Race and Cerebrospinal Fluid Leaks: Concerning Associations after Endonasal Transsphenoidal Pituitary Resection

Abstract

Objective To identify and describe differences in the rates of cerebrospinal fluid (CSF) leaks after transsphenoidal pituitary resection (TSPR) on a demographic basis.

Design Multi-institution health care database study.

Setting TriNetX research database.

Methods The database TriNetX was searched for rates of CSF leaks after TSPR. Patients were excluded if they had a CSF leak diagnosed any time prior to postoperative day number one. Demographic factors such as sex and race were compared in cohorts matched by other demographic characteristics, obstructive sleep apnea, body mass index categories, functional adenoma status, nicotine use, and concurrent lumbar drain placement.

Results A total of 8,741 patients were included in the analysis, with a total rate of postoperative CSF leak of 2.62%. After matching, race and sex were both significant risk factors for CSF leak, with Black patients having a higher risk when compared with White patients (risk ratio [RR]: 1.68, 95% confidence interval [CI]: 1.08–2.60) and females having a higher risk compared with males (RR: 1.33, 95% CI: 1.00–1.77).

Conclusion Even when matching for obstructive sleep apnea, weight, functional adenoma status, nicotine use, and concurrent lumbar drain placement, Black and female patients had higher rates of CSF leaks in the month following surgery. This finding highlights an important gap in the literature that should be addressed through future prospective studies and the need to better understand potential demographic disparities in health care.

Keywords

disparities - health inequity - pituitary adenoma - transsphenoidal - skull base surgery - postoperative outcomes - diversity - equity and inclusion

Data Availability Statement

All data supporting the findings of this study are available within the paper and its Supplementary Information.

