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Published on: February 29, 2020
Risk factors for cerebrospinal fluid leak in pediatric patients undergoing endoscopic endonasal skull base surgery
Amanda L Stapleton1, Elizabeth C Tyler-Kabara2, Paul A Gardner2
1Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh of UPMC, United States.
Insights
Pediatric patients undergoing endoscopic endonasal surgery for skull base lesions face a high risk of cerebrospinal fluid (CSF) leaks, especially with clival chordomas. Intraoperative CSF leaks predict higher post-operative leak rates.
Area of Science:
- Neurosurgery
- Pediatric Oncology
- Otolaryngology
Background:
- Endoscopic endonasal surgery (EES) is increasingly used for pediatric skull base lesions.
- Cerebrospinal fluid (CSF) leaks are a known complication of skull base surgery.
- Identifying risk factors for post-operative CSF leaks in pediatric patients is crucial for improving outcomes.
Purpose of the Study:
- To identify risk factors associated with cerebrospinal fluid (CSF) leaks after endoscopic endonasal surgery (EES) in pediatric patients.
- To evaluate the incidence and predictors of post-operative CSF leaks in this population.
Main Methods:
- Retrospective chart review of pediatric patients (1 month to 18 years) undergoing EES for skull base lesions between 1999 and 2014.
- Analysis included five pathologies: craniopharyngioma, clival chordoma, pituitary adenoma, pituitary carcinoma, and Rathke's cleft cyst.
- Fisher's exact tests were employed to assess the statistical significance of various factors in predicting post-operative CSF leaks.
Main Results:
- Out of 70 EES procedures in 55 pediatric patients, 47 had intraoperative CSF leaks. Of these, 11 (23%) developed post-operative leaks requiring further surgery.
- Clival chordomas demonstrated the highest post-operative CSF leak rate at 36%.
- No statistically significant difference in leak rates was found based on reconstruction type, though non-vascularized flaps had a lower leak rate (9%) compared to vascularized flaps (28%). Post-operative hydrocephalus and perioperative lumbar drain use were not significant risk factors.
Conclusions:
- Pediatric patients experiencing an intraoperative CSF leak during EES for skull base lesions have a substantial risk of post-operative leaks.
- Clival chordomas represent a particularly high-risk pathology for CSF leaks in this cohort.
- The study found no statistical benefit of using vascularized flaps or perioperative lumbar drains in reducing post-operative CSF leak rates.
Objectives:
To determine the risk factors associated with cerebrospinal fluid (CSF) leak following endoscopic endonasal surgery (EES) for pediatric skull base lesions.
Methods:
Retrospective chart review of pediatric patients (ages 1 month to 18 years) treated for skull base lesions with EES from 1999 to 2014. Five pathologies were reviewed: craniopharyngioma, clival chordoma, pituitary adenoma, pituitary carcinoma, and Rathke's cleft cyst. Fisher's exact tests were used to evaluate the different factors to determine which had a statistically higher risk of leading to a post-operative CSF leak.
Results:
55 pediatric patients were identified who underwent 70 EES's for tumor resection. Of the 70 surgeries, 47 surgeries had intraoperative CSF leaks that were repaired at the time of surgery. 11 of 47 (23%) surgeries had post-operative CSF leaks that required secondary operative repair. Clival chordomas had the highest CSF leak rate at 36%. There was no statistical difference in leak rate based on the type of reconstruction, although 28% of cases that used a vascularized flap had a post-operative leak, whereas only 9% of those cases not using a vascularized flap had a leak. Post-operative hydrocephalus and perioperative use of a lumbar drain were not significant risk factors.
Conclusions:
Pediatric patients with an intra-operative CSF leak during EES of the skull base have a high rate of post-operative CSF leaks. Clival chordomas appear to be a particularly high-risk group. The use of vascularized flaps and perioperative lumbar drains did not statistically decrease the rate of post-operative CSF leak.
