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Lumbar Drain Use during Middle Fossa Approaches for Nonneoplastic Pathology of the Skull Base
Introduction The middle fossa craniotomy (MFCs) is commonly utilized for spontaneous cerebrospinal fluid (CSF) leaks, encephaloceles, and superior semicircular canal dehiscence (SSCD). This study compares postoperative outcomes of MFCs with and without LD use.
Methods A retrospective cohort study of adults over the age of 18 years presenting for the repair of nonneoplastic CSF leak, encephalocele, or SSCD via MFC from 2009 to 2021 was conducted. The main exposure of interest was the placement of an LD. The primary outcome was the presence of postoperative complications (acute/delayed neurologic deficit, meningitis, intracranial hemorrhage, and stroke). Secondary outcomes included operating room (OR) time, length of stay, recurrence, and need for reoperation.
Results In total, 172 patients were included, 96 of whom received an LD and 76 who did not. Patients not receiving an LD were more likely to receive intraoperative mannitol (n = 24, 31.6% vs. n = 16, 16.7%, p = 0.02). On univariate logistic regression, LD placement did not influence overall postoperative complications (OR: 0.38, 95% confidence interval [CI]: 0.05–2.02, p = 0.28), CSF leak recurrence (OR: 0.75, 95% CI: 0.25–2.29, p = 0.61), or need for reoperation (OR: 1.47, 95% CI: 0.48–4.96, p = 0.51). While OR time was shorter for patients not receiving LD (349 ± 71 vs. 372 ± 85 minutes), this difference was not statistically significant (p = 0.07).
Conclusion No difference in postoperative outcomes was observed in patients who had an intraoperative LD placed compared to those without LD. Operative times were increased in the LD cohort, but this difference was not statistically significant. Given the similar outcomes, we conclude that LD is not necessary to facilitate safe MCF for nonneoplastic skull base pathologies.
Keywordslumbar drain - superior semicircular canal dehiscence - encephalocele - cerebrospinal fluid leak
Received: 08 December 2022
Accepted: 27 March 2023
Accepted Manuscript online:
30 March 2023
Article published online:
21 April 2023
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- 1 McNulty B, Schutt CA, Bojrab D, Babu S. Middle cranial fossa encephalocele and cerebrospinal fluid leakage: etiology, approach, outcomes. J Neurol Surg B Skull Base 2020; 81 (03) 268-274
- 2 Carlson ML, Copeland III WR, Driscoll CL. et al. Temporal bone encephalocele and cerebrospinal fluid fistula repair utilizing the middle cranial fossa or combined mastoid-middle cranial fossa approach. J Neurosurg 2013; 119 (05) 1314-1322
- 3 Mozaffari K, Willis SL, Unterberger A. et al. Superior semicircular canal dehiscence outcomes in a consecutive series of 229 surgical repairs with middle cranial fossa craniotomy. World Neurosurg 2021; 156: e229-e234
- 4 Telischi FF, Landy H, Balkany TJ. Reducing temporal lobe retraction with the middle fossa approach using a lumbar drain. Laryngoscope 1995; 105 (02) 219-220
- 5 Nelson RF, Roche JP, Gantz BJ, Hansen MR. Middle cranial fossa (MCF) approach without the use of lumbar drain for the management of spontaneous cerebral spinal fluid (CSF) leaks. Otol Neurotol 2016; 37 (10) 1625-1629
- 6 Bien AG, Bowdino B, Moore G, Leibrock L. Utilization of preoperative cerebrospinal fluid drain in skull base surgery. Skull Base 2007; 17 (02) 133-139
- 7 Li J, Gelb AW, Flexman AM, Ji F, Meng L. Definition, evaluation, and management of brain relaxation during craniotomy. Br J Anaesth 2016; 116 (06) 759-769
- 8 Zhong J, Dujovny M, Perlin AR, Perez-Arjona E, Park HK, Diaz FG. Brain retraction injury. Neurol Res 2003; 25 (08) 831-838
- 9 Plotkin A, Han SM, Weaver FA. et al. Complications associated with lumbar drain placement for endovascular aortic repair. J Vasc Surg 2021; 73 (05) 1513-1524.e2
- 10 Grady RE, Horlocker TT, Brown RD, Maxson PM, Schroeder DR. Mayo Perioperative Outcomes Group. Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Anesth Analg 1999; 88 (02) 388-392
- 11 Kim YS, Kim SH, Jung SH, Kim TS, Joo SP. Brain stem herniation secondary to cerebrospinal fluid drainage in ruptured aneurysm surgery: a case report. Springerplus 2016; 5: 247
- 12 Bloch J, Regli L. Brain stem and cerebellar dysfunction after lumbar spinal fluid drainage: case report. J Neurol Neurosurg Psychiatry 2003; 74 (07) 992-994
- 13 Lane BC, Scranton R, Cohen-Gadol AA. Risk of brain herniation after craniotomy with preoperative lumbar spinal drainage: a single-surgeon experience of 365 patients among 3000 major cranial cases. Oper Neurosurg (Hagerstown) 2021; 20 (02) E77-E82
- 14 Huo CW, King J, Goldschlager T. et al. The effects of cerebrospinal fluid (CSF) diversion on post-operative CSF leak following extended endoscopic anterior skull base surgery. J Clin Neurosci 2022; 98: 194-202
- 15 Danciu I, Cowan JD, Basford M. et al. Secondary use of clinical data: the Vanderbilt approach. J Biomed Inform 2014; 52: 28-35
- 16 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)---a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
- 17 Harris PA, Taylor R, Minor BL. et al; REDCap Consortium. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform 2019; 95: 103208
- 18 Zwagerman NT, Wang EW, Shin SS. et al. Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial. J Neurosurg 2018; 10 (01) 1-7
- 19 Crowson MG, Cunningham III CD, Moses H, Zomorodi AR, Kaylie DM. Preoperative lumbar drain use during acoustic neuroma surgery and effect on CSF leak incidence. Ann Otol Rhinol Laryngol 2016; 125 (01) 63-68
- 20 Caggiano C, Penn DL, Laws Jr ER. The role of the lumbar drain in endoscopic endonasal skull base surgery: a retrospective analysis of 811 cases. World Neurosurg 2018; 117: e575-e579
- 21 Stapleton AL, Tyler-Kabara EC, Gardner PA, Snyderman CH, Wang EW. Risk factors for cerebrospinal fluid leak in pediatric patients undergoing endoscopic endonasal skull base surgery. Int J Pediatr Otorhinolaryngol 2017; 93: 163-166
- 22 Cain RB, Patel NP, Hoxworth JM, Lal D. Abducens palsy after lumbar drain placement: a rare complication in endoscopic skull base surgery. Laryngoscope 2013; 123 (11) 2633-2638
- 23 Ringel B, Carmel-Neiderman NN, Peri A. et al. Continuous lumbar drainage and the postoperative complication rate of open anterior skull base surgery. Laryngoscope 2018; 128 (12) 2702-2706
- 24 Wong AK, Shinners M, Wong RH. Minimally invasive repair of tegmen defects through keyhole middle fossa approach to reduce hospitalization. World Neurosurg 2020; 133: e683-e689
- 25 Walia A, Lander D, Durakovic N, Shew M, Wick CC, Herzog J. Outcomes after mini-craniotomy middle fossa approach combined with mastoidectomy for lateral skull base defects. Am J Otolaryngol 2021; 42 (01) 102794