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Hannan CJ, Kewlani B, Browne S, Javadpour M. Multi-layered repair of high-flow CSF fistulae following endoscopic skull base surgery without nasal packing or lumbar drains: technical refinements to optimise outcome. Acta Neurochir (Wien) 2023; 165:2299-2307. [PMID: 37074392 PMCID: PMC10409672 DOI: 10.1007/s00701-023-05581-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
AIMS Post-operative CSF leak remains a significant problem following endoscopic skull base surgery, particularly when there is a high-flow intra-operative CSF leak. Most skull base repair techniques are accompanied by the insertion of a lumbar drain and/or the use of nasal packing which have significant shortcomings. Our aim was to review the results of a large series of endoscopic skull base cases where a high-flow intra-operative CSF leak rate was encountered and repaired to assess if modifications in technique could reduce the post-operative CSF leak rate. METHODS A retrospective review of a prospectively maintained database of skull base cases performed by a single surgeon over a 10-year period was performed. Data regarding patient demographics, underlying pathology, skull base repair techniques and post-operative complications were analysed. RESULTS One hundred forty-two cases with high-flow intra-operative CSF leak were included in the study. The most common pathologies were craniopharyngiomas (55/142, 39%), pituitary adenomas (34/142, 24%) and meningiomas (24/142, 17%). The CSF leak rate was 7/36 (19%) when a non-standardised skull base repair technique was used. However, with the adoption of a standardised, multi-layer repair technique, the post-operative CSF leak rate decreased significantly (4/106, 4% vs. 7/36, 19%, p = 0.006). This improvement in the rate of post-operative CSF leak was achieved without nasal packing or lumbar drains. CONCLUSION With iterative modifications to a multi-layered closure technique for high-flow intra-operative CSF leaks, it is possible to obtain a very low rate of post-operative CSF leak, without lumbar drains or nasal packing.
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Affiliation(s)
| | - Bharti Kewlani
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Steven Browne
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
- School of Medicine, Trinity College Dublin, Dublin, Ireland.
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Gao W, Wang X, Fang Y, Hong Y, Yan W, Zhang S, Li C. Diagnostic Value of Non-Contrast CT in Cerebrospinal Fluid Leakage After Endoscopic Transnasal Surgery for Sellar and Suprasellar Tumors. Front Oncol 2022; 11:735778. [PMID: 35127466 PMCID: PMC8810488 DOI: 10.3389/fonc.2021.735778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022] Open
Abstract
We aimed to study the relationship between pneumocephalus on non-contrast CT (NCCT) and post-operative cerebrospinal fluid leakage (p-CFL) after endoscopic transsphenoidal sellar and suprasellar tumor surgeries. Data from patients who underwent endoscopic treatment for sellar or suprasellar tumors from January 2018 to March 2020 were consecutively collected and reviewed. The NCCT pneumocephalus (NP) was measured the first day after operation and the first day after the expansive sponge was extracted. p-CFL was determined according to post-operative clinical symptoms, high resolution CT and glucose test, and expert consensus. Of the 253 patients enrolled in this study, 32 (12.6%) had p-CFL. Compared with patients without p-CFL, patients with p-CFL had a higher occurrence of intra-operative CFL, a longer operation time, a higher rate of pneumocephalus on first-day NCCT after operation (i.e., first-day NP), and a higher rate of NP volume change between two NCCT measurements (referred to as the NP change) (all p < 0.05). In multivariate regression analysis, first-day NP was independently associated with p-CFL occurrence [odds ratio (OR)=6.395, 95% confidence interval (CI)=2.236-18.290, p=0.001). After adding the NP change into the regression model, first-day NP was no longer independently associated with p-CFL, and NP change (OR = 19.457, 95% CI = 6.095–62.107, p<0.001) was independently associated with p-CFL. The receiver operating characteristic curve comparison analysis showed that NP change had a significantly better predicting value than first-day NP (area under the curve: 0.988 vs. 0.642, Z=6.451, p=0.001). NP is an effective imaging marker for predicting p-CFL after endoscopic sellar and suprasellar tumors operation, and the NP change has a better predicting value.
