Neurosurgical focus最新文献

Objective: A significant complication of spine surgery is persistent postoperative CSF leak secondary to intentional or incidental durotomy. Traditionally, the gold standard for repair of simple durotomy has been primary surgical repair; however, this technique alone may not be possible for more complex durotomy and is often supplemented with sealants or fibrin glues. The authors add to the literature the largest series of spine surgery patients treated with TachoSil, a synthetic collagen patch containing human fibrinogen and human thrombin, for the management of incidental or intentional durotomy.

Methods: The authors identified all patients who underwent a spinal operation and were billed for operative use of TachoSil at their institution between January 1, 2023, and November 3, 2023. Demographic, clinical, and outcome variables were collected and analyzed using standard statistical methods. Categorical variables were reported as number (%), and continuous variables were reported as median (range).

Results: The authors retrieved 55 patients meeting their inclusion criteria. The population consisted of 29 (52.7%) females, had a median age of 52 years, and had a median BMI of 28.3 kg/m2. Of the repaired durotomies, 37 (67.3%) were intentional to the operation and 18 (32.7%) were incidental or secondary to trauma. Abnormal residual fluid collections were appreciated in 1 (1.8%) patient. Wound breakdown was observed in 2 (3.6%) patients. Thirty-day readmission was observed in 6 (10.9%) patients, and 30-day reoperation was necessary in 2 (3.6%) patients. Ninety-day readmission was observed in 7 (12.7%) patients and 90-day reoperation was necessary in 3 (5.5%) patients. One (1.8%) case of 30-day readmission was related to CSF leak, and no cases of 30-day or 90-day reoperation were related to dural closure failure.

Conclusions: This study is a brief examination of the demographic characteristics, surgical variables, and outcomes of durotomy repair in spine surgery with TachoSil and provides encouraging results for the continued use of the material in this context. This study provides the impetus for examination of TachoSil in larger, multi-institutional studies to establish it as a standard of care in spinal dural repair.

Objective: The aim of this study was to review a series of patients who underwent open cranial surgeries to evaluate the incidence of iatrogenic incisional CSF leaks and discuss its prevention and management. The authors also discuss the utility of the "folding technique" used in duraplasty as an alternative to conventional dural reconstruction techniques.

Methods: All patients undergoing open cranial surgery were reviewed, and those with incisional CSF leak were included in this study. CSF leakage was managed using either conservative nonsurgical methods or surgical interventions. When the conservative nonsurgical methods failed to curb the leak, surgical procedures such as lumbar external drainage (LED) using lumbar subarachnoid drainage, external ventricular drainage (EVD), a lumboperitoneal or ventriculoperitoneal shunt (VPS), and reexploration of the surgical site were considered.

Results: Between 2019 and 2024, 2149 patients underwent open cranial surgeries at our hospital for any cranial pathology; 39 (1.8%) of these patients experienced postoperative incisional CSF leakage. The majority of the pathologies requiring surgeries were located in the supratentorial region (76.9%). Patients were classified according to the type of dural closure technique used. Primary stitching, the patient's fascia, or synthetic dura (resorbable, nonresorbable, or both) were used for dural reconstruction. The median interval between the surgery and the start of the leakage was 19 (IQR 1-79) days in patients with no history of radiotherapy; however, this duration was longer in patients who received radiotherapy (median 45 [IQR 10-540] days). The surgical interventions for CSF leakage were classified as wound resuturing (combined with other conservative approaches such as tightened dressing and elevating the head end of the bed), LED or EVD, or surgical reexploration. The folding technique in duraplasty is a simple way to achieve watertight duraplasty even with autograft or synthetic material.

Conclusions: Incisional CSF leakage is a potentially preventable complication with high morbidity. Such cases could be managed via conservative approaches including wound resuturing, LED or EVD, and surgical reexploration. However, the management strategy is beyond any strict algorithm. This folding technique for duraplasty is a worthy replacement for conventional primary suturing for dural repair or reconstruction in cranial and even spinal defects. This study highlights the importance of regaining the watertight nature of the dura in the primary surgery to prevent any further intervention and lower the overall morbidity.

Objective: Through an eyebrow incision, the lateral supraorbital (LSO) keyhole approach provides access to various lesions in the anterior cranial fossa and affords many of the advantages of minimal access and minimally invasive surgery. The LSO approach and other minimal access approaches including various endonasal approaches to the anterior cranial fossa, however, have been associated with nonnegligible rates of CSF leaks postoperatively. The authors report their recent experience using calcium phosphate cement cranioplasty as a method of preventing CSF leakage after LSO keyhole craniectomy.

