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Challenging reconstructive techniques for skull base defect following endoscopic endonasal approaches

  • Clinical Article
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Abstract

Objective

We assessed the outcomes of various reconstructive methods for skull base defect after endoscopic endonasal approaches (EEA) depending on the degree of intraoperative cerebrospinal fluid (CSF) leaks.

Methods

Between Jan. 2008 and Sep. 2009, 122 consecutive patients underwent 124 EEA for sellar and extra-sellar lesions. Intraoperative CSF leaks were classified as grade 0, no intraoperative CSF leak; grade 1, low output; and grade 2, high-output based on the degree of CSF leakage and size of opening in the arachnoid membrane (<5 or ≥5 mm).

Results

Postoperative CSF leaks or meningitis occurred in 13 of 124 cases (10.5%). In 77 patients with grade 0, there was no postoperative CSF leak. Among 20 patients with grade 1 CSF leaks, four patients developed meningitis or postoperative CSF leak. Postoperative CSF leaks occurred in nine of 26 patients (34.6%) with grade 2 leaks. Comparison of reconstructive methods revealed that gasket-seal method provided better control of CSF leaks than free-fat graft in patients with grade 2 leaks (11.8% vs. 66.7%, p = 0.028). However, in grades 0 and 1, we found no difference among the various reconstructive methods.

Conclusion

The selection of reconstructive methods for skull base defects should be determined by the degree of CSF leaks. Although grade 0 or 1 leak requires relatively conservative management such as simple closure or free-tissue grafting, a more aggressive reconstructive technique is required to prevent postoperative complication in grade 2 CSF leak.

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Acknowledgment

This study was partially supported by a grant of the Korea Healthcare technology R&D Project, Ministry for Health & Welfare Affairs, Republic of Korea (A092255) and by the Samsung Biomedical Research Institute grant #SBRI C-B0-303-1.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Ilwondong 50, Gangnamku, 135-710, Seoul, South Korea

    Doo-Sik Kong, Se-Hwan Kim, Do-Hyun Nam, Kwan Park & Jong Hyun Kim

  2. Department of Otorhinolaryngology–Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

    Hyo Yeol Kim, Jin-Young Min & Hun-Jong Dhong

Authors
  1. Doo-Sik Kong
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  2. Hyo Yeol Kim
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  3. Se-Hwan Kim
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  4. Jin-Young Min
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  5. Do-Hyun Nam
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  6. Kwan Park
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  7. Hun-Jong Dhong
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Corresponding author

Correspondence to Doo-Sik Kong.

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Comment

This well-written article points out, once again, the real weak point of transsphenoidal surgery—i.e., the management of intra-postoperative CSF leak, especially when an extended approach to the skull base is performed.

Nowadays, an increasing number of neurosurgeons are evaluating the opportunity to deal with different lesions in most areas of the skull base from below, through such a surgical route, with satisfactory results either for the patients and the surgeons. The technique described suggests another excellent method to abbreviate the times of the surgical procedure, opening a new way for the reconstruction of the osteodural skull base defect, further improving patient postoperative discomfort.

Finally, we would like to highlight the importance of use of dedicated instruments: In our opinion, it cannot be apart from the surgical armamentarium of the modern neurosurgeon, already skilled or still in learning process, dealing with transsphenoidal surgery. It seems clear that a quite long learning curve is required to perform such a technical-demanding procedure routinely.

Paolo Cappabianca

Napoli, Italy

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Kong, DS., Kim, H.Y., Kim, SH. et al. Challenging reconstructive techniques for skull base defect following endoscopic endonasal approaches. Acta Neurochir 153, 807–813 (2011). https://doi.org/10.1007/s00701-011-0941-5

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  • DOI: https://doi.org/10.1007/s00701-011-0941-5

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