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Affiliation(s)
- Wei Gao
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
- Department of Neurosurgery, Changxing People’s Hospital, Changxing, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yuanjian Fang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yuan Hong
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Wei Yan
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Sheng Zhang
- Department of Neurology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
- *Correspondence: Sheng Zhang, ; Chenguang Li,
| | - Chenguang Li
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
- *Correspondence: Sheng Zhang, ; Chenguang Li,
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Baba E, Hattori Y, Tahara S, Morita A. Bacterial Flora in the Sphenoid Sinus Changes with Perioperative Prophylactic Antibiotic Administration. Neurol Med Chir (Tokyo) 2021; 61:361-366. [PMID: 33967178 PMCID: PMC8258010 DOI: 10.2176/nmc.oa.2020-0387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The complications of endonasal transsphenoidal surgery (ETSS) include meningitis and sinusitis, and these complications are troublesome. Some reports have investigated the type of bacteria and the susceptibility of sphenoid sinus mucosal flora to drugs. However, most specimens can be collected after perioperative antibiotic administration. In this study, 95 and 103 sphenoid sinus mucosal samples collected during ETSS from September 2013 to February 2015 and from June 2017 to January 2019, respectively, were examined for bacterial culture. Sphenoid sinus mucosal samples were collected after antibiotic administration in the first period, whereas samples were collected before antibiotic administration in the second period. Hence, the specimens in the second period were not affected by antibiotics. Moreover, drug susceptibility tests for the detected bacteria were performed. Overall, 52 and 51 bacterial isolates were collected during both periods. Gram-positive cocci (GPCs), including Staphylococcus aureus and Staphylococcus epidermidis, were more common in the non-antibiotic group than in the antibiotic group (p <0.01). However, the proportion of gram-negative rods (GNRs) did not significantly differ between the two groups (p = 0.54). The antibiotic group had a significantly higher proportion of bacteria resistant to ampicillin (p <0.01) and first-generation cephalosporin (p = 0.01) than the non-antibiotic group. In conclusion, there was a difference in bacterial flora in the sphenoid sinus mucosal samples collected before and after intraoperative antibiotic administration.
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Affiliation(s)
- Eiichi Baba
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School
| | - Yujiro Hattori
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School.,Department of Anatomy and Neurobiology, Graduate School of Medicine, Nippon Medical School
| | - Shigeyuki Tahara
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School
| | - Akio Morita
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School
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4
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Hannan CJ, Kelleher E, Javadpour M. Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review. Front Oncol 2020; 10:1614. [PMID: 32850466 PMCID: PMC7431707 DOI: 10.3389/fonc.2020.01614] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/24/2020] [Indexed: 01/04/2023] Open
Abstract
Following the introduction of fully endoscopic techniques for the resection of pituitary tumors, there was a rapid expansion of the indications for endonasal endoscopic surgery to include extrasellar tumors of the skull base. These techniques offer significant advantages over traditional open surgical approaches to the skull base, including improved tumor resection, and better post-operative neurological outcomes. Following their introduction, however, the initial rate of post-operative CSF leak was unacceptably high. Post-operative CSF leak following skull base surgery is a major source of morbidity, and can lead to the development of life-threatening intracranial infection. The use of vascularized naso-septal flaps transformed the management of these patients, significantly reducing the rate of post-operative CSF leak and increasing the number of patients that could benefit from this less invasive treatment modality. Adequate repair of iatrogenic defects in the skull base is of crucial importance for patients with skull base tumors, as the development of a post-operative CSF leak, and the associated complications can significantly delay the administration of the adjunctive oncological therapies these patients require. In this review, we provide an overview of the latest evidence regarding skull base reconstruction following endoscopic skull base surgery, and describe the skull base repair technique in use at our institution.
