Planum, tubercular, sellar and clival defects

Transsphenoidal and extended transsphenoidal approaches have provided improved surgical access to numerous intradural and extradural tumors from the retrosellar area to the craniovertebral junction. The evolution in reconstruction of planum, tubercular and clival skull base defects has progressed from the use of free tissue grafts alone to the use of free tissue grafts in combination with vascularized flaps. Sellar floor reconstruction is usually necessary only if intraoperative CSF leaks, prolapse of the suprasellar cistern, or bleeding from the medial aspect of the cavernous sinus occur. In patients with intraoperative CSF leak, accurate packing of the sella in the area of the arachnoid membrane tear, with or without packing of the sphenoid sinus, is performed. An increasing armamentarium of local and regional tissue flaps have reduced postoperative CSF leak rates to less than 5%. Future refinements in skull base reconstruction techniques will allow better management of patients at high risk for a postoperative CSF leak, especially those who have been previously irradiated and/or require revision surgery.