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Experience and modification of skull base reconstruction results in lower complications rates

  • Original Article - Pituitaries
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Objectives

To investigate the efficacy of nasal septum bone flap combined with vascularized pedicle nasoseptal flap (VP-NSF) in the treatment of high-flow cerebrospinal fluid (CSF) leakage in the endonasal endoscopic skull base surgery.

Methods

A total of 156 patients in group A used a multi-layer skull base reconstruction method of fat-absorbable artificial dura mater- fascia lata-VP-NSF, and were treated with drainage of the lumbar cistern after surgery, in addition, a total of 94 patients in group B used a multi-layer skull base reconstruction method of fat-absorbable artificial dura mater-nasal septal bone flap-VP-NSF, and no lumbar cistern drainage was performed after surgery. Analyzed and compared the differences of postoperative cerebrospinal fluid rhinorrhea, intracranial infection, re-repair, average bed rest time, pulmonary infection and deep venous thrombosis of lower extremities were analyzed and compared in the two groups.

Results

In group A, 11 cases of cerebrospinal fluid rhinorrhea occurred after operation. In addition, 15 cases developed intracranial infection. During this period, there were 20 cases of pulmonary infection and 3 cases of deep venous thrombosis of lower extremities. In group B, there were 1 case of cerebrospinal fluid rhinorrhea (P < 0.05), 2 cases of intracranial infection (P < 0.05), 2 cases of pulmonary infection (P < 0.05), and 0 case of deep venous thrombosis of lower extremities (P > 0.05).

Conclusion

Nasal septum bone flap combined with VP-NSF is effective in the treatment of high-flow CSF leaks in the endonasal endoscopic skull base surgery, which can avoid postoperative lumbar cistern drainage and is worth popularizing.

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Availability of data and material

All of the individual participant data included in this study are available upon request by contact with the corresponding author.

Abbreviations

CSF:

Cerebrospinal fluid

ON:

Optic nerve

PS:

Pituitary stalk

OS:

Ostium sphenoidalis

VP-NSF:

Vascularized pedicle nasoseptal flap

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Acknowledgements

We express our sincere appreciation to Dr. Le Yang (Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China) for the review, revise and language editing to the paper.

Funding

This work was supported by National Natural Science Foundation of China (grant no. 81460381), the Key research and invention plan of Jiangxi Science and Technology Department (20192BBG70026); Ganpo555 engineering excellence of Jiangxi science and Technology Department (2013). National Natural Science Foundation of China,81460381,Bin Tang,Key research and invention plan of Jiangxi Science and Technology Department,20192BBG70026,Bin Tang,Ganpo555 engineering excellence of Jiangxi science and Technology Department,2013,Tao Hong

Author information

Authors and Affiliations

  1. Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, No.17 Yongwai Street, Nanchang, 330006, Jiangxi Province, China

    Chenghuan Luo, Shenhao Xie, Tao Hong & Bin Tang

  2. Department of Neurosurgery, Dongguan People’s Hospital, Dongguan, China

    Chenghuan Luo & Xiaohong Liu

Authors
  1. Chenghuan Luo
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  2. Xiaohong Liu
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  3. Shenhao Xie
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  4. Tao Hong
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  5. Bin Tang
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Contributions

B.T. made contributions to conception and design. C.H.L and X.H.L acquired the data and analyzed the consequence. C.H.L and S.H.X designed the study and drafting the article. T.H revised the manuscript. The authors have read and approved the final manuscript.

Corresponding author

Correspondence to Bin Tang.

Ethics declarations

Ethics approval and consent to participate

The survey was approved by the Ethical Committee of the First Affiliated Hospital of Nanchang University review board. The informed consent was provided by all the patients, and this study was conducted in accordance with the relevant guidelines. Patients were informed that they had the opportunity to opt out if they were not willing to participate.

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Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Comments

Successful closure of anterior skull base defects as a consequence of endonasal endoscopic procedures is an essential element of the success of such operations. I agree with the authors that reconstruction of the bony layer of such defects is helpful in providing replacement of a crucial structural element that leads to enhanced success in eliminating avenues for egress of cerebrospinal fluid. I have found in my own practice that following a philosophy of utilizing "inlay" grafts versus "onlay" grafts leads to more success in most any location along the skull base. The advantage of an inlay technique is allowing avoidance of lumbar cerebrospinal fluid diversion. The concept is to take advantage of the pressure of the fluid inside the cranial compartment to tamponade the inlaid graft material against the native dura surrounding the defect. Also critical is to make sure that the inlaid graft material is of sufficient size to cover beyond the margins of the defect. This works to allow the intracranial pressure to press the redundant graft material against the structural elements to help create a seal. Operating with this concept, diversion of cerebrospinal fluid becomes counterproductive and lessens the chance of forming a good seal. The material utilized in my practice is bone if available. This is not always the case and therefore titanium mesh or a plate of some sort is a good substitute in my practice. Most important in my opinion is to place the bone inside the defect in order to anchor the flap to prevent movement. I essentially "lock" the bone or titanium piece in place by setting it against the inside edge of the bony defect.

Following the concept of reconstruction of all anatomical layers in closure of surgical defects is a basic teaching in my department. No matter the size of the defect, including a structurally solid element to replace the bone layer is unlikely to result in regret. I commend the authors for bringing this information to our collective attention and do not view the fact that this is not a randomized series as a negative in terms of the validity of this data.

John Day

Arkansas, USA

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Luo, C., Liu, X., Xie, S. et al. Experience and modification of skull base reconstruction results in lower complications rates. Acta Neurochir 164, 1127–1133 (2022). https://doi.org/10.1007/s00701-021-05082-w

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  • DOI: https://doi.org/10.1007/s00701-021-05082-w

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