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Affiliation(s)
- Cathal John Hannan
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester, United Kingdom
| | - Eoin Kelleher
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland.,School of Medicine, Trinity College Dublin, Dublin, Ireland
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Park HH, Ronconi D, Hanakita S, Watanabe K, Labidi M, Bernat AL, Froelich S. Endoscopic endonasal approach to the mesial temporal lobe: anatomical study and clinical considerations for a selective amygdalohippocampectomy. Acta Neurochir (Wien) 2020; 162:881-891. [PMID: 31834499 DOI: 10.1007/s00701-019-04163-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 11/30/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Selective amygdalohippocampectomy (AH) is a surgical option for patients with medically intractable seizures from mesial temporal lobe pathology. The transcranial route is considered the best method to achieve this goal. However, the standard approach through the neocortex is still invasive. The risks can be minimized if the mesial temporal lobe is resected while preserving the lateral temporal lobe and the Meyer's loop. This study explores the feasibility of selective AH by endoscopic endonasal approach (EEA) in cadaveric specimens. METHODS The endoscopic anatomy of the mesial temporal lobe and the feasibility of a successful selective AH were studied in six hemispheres from three injected human cadavers. Quantitative analyses on the extent of resection and angles of exposure were performed based on CT and MRI studies of pre- and post-selective AH and measurements taken during dissections. RESULTS The EEA V1-V2 corridor provided a direct and logical line of access to the mesial temporal lobe, following its natural trajectory with no brain retraction and minimal exposure of the pterygopalatine fossa. The components of the mesial temporal lobe were resected just as selectively and easily as the transcranial route, but without compromising the structures of the lateral temporal lobe or the Meyer's loop. CONCLUSIONS The EEA V1-V2 corridor demonstrated its selective resectability and accessibility of the mesial temporal lobe in cadaveric specimens. The clinical value of this approach should be explored responsibly by a surgeon with both competent microsurgical skills and experiences in EEA.
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Affiliation(s)
- Hun Ho Park
- Department of Neurosurgery, Lariboisière Hospital, 2 Rue Ambroise Pare, 75475, Paris, France
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea
| | - Daniel Ronconi
- Department of Neurosurgery, Lariboisière Hospital, 2 Rue Ambroise Pare, 75475, Paris, France
| | - Shunya Hanakita
- Department of Neurosurgery, Lariboisière Hospital, 2 Rue Ambroise Pare, 75475, Paris, France
| | - Kentaro Watanabe
- Department of Neurosurgery, Lariboisière Hospital, 2 Rue Ambroise Pare, 75475, Paris, France
| | - Moujahed Labidi
- Department of Neurosurgery, Lariboisière Hospital, 2 Rue Ambroise Pare, 75475, Paris, France
| | - Anne-Laure Bernat
- Department of Neurosurgery, Lariboisière Hospital, 2 Rue Ambroise Pare, 75475, Paris, France
| | - Sébastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, 2 Rue Ambroise Pare, 75475, Paris, France.
- Paris VII-Diderot University, Paris, France.
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6
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Youngerman BE, Kosty JA, Gerges MM, Tabaee A, Kacker A, Anand VK, Schwartz TH. Acellular dermal matrix as an alternative to autologous fascia lata for skull base repair following extended endoscopic endonasal approaches. Acta Neurochir (Wien) 2020; 162:863-873. [PMID: 32048039 DOI: 10.1007/s00701-019-04200-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 12/24/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Skull base reconstruction after extended endoscopic endonasal approaches (EEAs) can be challenging. In addition to the nasoseptal flap, which has been adopted by most centers, autologous fascia lata is also often utilized. Harvesting of fascia lata requires a separate thigh incision, may prolong recovery, and results in a visible scar. In principal, the use of non-autologous materials would be preferable to avoid a second incision and maintain the minimally invasive nature of the approach, assuming the CSF leak rate is not compromised. OBJECTIVE To assess the efficacy of acellular dermal matrix (ADM) as a non-autologous alternative to autologous fascia lata graft for watertight closure of the cranial base following EEAs. METHODS A retrospective chart review of extended EEAs performed before and after the transition from fascia lata to ADM was performed. Cases were frequency matched for approach, pathology, BMI, use of lumbar drainage, and tumor volume. Power analysis was performed to estimate the sample size needed to demonstrate non-inferiority. RESULTS ADM was used for watertight closure of the cranial base in 19 consecutive extended endoscopic endonasal approaches (16 gasket-seals and 3 buttons) with 1 postoperative CSF leak at the last follow-up (median 5.3, range 1.0-12.6 months). All patients had high-flow intraoperative leaks. The cohort included 8 meningiomas, 8 craniopharyngiomas, 2 chordomas, and 1 pituicytoma ranging in size from 0.2 to 37.2cm3 (median 5.5, IQR 2.8-13.3 cm3). In 19 historical controls who received fascia lata, there were 2 postoperative CSF leaks. CONCLUSIONS Preliminary results suggest that ADM provides a non-inferior non-autologous alternative to fascia lata for watertight gasket-seal and button closures following extended EEAs, potentially reducing or eliminating the need to harvest autologous tissue.
