rhinorrhea related to idiopathic intracranial hypertension. Curr Opin Otolaryngol Head Neck Surg 2018; 26:46-51. [DOI: 10.1097/moo.0000000000000424] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Venous Sinus Stenting in the Management of Patients with Intracranial Hypertension Manifesting with Skull Base Cerebrospinal Fluid Leaks. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.087] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Roxbury CR, Saavedra T, Ramanathan M, Lim M, Ishii M, Gallia GL, Reh DD. Layered sellar reconstruction with avascular free grafts: Acceptable alternative to the nasoseptal flap for repair of low-volume intraoperative cerebrospinal fluid leak. Am J Rhinol Allergy 2017; 30:367-71. [PMID: 27657903 DOI: 10.2500/ajra.2016.30.4356] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although the nasoseptal flap has become the method of choice for reconstruction of intraoperative cerebrospinal fluid (CSF) leak in endoscopic minimally invasive surgery of the skull base, layered avascular graft techniques, including allografts and middle turbinate mucosal autografts, may provide comparable reconstructive success with decreased nasal morbidity. OBJECTIVE To describe a method of reconstruction of intraoperative CSF leak in endoscopic surgery of the sella turcica and analyze its postoperative success rate and associated comorbidities. METHODS A retrospective review of expanded endonasal sellar tumor resections from 2008-2014 was performed, and cases of layered intraoperative skull base reconstruction with avascular free grafts were identified. Demographic factors and comorbidities that predisposed to reconstruction failure (obstructive sleep apnea, obesity) were determined. Reconstruction-related nasal complications were also identified. Postoperative CSF leak rate was determined, and statistical analysis was performed to identify predictive factors for reconstructive failure. RESULTS Seventy-three cases were identified. Layered closure with avascular free grafts was performed. There were five cases of postoperative CSF leak (6.85%). The mean follow-up was 19 months (range, 1-76 months). Intraoperative high-flow CSF leak was a significant predictor of reconstruction failure on univariate (odds ratio 22 [95% confidence interval, 2.26-214]; p = 0.008) and multivariate analysis (odds ratio 33.6 [95% confidence interval, 2.30-492]; p = 0.010). There were no significant differences in postoperative leak rates among bony overlay graft types. There were five patients (7.9%) who experienced persistent crusting after surgery. There were no significant differences in crusting rates between allografts and mucosal grafts. There were no postoperative mucoceles. CONCLUSION In cases of low-volume intraoperative CSF leak, layered skull base repair with avascular free grafts was an acceptable alternative to the nasoseptal flap, which may reduce prolonged sinonasal healing and donor-site morbidities.
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Affiliation(s)
- Christopher R Roxbury
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Teachey W, Grayson J, Cho DY, Riley KO, Woodworth BA. Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks. Laryngoscope 2017; 127:2011-2016. [PMID: 28512741 DOI: 10.1002/lary.26612] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/22/2017] [Accepted: 03/10/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Spontaneous cerebrospinal fluid (CSF) leaks are associated with increased intracranial pressure (ICP) and considered a manifestation of idiopathic intracranial hypertension. Although postoperative acetazolamide and placement of CSF shunt systems are considered valuable interventions for elevated ICP, the impact on recurrence rate remains unclear. The objective of this study was to systematically review evidence from reported literature to evaluate whether postoperative ICP management reduces recurrence rates after primary endoscopic repair. STUDY DESIGN Prospective case series and systematic review. METHODS Demographics, defect location, success rates, and ICP management in spontaneous CSF leak patients were prospectively collected over 8 years. A search was also conducted in PubMed to identify studies reporting cases of spontaneous CSF rhinorrhea. RESULTS Fifty-six articles with nonduplicated data were identified and combined with a prospective series of 108 patients for a total of 679 patients treated for spontaneous CSF rhinorrhea. Average age was 50.4 years with 77% female. Average body mass index was 35.8 kg/m2 . Defects were most commonly located in the sphenoid sinus (n = 334) followed by the ethmoid (n = 318) and the frontal sinus (n = 46). Successful primary repair was 92.82% in patient cohorts where ICP evaluation and intervention with acetazolamide or CSF shunt systems was performed, but was significantly decreased to 81.87% in series with no active management of elevated ICP (P < .001). CONCLUSIONS Evaluation and intervention for elevated ICP in spontaneous CSF leaks is associated with significantly improved success rates following primary endoscopic repair. LEVEL OF EVIDENCE 4. Laryngoscope, 127:2011-2016, 2017.
