Multi-Layer Onlay Graft Using Hydroxyapatite Cement Placement without Cerebrospinal Fluid Diversion for Endoscopic Skull Base Reconstruction

Abstract Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

Download Full-text

Pericranial Flap for Endoscopic Anterior Skull-Base Reconstruction

Neurosurgery ◽

10.1227/01.neu.0000365620.59677.ff ◽

2010 ◽

Vol 66 (3) ◽

pp. 506-512 ◽

Cited By ~ 73

Author(s):

Mihir R. Patel ◽

Rupali N. Shah ◽

Carl H. Snyderman ◽

Ricardo L. Carrau ◽

Anand V. Germanwala ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Preoperative Planning ◽

Cranial Base ◽

Anterior Skull Base ◽

Dural Defect ◽

Skull Base Reconstruction ◽

Pericranial Flap ◽

Endonasal Reconstruction ◽

Ventral Skull Base

Abstract BACKGROUND One of the major challenges of cranial base surgery is reconstruction of the dural defect and prevention of postoperative cerebrospinal fluid (CSF) fistula. The introduction of endoscopic techniques and an endonasal approach to the ventral skull base has created new challenges for reconstruction. OBJECTIVE We have developed an endoscopic pericranial flap (PCF) for skull base reconstruction and hereby present the initial cohort of patients who had endonasal reconstruction with a PCF after endoscopic skull base resection. We also demonstrate a method to radiographically incorporate anticipated skull base defects for preoperative planning of PCF length. METHODS Dural defects after endonasal skull base resection of invasive tumors were reconstructed with an onlay PCF (n = 10). We performed radiological studies to assist preoperative planning for where to make incisions while harvesting a PCF for anterior skull base, sellar, and clival defects. RESULTS Each of the 10 patients had excellent healing of their skull base and had no evidence of any postoperative cerebrospinal fluid leaks. Eight patients had radiation therapy without flap complications. Radiographic studies demonstrate that the adequate PCF length, covering defects of the anterior skull base, sellar, and clival defects are 11.31 to 12.44 cm, 14.31 to 15.57 cm, and 18.5 to 20.42 cm, respectively. CONCLUSION The PCF provides an option for endonasal reconstruction of cranial base defects and can be harvested endoscopically. Pre-operative radiographic evaluation may guide surgical planning. There is minimal donor site morbidity, and the flap provides enough surface area to cover the entire ventral skull base.

Download Full-text

Endonasal Endoscopic Management of Frontal Sinus Cerebrospinal Fluid Leak

American Journal of Rhinology and Allergy ◽

10.2500/ajra.2017.31.4478 ◽

2017 ◽

Vol 31 (6) ◽

pp. 406-411 ◽

Cited By ~ 7

Author(s):

Javaneh Jahanshahi ◽

Mehdi Zeinalizadeh ◽

Hasan Reza Mohammadi ◽

Seyed Mousa Sadrehosseini

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Frontal Sinus ◽

Surgical Approaches ◽

Endoscopic Management ◽

Graft Material ◽

Endoscopic Repair ◽

Skull Base Reconstruction ◽

Csf Rhinorrhea

Background A frontal sinus leak is uncommon and is seen in ∼15% of cases of patients with cerebrospinal fluid (CSF) rhinorrhea. Now, endonasal endoscopic techniques have been reported to reconstruct skull base defects in the frontal sinus with a favorable outcome. Objective To review our experience in the repair of frontal sinus CSF leaks through an endonasal endoscopic approach. Methods Twenty-four patients with a frontal sinus leak who underwent endonasal endoscopic repair entered the study. Clinical presentation, location, frontal sinusotomy, graft material, follow-up, and frontal sinus status were evaluated. Results Among >100 cases of surgically repaired CST rhinorrhea, the frontal sinus was the site of the leak in 24 patients (mean age, 28.9 years; mean follow-up, 22 months). The etiology consisted of spontaneous leak and traumatic leak; whereas patients with skull base reconstruction after removal of tumor were excluded. Surgical approaches included Draf IIb, Draf III, Draf IIa in 20, 3, and 1 patients, respectively. Tree autografts as two-layer inlay fat–muscle and onlay fascia lata were used in the majority of patients. A success rate was achieved in 95.83% of the patients. Conclusion Endonasal endoscopic repair of a frontal sinus leak was a successful procedure, with a low failure rate and minimal morbidity.