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Affiliation(s)
- Brett E Youngerman
- Department of Neurosurgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA.
| | - Jennifer A Kosty
- Department of Neurosurgery, Ochsner Louisiana State University Shreveport, Shreveport, LA, USA
| | - Mina M Gerges
- Department of Neurosurgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Abtin Tabaee
- Department of Otolaryngology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Ashutosh Kacker
- Department of Otolaryngology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Vijay K Anand
- Department of Otolaryngology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA.
- Department of Otolaryngology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA.
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Lee SJ, Cohen J, Chan J, Walgama E, Wu A, Mamelak AN. Infectious Complications of Expanded Endoscopic Transsphenoidal Surgery: A Retrospective Cohort Analysis of 100 Cases. J Neurol Surg B Skull Base 2019; 81:497-504. [PMID: 33134016 DOI: 10.1055/s-0039-1696999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/08/2019] [Indexed: 12/14/2022] Open
Abstract
Objective To identify perioperative factors that may predict postoperative cerebrospinal fluid (CSF) leak and meningitis following expanded endoscopic transsphenoidal surgery (EETS). Study Design This is a retrospective study. This study was set at the Cedars-Sinai Medical Center, Los Angeles. A total of 78 patients who underwent EETS between January 2007 and November 2018 were participated. The main outcome measures were CSF leak and meningitis. Results A total of 78 patients underwent a total of 100 EETS procedures; 17.9 and 10.3% of patients developed postoperative CSF leaks and meningitis, respectively. Out of eight, three patients with meningitis did not develop an observable CSF leak. The risk of developing meningitis in patients with a CSF leak was significantly higher than those without a leak, with an odds ratio (OR) of 11.48 (95% confidence interval, 2.33-56.47; p = 0.004). Pituicytomas were significantly associated with meningitis compared with other pathologies. No other patient-specific factors were identified as risks for leak or meningitis, including method of skull base repair, sex, tumor volume, or body mass index, although there was a strong trend toward reduced CSF leak rates in patient with nasoseptal flaps used for skull base repair, compared with those without (9.5 vs. 25%). CSF protein was consistently elevated on the first CSF values obtained when meningitis was suspected. Conclusion CSF leak and meningitis are common complications of expanded endonasal surgery No statistically significant risk factors for developing a postoperative leak other than the pathology of pituicytoma were identified, including method of skull base repair, although the use of a vascularized nasoseptal flap did trend toward a reduced CSF leak rate. CSF protein is the most sensitive marker for the presumptive diagnosis and timely treatment of meningitis.
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Affiliation(s)
- Seung J Lee
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Justin Cohen
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Julie Chan
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Evan Walgama
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Arthur Wu
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
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Ben-Ari O, Wengier A, Ringel B, Carmel Neiderman NN, Ram Z, Margalit N, Fliss DM, Abergel A. Nasoseptal Flap for Skull Base Reconstruction in Children. J Neurol Surg B Skull Base 2018; 79:37-41. [PMID: 29404239 DOI: 10.1055/s-0037-1617435] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Objective The endoscopic endonasal approach is being increasingly used for the resection and reconstruction of anterior skull base (ASB) lesions. Vascularized nasoseptal flaps (NSF) have become the workhorse for the reconstruction of ASB defects, resulting in a significant decrease in the incidence of cerebrospinal fluid (CSF) leaks. The objective of this study was to investigate the efficacy and safety of NSF in children. Methods This is a retrospective analysis of the medical records of all patients under the age of 18 years who underwent endoscopic repair of ASB lesions with the use of NSF at our tertiary medical center between 1/2011 and 8/2016. Results Twelve children underwent ASB defect repair for both benign and malignant neoplasms using the endoscopic endonasal NSF technique. Four children had previously undergone ASB surgery. The male-to-female ratio was 1:1, the average age was 12.3 years, the average hospitalization time was 8.3 days, and the maximum follow-up period was 24 months, during which craniofacial growth appeared to be unimpaired. A lumbar drain was used postoperatively in six cases. Crust formation and synechia were observed in two cases. There was one case of a major long-term complication (a CSF leak followed by meningitis). Conclusions Endoscopic endonasal NSF was both an effective and a safe technique for ASB defect reconstruction in 12 children for both benign and malignant neoplasms. It had a high success rate and a low complication rate. No apparent negative influence on craniofacial growth was observed in our series.
