Are Routine Lumbar Drains Necessary for Endoscopic Reconstruction after Resection of Anterior and Central Skull Base Tumors?

Abstract

Introduction and Objectives

The expanded endonasal approach (EEA) is historically associated with high rates of postoperative cerebrospinal fluid (CSF) leak. Therefore, many surgeons advocate for routine lumbar drain (LD) placement despite mixed evidence of their efficacy. We report outcomes for anterior and central skull base reconstructions after EEA without LDs.

Design, Setting, and Participants

A retrospective review was conducted evaluating consecutive patients undergoing EEAs for resection of central and anterior skull base pathology from 2015 to 2024 at two academic institutions.

Main Outcome Measures

Incidence of postoperative CSF leak.

Results

Eighty-five patients underwent a total of 89 EEAs. Patients were predominantly female (62.9%) with an average age of 45.1 years (range 11 months–84 years). Tumors included primarily craniopharyngiomas (49.4%) and meningiomas (46.1%). No LDs were placed perioperatively, and there was an 100% intraoperative high-flow CSF leak rate. Skull base reconstruction was performed using pedicled nasoseptal flaps (NSFs) in all cases, tensor fascia lata grafts in 82 cases, and fat grafts in 78 cases. The postoperative CSF leak rate was 7.9%. Suprasellar tumors were associated with lower rates of postoperative CSF leak compared with tuberculum sella and planum sphenoidale pathology (p = 0.030), whereas meningiomas trended toward higher CSF leak rates compared with craniopharyngiomas (p = 0.059).

Conclusion

We report a low rate of postoperative CSF leak without LD placement after EEA. Our results suggest that successful skull base reconstructions may be performed with multilayered closures using vascularized NSFs without the need for routine CSF diversion.

Keywords

skull base reconstruction - postoperative CSF leak - expanded endonasal approach - lumbar drain - nasoseptal flap - endoscopic skull base surgery

Authors' Contribution

J.C.H.: Literature review, data collection, analysis, drafting; D.K.L.: conception, analysis, drafting, interpretation; I.T.: Data collection, manuscript drafting; A.D.W: conception, interpretation; J.E.D.: conception, interpretation; M.A.K.: conception, interpretation; C.J.: conception, interpretation; J.Y.K.L.: conception, interpretation; P.B.S.: conception, interpretation; J.N.P.: conception, analysis, interpretation; N.D.A.: conception, analysis, interpretation, project leadership.

Publication History

Received: 22 October 2024

Accepted: 03 April 2025

Accepted Manuscript online:
07 April 2025

Article published online:
02 May 2025

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