BioGlue for prevention of postoperative cerebrospinal fluid leaks in transsphenoidal surgery: a case series

Object Cerebrospinal fluid leaks due to unrecognized durotomy during spinal surgery are often managed with a second surgery for dural closure. CT-guided percutaneous patching targeted to the dural defect offers an alternative to surgery since it can be performed in a minimally invasive fashion without the need for general anesthesia. This case series describes the authors' experience using targeted CT-guided percutaneous patching to repair incidental durotomies incurred during spinal surgery. Methods This investigation is a retrospective case series involving patients who underwent CT-guided percutaneous patching of surgical incidental durotomies and were referred between January 2007 and June 2013. Their presenting clinical history, myelographic findings, and clinical outcomes, including the need for eventual surgical duraplasty, were reviewed. Results Nine cases were identified, including 7 durotomies incurred during lumbar discectomy, one due to a medial transpedicular screw breach, and one incurred during vertebrectomy for spinal osteosarcoma. All patients who had favorable outcomes with percutaneous intervention alone had 2 common features: dural defect of 4 mm or smaller and absence of a pseudomeningocele. Patients with CSF leaks complicated by pseudomeningocele and those with a dural defect of 6 mm or more all required eventual surgical management. Conclusions The authors' results suggest that findings on CT myelography may help predict which patients with postsurgical durotomy can be treated with percutaneous intervention. In particular, CT-guided patching may be more likely to be successful in those patients with dural defects of less than 5 mm and without pseudomeningocele. In patients with larger dural defects or pseudomeningoceles, percutaneous blood patching alone is unlikely to be successful.

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Opiate Use After Endoscopic Endonasal Transsphenoidal Surgery

American Journal of Rhinology and Allergy ◽

10.1177/19458924211061990 ◽

2021 ◽

pp. 194589242110619

Author(s):

Tara J. Wu ◽

Reza Kianian ◽

Emmanuel G. Villalpando ◽

Morcos N. Nakhla ◽

Christine Wells ◽

...

Keyword(s):

Risk Factors ◽

Cerebrospinal Fluid ◽

Linear Regression ◽

Multiple Linear Regression ◽

Transsphenoidal Surgery ◽

Endoscopic Endonasal ◽

Opiate Use ◽

Endoscopic Endonasal Transsphenoidal Surgery ◽

Cerebrospinal Fluid Leaks ◽

Grade 3

Background The literature on opiate use after endoscopic endonasal transsphenoidal surgery (EETS) is limited. Objective To determine the risk factors for higher opiate use following EETS and the quantity of opiates used after discharge. Methods A retrospective review of 144 patients undergoing EETS from July 2018 to July 2020 was conducted. Patient, tumor, and surgical factors were documented. Pain scores and medications used on postoperative days (POD) 0 and 1, and discharge prescriptions, were recorded. Opiate use was quantified using morphine milligram equivalents (MME) dose. Multiple linear regression determined risk factors independently associated with POD0 to 1 opiate use. Results On POD 0 to 1, mean pain score was 4.9/10 (standard deviation [SD] ± 2.0). Mean acetaminophen use was 3.4 tablets (SD ± 1.6; 650 mg per tablet). Mean opiate use was 35.6 MME (SD ± 36.3), equivalent to 4.7 tablets (SD ± 4.8) of oxycodone 5 mg. Multiple linear regression showed that current smokers required an additional 37.1 MME ( P = .011), and patients with grade 3 intraoperative cerebrospinal fluid leaks required an additional 36.7 MME ( P = .046) on POD0 to 1. On discharge, mean opiate prescription was 117.7 MME (SD ± 102.1), equivalent to 15.7 tablets (SD ± 13.6) of oxycodone 5 mg. Thirty-nine patients (27.1%) did not require prescriptions. Only 10 patients (6.9%) required opiate refill(s) within 30 days after surgery. Conclusion Patients undergoing EETS have higher opiate needs compared to those undergoing endoscopic sinus surgery, although the overall requirements are still considered low. Independent risk factors associated with higher opiate use in the immediate postoperative period included current smokers and grade 3 intraoperative cerebrospinal fluid leaks.

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Cerebrospinal Fluid Leaks of the Posterior Fossa: Patient Characteristics and Imaging Features

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1697976 ◽

2019 ◽

Author(s):

Kristen L. Yancey ◽

Nauman F. Manzoor ◽

Robert J. Yawn ◽

Matthew O'Malley ◽

Alejandro Rivas ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Posterior Fossa ◽

Case Series ◽

Preoperative Imaging ◽

Imaging Features ◽

Lateral Skull Base ◽

Tegmen Tympani ◽

Significant Difference ◽

Cerebrospinal Fluid Leaks

Abstract Objectives The main purpose of this article is to investigate the prevalence and features of posterior fossa defects (PFD) in spontaneous cerebrospinal fluid leaks (sCSFL). Design Retrospective case series. Setting Tertiary skull base center. Participants Consecutive adults undergoing lateral skull base repair of sCSFL between 2003 and 2018. Main Outcome Measures The following data were collected: demographics, comorbidities, radiology and intraoperative findings, and surgical outcomes including complications and need for revision surgery or shunt placement. Patients with incomplete data or leaks following skull base surgery, trauma, or chronic ear disease were excluded. Results Seventy-one patients (74% female, mean age 56.39 ± 11.50 years) underwent repair of spontaneous lateral skull base leaks. Eight ears (7 patients, 11.1%) had leaks involving the posterior fossa plate in addition to defects of the tegmen mastoideum (50%), tegmen tympani (25%), or both (25%). Patients with PFDs more often had bilateral tegmen thinning on imaging (75%, odds ratio [OR]: 10.71, 95% confidence interval [CI]: 2.20–54.35, p = 0.005) and symptomatic bilateral leaks (OR: 9.67, 95% CI: 2.22–40.17, p = 0.01. All PFD patients had arachnoid granulations adjacent to ipsilateral mastoid cell opacification. However, this finding was often subtle and rarely included on the radiology report. There was no significant difference in body mass index, age, presenting complaints, or operative success between the PFD and isolated tegmen defect sCSFL cohorts. Conclusions The posterior fossa is an uncommon location for sCSFL. Careful review of preoperative imaging is often suggestive and can inform surgical approach. PFD patients are similar to those with isolated tegmen-based defects in presentation, comorbidities, and outcomes.

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