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Affiliation(s)
- William Teachey
- Department of Otolaryngology , University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Jessica Grayson
- Department of Otolaryngology , University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Do-Yeon Cho
- Department of Otolaryngology , University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Kristen O Riley
- Department of Neurosurgery , University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Bradford A Woodworth
- Department of Otolaryngology , University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
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Adams AS, Russell PT, Duncavage JA, Chandra RK, Turner JH. Outcomes of Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea without Lumbar Drains. Am J Rhinol Allergy 2016; 30:424-429. [DOI: 10.2500/ajra.2016.30.4371] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective Lumbar drains (LD) are commonly used during endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea, either to facilitate graft healing or to monitor CSF fluid dynamics. However, the indications and necessity of LD placement remains controversial. The current study sought to evaluate endoscopic CSF leak repair outcomes in the setting of limited LD use. Methods Patients who underwent endoscopic repair of CSF rhinorrhea between 2004 and 2014 were identified by a review of medical records. Demographic and clinical data were extracted and compared between patients who had surgery with and patients who had surgery without a perioperative LD. A univariate analysis was performed to identify factors predictive of recurrence. Results A total of 107 patients (116 surgical procedures) were identified, with a mean follow-up of 15.8 months. Eighty-eight of 107 patients (82.2%) had surgery without an LD. The mean hospital stay was 4.48 days in the LD group versus 1.03 days in the non-LD group (p ≤ 0.00001). There was no difference in recurrence rate between the LD and non-LD groups. Predictors of recurrence included repair technique (p = 0.04) and size of defect (p = 0.005). Body mass index, leak site (ethmoid, sphenoid, frontal), and etiology (spontaneous, iatrogenic, traumatic) were not predictive of leak recurrence. Conclusion Use of LDs in endoscopic CSF leak repair was not associated with reduced recurrence rates, regardless of leak etiology, and resulted in a significant increase in hospital length of stay. Although the use of perioperative LDs to monitor CSF dynamics may have some therapeutic and diagnostic advantages, it may not be associated with clinically significant improvements in patient outcomes or recurrence rates.
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Affiliation(s)
- Austin S. Adams
- Department of Otolaryngology—Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Paul T. Russell
- Department of Otolaryngology—Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James A. Duncavage
- Department of Otolaryngology—Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Rakesh K. Chandra
- Department of Otolaryngology—Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Justin H. Turner
- Department of Otolaryngology—Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
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Shahjouei S, Hanaei S, Habibi Z, Hoseini M, Ansari S, Nejat F. Randomized clinical trial of acetazolamide administration and/or prone positioning in mitigating wound complications following untethering surgeries. J Neurosurg Pediatr 2016; 17:659-66. [PMID: 26824595 DOI: 10.3171/2015.8.peds15393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE No evidence-based guideline has been approved for the postoperative management of pediatric patients with tethered cord syndrome (TCS). The purpose of this randomized clinical trial was to evaluate the effectiveness of prone positioning and acetazolamide administration on complication rates following spinal cord untethering surgeries. METHODS From October 2012 to February 2015, patients with a primary diagnosis of TCS who were admitted to the Children's Medical Center Hospital of Iran were randomly allocated to 1 of 4 intervention modality groups postoperatively: 1) Group A, acetazolamide administration for 10 days; 2) Group B, prone positioning for 10 days; 3) Group C, acetazolamide administration and prone positioning for 10 days; and 4) Group D, no intervention. CSF leakage, CSF collection, wound dehiscence, operative site infection, and secondary surgical wound repair were considered failure. RESULTS A total of 161 patients were enrolled in this study (Group A, n = 39 [24.2%]; Group B, n = 41 [25.5%]; Group C, n = 39 [24.2%]; and Group D, n = 42 [26.1%]). The overall failure rate was 12.42% (20 patients). Complication rates through pooled analyses were as follows: CSF leakage (n = 9, 5.6%), CSF collection (n = 12, 7.5%), wound dehiscence (n = 2, 1.2%), and infection of operation site (n = 3, 1.9%). Two patients (1.2%) required surgical secondary wound repair due to complications. CSF leakage and collection rates were significantly lower in patients who underwent prone positioning (p = 0.042 and 0.036, respectively). The administration of acetazolamide, either isolated or in combination with prone positioning, not only could not significantly lower the complication rates, but also added the burden of side effects. CONCLUSIONS The current study demonstrates the possible role of prone positioning in mitigating the complication rates subsequent to untethering surgeries. Clinical trial registration no.: NCT01867268 ( clinicaltrials.gov ).
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Affiliation(s)
- Shima Shahjouei
- Department of Neurosurgery, Children's Hospital Medical Center, and
| | - Sara Hanaei
- Department of Neurosurgery, Children's Hospital Medical Center, and
| | - Zohreh Habibi
- Department of Neurosurgery, Children's Hospital Medical Center, and
| | - Mostafa Hoseini
- Department of Statistics and Epidemiology, Tehran University of Medical Science, Tehran, Iran; and
| | - Saeed Ansari
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Farideh Nejat
- Department of Neurosurgery, Children's Hospital Medical Center, and
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Solomon D, Moghekar A, Blitz A. Paradoxical supine overdrainage with ventriculoatrial shunt. Fluids Barriers CNS 2015. [PMCID: PMC4582740 DOI: 10.1186/2045-8118-12-s1-p50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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