Methods: A retrospective medical records review was performed for 9 consecutive patients undergoing operations by the senior authors using the LSO keyhole approach with skull defect repair using calcium phosphate cement cranioplasty alone between 2022 and 2024. Review of the medical records included clinic notes, imaging studies, and operative notes as well as details regarding the length of hospital stay, complications, and rate of tumor recurrence.

Results: Eight of 9 patients underwent resection of meningiomas, while 1 underwent resection of a cavernous malformation. The cohort consisted of 7 females (78%) and 2 males (22%) with a mean age of 55.2 years. The mean tumor volume among the 8 meningiomas was 18.09 cm3, and peritumoral edema was present in 8 of the 9 cases (89%). Gross-total resection was achieved in 7 of 8 meningioma cases (87.5%). Among the 9 patients, the mean length of hospital stay was 2.4 days. Two patients (22%) experienced complications. No patients experienced a CSF leak postoperatively. At a mean follow-up of 13.8 months, 1 patient (12.5%) experienced tumor recurrence.

Conclusions: Based on this and prior experience, the use of calcium phosphate cement cranioplasty alone following an LSO keyhole approach to the anterior cranial fossa is a safe alternative to traditional closure techniques, which rely on replacement of bone flap with plates and screws, and it might reduce the rate of postoperative CSF leakage. Larger studies are required to confirm these findings.

Objective: Dural sealant patches (DSPs) are a useful adjunct when closing the dura during cranial or spinal surgery to avoid cerebrospinal fluid (CSF) leakage or infection. Authors of this paper systematically review the outcomes and incidence of CSF leakage and infection with the use of a DSP versus conventional practice.

Methods: The MEDLINE, Embase, Cochrane Library, and Scopus databases were searched, and clinical trials and prospective or retrospective case-control and cohort studies with a low-risk of bias and involving any solid DSP used in adults for cranial or spinal cases were included. Studies that used a DSP in combination with another method of dural sealant closure, used a DSP as a dural substitute rather than an adjunctive closure device, or used hydrogel or polymer gel (i.e., nonsolid) dural sealant "patches" were excluded. A meta-analysis of comparative studies reporting outcomes relating to CSF leakage was performed together with a subgroup analysis for each DSP type. For comparative studies reporting outcomes relating to infection, a separate meta-analysis was conducted.

Results: Across the 7 noncomparative studies included, 669 patients received TachoComb (n = 421, 1 study), TachoSil (n = 8, 1 study), Liqoseal (n = 40, 1 study), TissuePatchDural (n = 144, 2 studies), or Hemopatch (n = 56, 2 studies). Across the 6 comparative studies included, 1013 patients received TachoSil (n = 784, 3 studies), TissuePatchDural (n = 147, 2 studies), or Hemopatch (n = 82, 1 study). When considering the rates of CSF leakage or infection, 2/6 comparative studies found DSPs to be significantly more effective than current practice, while the remaining 4/6 demonstrated noninferiority compared to current practice. All studies considered the DSPs to be safe. A meta-analysis revealed significant improvements in the incidence of CSF leakage with the use of a DSP overall, but the improvements in CSF leak rates for the TachoSil and TissuePatchDural subgroups did not reach statistical significance. The single study evaluating Hemopatch did find statistically significant improvements in CSF leak rates. There were no significant differences in infection between the DSP groups.

Conclusions: There was a significant improvement in the incidence of CSF leaks with the use of DSPs. Comparisons among DSP types and evaluations of outcomes relating to infection should be the focus of further research in this area.

Objective: The goal of this study was to evaluate the efficacy of watertight dural closure (WTDC) in preventing postoperative CSF leakage during extended endoscopic transnasal surgery (ETS) for skull base tumors, while preserving sinonasal quality by omitting the routine use of a nasoseptal flap.

Methods: This retrospective study included 28 patients who underwent ETS and experienced Esposito grade 3 CSF leakage at a single institution between June 2022 and June 2024. WTDC was performed using fascia lata grafts and various suturing techniques. Surgical videos and electronic medical records were reviewed to assess suturing times and postoperative outcomes. The efficacy of WTDC in preventing CSF leakage was evaluated, and the technical aspects of the procedure were analyzed.