Publication History

Received: 10 October 2024

Accepted: 16 December 2024

Accepted Manuscript online:
19 December 2024

Article published online:
23 January 2025

• References

• 1 Grotenhuis JA. Costs of postoperative cerebrospinal fluid leakage: 1-year, retrospective analysis of 412 consecutive nontrauma cases. Surg Neurol 2005; 64 (06) 490-493 , discussion 493–494
• 2 van Aken MO, Feelders RA, de Marie S. et al. Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumbar drainage reduces the risk for meningitis. Pituitary 2004; 7 (02) 89-93
• 3 Slot EMH, Sabaoglu R, Voormolen EHJ, Hoving EW, van Doormaal TPC. Cerebrospinal fluid leak after transsphenoidal surgery: a systematic review and meta-analysis. J Neurol Surg B Skull Base 2021; 83 (Suppl. 02) e501-e513
• 4 Han ZL, He DS, Mao ZG, Wang HJ. Cerebrospinal fluid rhinorrhea following trans-sphenoidal pituitary macroadenoma surgery: experience from 592 patients. Clin Neurol Neurosurg 2008; 110 (06) 570-579
• 5 Patel PN, Stafford AM, Patrinely JR. et al. Risk factors for intraoperative and postoperative cerebrospinal fluid leaks in endoscopic transsphenoidal sellar surgery. Otolaryngol Head Neck Surg 2018; 158 (05) 952-960
• 6 Huyett P, Soose RJ, Schell AE. et al. Risk of postoperative complications in patients with obstructive sleep apnea following skull base surgery. Otolaryngol Head Neck Surg 2018; 158 (06) 1140-1147
• 7 Zimmermann TM, Marcellino CR, Choby GW. et al. Timing of postoperative CSF leak after endoscopic skull base surgery in patients with obstructive sleep apnea. J Neurol Surg B Skull Base 2019; 80 (04) 392-398
• 8 Zhao J, Wang S, Zhao X, Cui H, Zou C. Risk factors of cerebrospinal fluid leakage after neuroendoscopic transsphenoidal pituitary adenoma resection: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 14: 1263308
• 9 Stanford FC. The importance of diversity and inclusion in the healthcare workforce. J Natl Med Assoc 2020; 112 (03) 247-249
• 10 Alter DA, Naylor CD, Austin P, Tu JV. Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction. N Engl J Med 1999; 341 (18) 1359-1367
• 11 Chetty R, Stepner M, Abraham S. et al. The association between income and life expectancy in the United States, 2001-2014. JAMA 2016; 315 (16) 1750-1766
• 12 Cote DJ, Ostrom QT, Gittleman H. et al. Glioma incidence and survival variations by county-level socioeconomic measures. Cancer 2019; 125 (19) 3390-3400
• 13 Curry Jr WT, Barker II FG. Racial, ethnic and socioeconomic disparities in the treatment of brain tumors. J Neurooncol 2009; 93 (01) 25-39
• 14 Mackenbach JP, Stirbu I, Roskam AJ. et al; European Union Working Group on Socioeconomic Inequalities in Health. Socioeconomic inequalities in health in 22 European countries. N Engl J Med 2008; 358 (23) 2468-2481
• 15 Wiemken TL, Carrico RM, Furmanek SP. et al. Socioeconomic position and the incidence, severity, and clinical outcomes of hospitalized patients with community-acquired pneumonia. Public Health Rep 2020; 135 (03) 364-371
• 16 Sabahi M, Maroufi SF, Wierzbicka A, Maniakhina L, Adada B, Borghei-Razavi H. Healthcare disparities in pituitary surgery: a systematic review. Neurosurg Focus 2023; 55 (05) E15
• 17 Gordon AJ, Dastagirzada Y, Schlacter J. et al. Health care disparities in transsphenoidal surgery for pituitary tumors: an experience from neighboring urban public and private hospitals. J Neurol Surg B Skull Base 2022; 84 (06) 560-566
• 18 Tiwari C, Maung E, Gelinne A. et al. Disparities in postoperative endocrine outcomes after endoscopic-assisted transsphenoidal pituitary adenoma resection. Cureus 2022; 14 (11) e31934
• 19 Totten DJ, Schueth E, Saltagi MZ. et al. Trends in spontaneous cerebrospinal fluid leak repairs in the United States, 2009-2018. Otol Neurotol Open 2022; 2 (04) e021
• 20 Alshakhs M, Jackson B, Ikponmwosa D, Reynolds R, Madlock-Brown C. Multimorbidity patterns across race/ethnicity as stratified by age and obesity. Sci Rep 2022; 12 (01) 9716
• 21 Lobo BC, Baumanis MM, Nelson RF. Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: a systematic review. Laryngoscope Investig Otolaryngol 2017; 2 (05) 215-224
• 22 Wang MTM, Bhatti MT, Danesh-Meyer HV. Idiopathic intracranial hypertension: pathophysiology, diagnosis and management. J Clin Neurosci 2022; 95: 172-179
• 23 Kuan V, Denaxas S, Patalay P. et al; Multimorbidity Mechanism and Therapeutic Research Collaborative (MMTRC). Identifying and visualising multimorbidity and comorbidity patterns in patients in the English National Health Service: a population-based study. Lancet Digit Health 2023; 5 (01) e16-e27
• 24 Tampourlou M, Fountas A, Ntali G, Karavitaki N. Mortality in patients with non-functioning pituitary adenoma. Pituitary 2018; 21 (02) 203-207
• 25 Cote DJ, Ruzevick JJ, Kang KM. et al. Association between socioeconomic status and presenting characteristics and extent of disease in patients with surgically resected nonfunctioning pituitary adenoma. J Neurosurg 2022; 137 (06) 1699-1706
• 26 Birkenbeuel JL, Lehrich BM, Goshtasbi K, Abiri A, Hsu FPK, Kuan EC. Refusal of surgery in pituitary adenoma patients: a population-based analysis. Cancers (Basel) 2022; 14 (21) 20221030
• 27 Butterfield JT, Golzarian S, Johnson R. et al. Racial disparities in recommendations for surgical resection of primary brain tumours: a registry-based cohort analysis. Lancet 2022; 400 (10368): 2063-2073
• 28 Chalif EJ, Couldwell WT, Aghi MK. Effect of facility volume on giant pituitary adenoma neurosurgical outcomes. J Neurosurg 2022; 137 (03) 658-667
• 29 Mukherjee D, Zaidi HA, Kosztowski T. et al. Predictors of access to pituitary tumor resection in the United States, 1988-2005. Eur J Endocrinol 2009; 161 (02) 259-265
• 30 Stone G, Samaan JS, Samakar K. Racial disparities in complications and mortality after bariatric surgery: a systematic review. Am J Surg 2022; 223 (05) 863-878
• 31 Abella MKIL, Lee AY, Agonias K, Maka P, Ahn HJ, Woo RK. Racial disparities in general surgery outcomes. J Surg Res 2023; 288: 261-268
• 32 Singh P, Debbaneh P, Rivero A. Racial disparities in tympanoplasty surgery: a 30-day morbidity and mortality national cohort study. Otol Neurotol 2022; 43 (10) e1129-e1135
• 33 Iwata AJ, Williams AM, Taylor AR, Chang SS. Socioeconomic disparities and comorbidities, not race, affect salivary gland malignancy survival outcomes. Laryngoscope 2017; 127 (11) 2545-2550
• 34 Alharbi S, Harsh G, Ajlan A. Perioperative lumbar drain utilization in transsphenoidal pituitary resection. Neurosciences (Riyadh) 2018; 23 (01) 46-51
• 35 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; 131 (04) 1172-1178
• 36 Honegger J, Grimm F. The experience with transsphenoidal surgery and its importance to outcomes. Pituitary 2018; 21 (05) 545-555