Approach-related complications of extradural anterior petrosal approach: systematic review and meta-analysis

The extradural anterior petrosal approach (EAPA) is a surgical technique utilized to access pathologies in the petroclival region and the anterolateral aspect of the brainstem, allowing enhanced visualization and maneuverability. Despite its advantages, the EAPA is associated with significant potential complications that remain a topic of debate within the neurosurgical community. This meta-analysis aims to evaluate the incidence of approach-related complications following EAPA. A systematic literature review was conducted across several databases, including PubMed, Scopus, and Embase. The primary outcome was cerebrospinal fluid (CSF) leak, while secondary outcomes included facial palsy, hearing loss, temporal lobe injury, postoperative seizures, and dry eye. Statistical analysis was performed using RStudio 2024.04.1 + 748. Heterogeneity was assessed using I² statistics. Sensitivity analysis was performed with the leave-one-out test. The risk of bias was assessed using ROBINS-I for non-randomized studies. Publication bias was assessed using a funnel plot and Furuya-Kanamori's Doi plot. Exclusion criteria were cases of intradural anterior petrosal approaches and articles where the data concerning approach-related complications could not be extracted. Our systematic search yielded 1098 articles, of which five met the inclusion criteria, encompassing 404 patients. The overall CSF leak rate was estimated at 3.15% (95% CI: 0.07-8.92), with a lower reoperation rate for CSF leaks at 0.40%. Other complications included temporal lobe injury (1.12%), postoperative seizures (2.42%), approach-related facial palsy (2.23%), and approach-related hearing loss (1.04%). Notably, the incidence of postoperative dry eye was reduced from 6.04 to 2.36% following refinements in surgical practices. The EAPA is a safe procedure with a low complication rate when performed in specialized centers. Outcomes depend on meticulous technique, experienced teams, comprehensive preoperative assessment, and neurophysiological monitoring. This meta-analysis is the first to focus on approach-related complications of EAPA, providing valuable insights to enhance surgical safety and patient care.