Results: Among the 28 patients (14 female, 14 male), WTDC was successfully achieved in 14 cases, with near-watertight closure in the remaining 14. The average suturing time decreased with experience, showing a trend of improved efficiency. No postoperative CSF leaks were observed, and 1 case of postoperative meningitis resolved without sequelae. Despite significant risk factors for CSF leakage, WTDC was effective in all patients without the routine use of lumbar drainage.

Conclusions: WTDC in ETS is a reliable method for preventing postoperative CSF leakage, particularly in complex skull base surgeries with high-risk factors. This technique avoids the complications associated with nasoseptal flap use, preserves sinonasal quality, and reduces the need for lumbar drainage, making it a valuable option for skull base reconstruction.

Objective: CSF leaks are a common complication of spinal surgery, occurring in 3%-16% of elective cases and up to 12% of operatively managed traumatic spinal injuries. They can also occur following lumbar puncture. However, there are limited data on utilization and reimbursement trends within Medicare for CSF leak repairs. Characterizing the economic burden and market of spinal CSF leak repair has implications for optimizing effective management strategies. This study evaluates reimbursement and utilization trends for both surgical repair and epidural blood patch (EBP) management of spinal CSF leaks between the years 2000 and 2021.

Methods: The 2000-2021 provider utilization and payment files from the Centers for Medicare & Medicaid Services was queried to identify all spinal CSF leak repair procedures billed to Medicare part B. For each management strategy, the number of procedures, total charges submitted by providers, and total Medicare reimbursements were extracted. Monetary data were adjusted to 2021 US dollars using changes to the Consumer Price Index. Spearman rank correlation coefficients were used to analyze trends in reimbursement and utilization.

Results: From 2000 to 2021, 62,826 open surgical repairs were reported with $37,082,407 paid in reimbursement (45.9% repaired without additional laminectomy, 28.8% with laminectomy, and 25.3% requiring a spinal dural graft). An additional 63,227 EBPs were reported for CSF leak repair with $7,567,776 in reimbursement. Reimbursement for CSF leak repair without laminectomy totaled $15,707,094; repairs with laminectomy, $12,429,690; and use of spinal dural grafts, $8,945,444. Both a significant 162% increase in the utilization of spinal dural grafts (333 to 872, p < 0.001) and a decrease in reimbursement ($671 to $496, p = 0.02) was observed from 2000 to 2021. There was a significant 31% decrease in reimbursement for EBP ($148 to $102, p < 0.001).

Conclusions: Significant variability exists in the management strategy and rates of utilization and reimbursement for treating spinal durotomy. Despite increasing utilization of spinal dural grafts, reimbursement has declined between the years 2000 and 2021. Further studies are required to optimize both the cost effectiveness and efficacy of spinal durotomy repair techniques.

Objective: The authors evaluated the intermediate-term outcomes of a skull base reconstruction technique using hydroxyapatite cranioplasty combined with a nasoseptal flap following endoscopic endonasal surgery (EES) for suprasellar tumors. Specifically, the evaluation focused on the avoidance of lumbar CSF drainage, prevention of CSF leakage, and incidence of postoperative complications, including meningitis and nasoseptal flap necrosis, during a minimum follow-up of 2 years.

Methods: This multicenter study included patients who met the following criteria: 1) underwent EES for tuberculum sellae meningiomas or craniopharyngiomas, 2) received dual application of hydroxyapatite cranioplasty and reconstruction using a nasoseptal flap, 3) had a follow-up duration of at least 2 years, and 4) did not undergo lumbar drainage of CSF postoperatively. The success rate of reconstruction was determined based on postoperative CSF leakage, associated complications, meningitis, postoperative hospital length of stay (LOS), and would dehiscence.

Results: A total of 198 patients from three institutions diagnosed with tuberculum sellae meningioma (86 patients) or craniopharyngioma (112 patients) were included in this study. The median follow-up duration was 39 months. No patient underwent postoperative lumbar drainage of CSF. Postoperatively, only 3 patients (1.5%) experienced CSF leaks requiring reoperation. The median hospital LOS after surgery was 5 days. Other postoperative complications included atypical meningitis in 5 patients and wound dehiscence in 3 patients during the follow-up period. All patients with nonbacterial meningitis were treated with intravenous antibiotics and dexamethasone medication for 2 weeks.

Conclusions: The combination of hydroxyapatite cranioplasty and a nasoseptal flap in reconstruction following EES decreased the requirement for postoperative lumbar CSF drainage and shortened hospital LOSs with minimal morbidities. Nevertheless, careful attention to the risks of meningitis and central necrosis of a nasoseptal flap is crucial for optimizing patient outcomes.