Download Full-text

Collagen matrix as an inlay in endoscopic skull base reconstruction

The Journal of Laryngology & Otology ◽

10.1017/s0022215117001499 ◽

2017 ◽

Vol 132 (3) ◽

pp. 214-223 ◽

Cited By ~ 4

Author(s):

G M Oakley ◽

J M Christensen ◽

M Winder ◽

B P Jonker ◽

A Davidson ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Case Series ◽

Cerebrospinal Fluid Leak ◽

Collagen Matrix ◽

Intracranial Bleeding ◽

Skull Base Reconstruction ◽

Delayed Complications ◽

Fluid Leak

AbstractBackground:Multi-layer reconstruction has become standard in endoscopic skull base surgery. The inlay component used can vary among autografts, allografts, xenografts and synthetics, primarily based on surgeon preference. The short- and long-term outcomes of collagen matrix in skull base reconstruction are described.Methods:A case series of patients who underwent endoscopic skull base reconstruction with collagen matrix inlay were assessed. Immediate peri-operative outcomes (cerebrospinal fluid leak, meningitis, ventriculitis, intracranial bleeding, epistaxis, seizures) and delayed complications (delayed healing, meningoencephalocele, prolapse of reconstruction, delayed cerebrospinal fluid leak, ascending meningitis) were examined.Results:Of 120 patients (51.0 ± 17.5 years, 41.7 per cent female), peri-operative complications totalled 12.7 per cent (cerebrospinal fluid leak, 3.3 per cent; meningitis, 3.3 per cent; other intracranial infections, 2.5 per cent; intracranial bleeding, 1.7 per cent; epistaxis, 1.7 per cent; and seizures, 0 per cent). Delayed complications did not occur in any patients.Conclusion:Collagen matrix is an effective inlay material. It provides robust long-term separation between sinus and cranial cavities, and avoids donor site morbidity, but carries additional cost.

Download Full-text

Principles of Skull Base Reconstruction After Ablative Head and Neck Cancer Surgery

Otorhinolaryngology Clinics - An International Journal ◽

10.5005/jp-journals-10003-1021 ◽

2010 ◽

Vol 2 (1) ◽

pp. 87-94 ◽

Cited By ~ 1

Author(s):

Joseph Curry ◽

Zoukaa Sargi

Keyword(s):

Cerebrospinal Fluid ◽

Head And Neck Cancer ◽

Skull Base ◽

Cerebrospinal Fluid Leak ◽

Craniofacial Skeleton ◽

Skull Base Reconstruction ◽

Technical Aspects ◽

The Individual ◽

Skull Base Defects ◽

Fluid Leak

Abstract “Resection of malignancies of the skull base can result in significant functional and cosmetic morbidity as well as mortality. Reconstructive efforts provide not only functional and cosmetic rehabilitation, but also allow for the avoidance of potentially disastrous complications such as cerebrospinal fluid leak or meningitis. The optimal reconstruction is determined both by a patient based approach and a defect based approach. Skull base defects can be addressed by the separate components of the craniofacial skeleton in which they involve, and therefore the individual reconstructive issues which must be addressed. In this article, we describe an approach to skull base reconstruction and the technical aspects of the available reconstructive options.

Download Full-text

Cerebrospinal Fluid Leak Repair Simulation Model: Face, Content, and Construct Validation

American Journal of Rhinology and Allergy ◽

10.1177/1945892420952262 ◽

2020 ◽

pp. 194589242095226

Author(s):

Abdulaziz AlQahtani ◽

Abeer Albathi ◽

Paolo Castelnuovo ◽

Fahad Alfawwaz

Keyword(s):