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Affiliation(s)
- Oded Ben-Ari
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Wengier
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barak Ringel
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Narin N Carmel Neiderman
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nevo Margalit
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avraham Abergel
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hirsch J, Vacas S, Terrando N, Yuan M, Sands LP, Kramer J, Bozic K, Maze MM, Leung JM. Perioperative cerebrospinal fluid and plasma inflammatory markers after orthopedic surgery. J Neuroinflammation 2016; 13:211. [PMID: 27577265 PMCID: PMC5006595 DOI: 10.1186/s12974-016-0681-9] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 08/18/2016] [Indexed: 12/14/2022] Open
Abstract
Background Postoperative delirium is prevalent in older patients and associated with worse outcomes. Recent data in animal studies demonstrate increases in inflammatory markers in plasma and cerebrospinal fluid (CSF) even after aseptic surgery, suggesting that inflammation of the central nervous system may be part of the pathogenesis of postoperative cognitive changes. We investigated the hypothesis that neuroinflammation was an important cause for postoperative delirium and cognitive dysfunction after major non-cardiac surgery. Methods After Institutional Review Board approval and informed consent, we recruited patients undergoing major knee surgery who received spinal anesthesia and femoral nerve block with intravenous sedation. All patients had an indwelling spinal catheter placed at the time of spinal anesthesia that was left in place for up to 24 h. Plasma and CSF samples were collected preoperatively and at 3, 6, and 18 h postoperatively. Cytokine levels were measured using ELISA and Luminex. Postoperative delirium was determined using the confusion assessment method, and cognitive dysfunction was measured using validated cognitive tests (word list, verbal fluency test, digit symbol test). Results Ten patients with complete datasets were included. One patient developed postoperative delirium, and six patients developed postoperative cognitive dysfunction. Postoperatively, at different time points, statistically significant changes compared to baseline were present in IL-5, IL-6, I-8, IL-10, monocyte chemotactic protein (MCP)-1, macrophage inflammatory protein (MIP)-1α, IL-6/IL-10, and receptor for advanced glycation end products in plasma and in IFN-γ, IL-6, IL-8, IL-10, MCP-1, MIP-1α, MIP-1β, IL-8/IL-10, and TNF-α in CSF. Conclusions Substantial pro- and anti-inflammatory activity in the central neural system after surgery was found. If confirmed by larger studies, persistent changes in cytokine levels may serve as biomarkers for novel clinical trials. Electronic supplementary material The online version of this article (doi:10.1186/s12974-016-0681-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jan Hirsch
- Department of Anesthesia and Perioperative Care, University of California San Francisco, 521 Parnassus Avenue, San Francisco, CA, 94143-0648, USA. .,Anesthesia Service, San Francisco VA Medical Center, Mail 129, 4150 Clement Street, San Francisco, CA, 94121, USA.
| | - Susana Vacas
- Department of Anesthesia and Perioperative Care, University of California San Francisco, 521 Parnassus Avenue, San Francisco, CA, 94143-0648, USA
| | - Niccolo Terrando
- Department of Anesthesia and Perioperative Care, University of California San Francisco, 521 Parnassus Avenue, San Francisco, CA, 94143-0648, USA
| | - Miao Yuan
- Center of Gerontology, Virginia Tech University, 230 Grove Lane (0555), Blacksburg, VA, 24061, USA
| | - Laura P Sands
- Center of Gerontology, Virginia Tech University, 230 Grove Lane (0555), Blacksburg, VA, 24061, USA
| | - Joel Kramer
- Department of Neurology, Memory and Aging Center, University of California San Francisco, 1500 Owens St. #320, San Francisco, CA, 94158, USA
| | - Kevin Bozic
- Department of Orthopedic Surgery, University of California San Francisco, 500 Parnassus Avenue, MU 320W, San Francisco, CA, 94143-0728, USA
| | - Mervyn M Maze
- Department of Anesthesia and Perioperative Care, University of California San Francisco, 521 Parnassus Avenue, San Francisco, CA, 94143-0648, USA
| | - Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California San Francisco, 521 Parnassus Avenue, San Francisco, CA, 94143-0648, USA
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