Objective: The endonasal transsphenoidal approach (ETA) developed over the years has become the standard of care for sellar and parasellar lesions. However, because it necessitates the removal of the skull base bone, it is often accompanied by CSF leakage. The authors aimed to provide technical nuances and analyze the results of their routine fat grafting technique after ETA.

Methods: A consecutive patient cohort (2004-2024) of 168 patients who underwent ETA for sellar and parasellar lesions and the modified fat grafting technique for skull base repair were retrospectively reviewed.

Results: Overall, combined ETA and transcranial approach (TCA) was performed in 7 (4.2%) patients, and 4 (2.4%) patients had prior transsphenoidal surgery. The size of the lesion was < 10 mm in 24 (14.3%) patients, 10-30 mm in 93 (55.4%), and > 30 mm in 51 (30.4%). Histopathological diagnoses were as follows: 154 (91.7%) pituitary adenomas, of which 45 (26.8%) were secreting; 8 (4.8%) Rathke's cleft cysts; 2 (1.2%) inflammatory/autoimmune lesions; 2 (1.2%) craniopharyngiomas; 1 (0.6%) renal cell carcinoma metastasis; and 1 (0.6%) chordoma. Gross-total resection was achieved in 127 (75.6%) patients, near-total resection in 22 (13.1%), and subtotal resection/partial resection/biopsy in 19 (11.3%). Overall, 122 (72.6%) procedures had intraoperative CSF leakage. Postoperative CSF leakage was observed in 1 (0.6%) patient treated with a revision operation and regrafting with a slightly larger graft and lumbar drainage.

Conclusions: Even slight modifications in contemporary surgical techniques and the addition of an innovative approach may improve the treatment of sellar and parasellar lesions via ETA and reduce the risk of CSF leakage. The authors have developed and described a modified fat grafting technique with gradual crafting and preprocessing of the abdominal fat tissue for skull base repair, and they have demonstrated its effectiveness in significantly reducing the CSF leak rate. This technique enables adequate reconstruction of skull base defects with low donor-site complication rates and obviates the need for external lumbar drainage.

Objective: The purpose of this study was to evaluate the outcome of a modified graded reconstruction technique based on the size of intraoperative CSF leaks in patients undergoing endoscopic endonasal surgery performed by a single surgeon in the early years of his practice.

Methods: The database of patients who underwent endoscopic endonasal approaches (EEAs) between September 2020 and August 2024 was included. Surgical complexity was categorized into levels II, III, and IV. Intraoperative CSF leak was categorized into 4 grades (0-3). Patients were divided into 2 timeline groups (those undergoing an EEA between 2020 and 2022 [group A] and between 2023 and 2024 [group B]) to assess the trends in surgical complexity and repair outcomes.

Results: A total of 69 patients with a mean age of 56 ± 16.9 years (range 12-83 years) were identified; 34 (49.3%) were female. The median body mass index was 31 (> 25 in 82.6%). The most common pathology was nonsecretory macroadenoma (57.9%). The EEA at complexity levels II, III, and IV was performed in 36.2%, 46.4%, and 17.4% of the patients, respectively. Intraoperative CSF leaks grades 1, 2, and 3 were encountered in 39.1%, 7.2%, and 17.4% of the patients, whereas 36.2% did not develop leaks (grade 0). Fat grafts and collagen matrix were used for all patients with grades 1-3. Patients with complexity level II only developed grade 1 and 2 leaks, and none of level III developed grade 3. A nasoseptal flap was used in 4 patients (5.8%), with all having level IV surgery and grade 3 intraoperative leak. Only 1 patient (1.4%) developed a postoperative CSF leak, and a lumbar drain was only used for this patient (1.4%) at the revision surgery. The rate of grades 2 and 3 leaks in group B was significantly lower than in group A (8.3% vs 33.3%, p = 0.022). Temporary nasal packing usage was also significantly lower in group B (8.3%) than in group A (28.9%) (p = 0.049), whereas high-complexity EEA rates and pedicled flap usage were not correlated with the year of surgery.

Conclusions: A graded endoscopic endonasal repair protocol, combined with the judicious use of lumbar drains and nasoseptal flaps rather than a reflexive approach, helps in minimizing postoperative CSF leak rates. Cross-training of neurosurgery graduates focusing on skull base practice is highly recommended for maximizing good outcomes in their early years of practice. With growing experience, intraoperative leak rates tend to decrease, and the reconstruction relies on a tailored multilayer strategy rather than bulky synthetic materials.