Cerebrospinal Fluid ◽

Construct Validity ◽

Simulation Model ◽

Skull Base ◽

Cerebrospinal Fluid Leak ◽

Skull Base Reconstruction ◽

Reconstruction Surgery ◽

Item Questionnaire ◽

The Face ◽

Fluid Leak

Background Cerebrospinal fluid leak (CSFL) repair simulation models are scarce; however, these models are valuable tools for skull base reconstruction surgery training. Objectives This study aims to assess the face, content, and construct validity of a CSFL repair simulation model. Method Eight novices (residents- PGY3) and eight experts have performed skull base reconstruction in multiple sites in twelve human cadaveric heads in simulated surgical environment. The experts completed a post-study 21-item questionnaire to assess the face and content validity. The performances of the participants were recorded and scored by two independent investigators who were blinded to the participant's level. Global Rating Scale of Operative Performance (GRSOP) and a Specific Skull Base Reconstruction Checklist (SBRC) were used to score the performances. Results The responses from the expert group for the 21-item questionnaire were high for all items (4.13–4.88 out of 5). The internal consistency reliability of the questionnaire and the intraclass correlation, which was derived by Cronbach’s Alpha, were 0.913 and 0.941 respectively. Differences in construct validity between the two groups were statistically significant for both the GRSOP and SBRS (P-value < 0.001). Conclusion We demonstrated the face, content, and construct validity of the CSFL repair simulation model, which facilitates the acquisition of technical skills necessary for skull base reconstruction surgery. The model includes realistic features that make it useful in educational courses.

Download Full-text

Learning curve and technical nuances of endoscopic skull base reconstruction with nasoseptal flap to control high-flow cerebrospinal fluid leakage: reconstruction after endoscopic skull base surgery other than pituitary surgery

European Archives of Oto-Rhino-Laryngology ◽

10.1007/s00405-021-06877-4 ◽

2021 ◽

Author(s):

Woori Park ◽

Do-Hyun Nam ◽

Doo-Sik Kong ◽

Kyung Eun Lee ◽

Song I Park ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Learning Curve ◽

Skull Base ◽

Skull Base Surgery ◽

Pituitary Surgery ◽

High Flow ◽

Cerebrospinal Fluid Leakage ◽

Nasoseptal Flap ◽

Skull Base Reconstruction ◽

Endoscopic Skull Base Surgery

Download Full-text

Endoscopic skull base reconstruction of large defects: retrospective analysis of 30 cases

Russian journal of neurosurgery ◽

10.17650/1683-3295-2021-23-1-91-100 ◽

2021 ◽

Vol 23 (1) ◽

pp. 91-100

Author(s):

E. V. Shelesko ◽

N. A. Chernikova ◽

A. D. Kravchuk ◽

D. N. Zinkevich ◽

A. I. Belov

Keyword(s):

Cerebrospinal Fluid ◽

Statistical Analysis ◽

Skull Base ◽

Retrospective Analysis ◽

Postoperative Period ◽

Cerebrospinal Fluid Leak ◽

Chi Square ◽

Skull Base Reconstruction ◽

Study Objective ◽

Lumbar Drainage

Background. Endoscopic skull base reconstruction of large defects is a difficult issue in neurosurgery, as there are problems associated with a wide dural resection, intra-arachnoid dissection (due to removal of the meningocele or resection of an intracranially spreading tumor), and exposure to high-flow cerebrospinal fluid within the cisterns. But perhaps the most significant influence is the larger nonvascularized reconstructive bed – cerebrospinal fluid on one side and sinus cavity (air) on the other.The study objective is to analyze our own experience in treating patients with large defects of the skull base and, based on the results obtained, to optimize the method of reconstruction.Materials and methods. A retrospective analysis of 30 cases of reconstruction of large defects of skull base of various etiologies. The results of surgery in the early and late postoperative period were evaluated. Statistical analysis was carried out using the exact Fisher criterion and the analysis of arbitrary contingency tables using the chi-square criterion. A literature review was conducted to compare the data obtained with the results of other studies.Results. In the group of patients (n = 16) for whom reconstruction was performed only with free transplants the effectiveness of reconstruction was 75 %. In the group of patients (n = 14) who underwent the last stage of reconstruction using a vascularized pedicled nasoseptal flap, the plastic surgery efficiency was 100 %. According to statistical analysis, there is a relationship between the choice of transplant type and the multilayer technique (p <0.05). The use of lumbar drainage did not affect the recurrence of cerebrospinal fluid leak in the postoperative period (p >0.05).Conclusion. Endoscopic skull base reconstruction can be effectively used for defects of the skull base >1.5 cm. When choosing the technique of reconstruction of large defects of the skull base, preference should be given to multilayer plastic using vascularized flaps. The use of lumbar drainage for reconstruction of large defects is a justified method in the case of a clear definition of indications for its use, based on a comparison of the possible benefits and risks associated with the invasiveness of the method.

Download Full-text