School of Medicine, Southeast University, Nanjing, China.
Department of Neurosurgery, Jinling Hospital, Nanjing, China.
Br J Neurosurg. 2022 Aug;36(4):436-446. doi: 10.1080/02688697.2020.1849548. Epub 2021 Jan 21.
Endoscopic endonasal surgery (EES) is one of the preferred options for skull base pathologies. Cerebrospinal fluid (CSF) leak is a significant complication of EES and neurosurgeons have proposed various reconstructive strategies to decrease this morbidity. We describe and compare the efficacy of these strategies.
We searched PubMed, Cochrane Library, and Web of Science for publications between 1990 and November 2019. We defined a reconstruction hierarchy of seven levels from inside to outside: fat graft, intracranial intradural layer (inlay), intracranial extradural layer (onlay), buttress, mucosal flap, nasal packing and lumbar drainage. A single-arm analysis was performed for the primary outcome of CSF leak rate.
Of 3641 records identified, 48 studies met the inclusion criteria. Pituitary tumors had lower postoperative CSF leak rate than other diseases (1.8% vs. 6.5%, RD = -4.7% [-7.1%, -2.1%]). In high CSF flow group, the post-operative leak rate was reduced by application of mucosal flap (4.3% vs. without mucosal flap at 12.8%, RD = -8.5% [-15.1%, -1.9%]). The use of inlay showed potential of decreasing the post-operative leak rate (5.0% vs. 7.2%, RD = -2.2% [-7.7%, 3.3%]). In low CSF flow group, tampon was better than balloon for nasal packing (1.0% vs. 10.5%, RD = -9.5% [-16.5%, -2.4%]).
Mucosal flap and inlay for high-flow intraoperative CSF leak and tampon (compared with balloon) for low-flow intraoperative CSF leak, improved the postoperative CSF leak rate. Further studies are required to establish more robust evidence.
内镜经鼻颅底手术（EES）是颅底病变的首选治疗方法之一。脑脊液（CSF）漏是 EES 的一个严重并发症，神经外科医生提出了各种重建策略来降低这种发病率。我们描述并比较了这些策略的效果。
我们在 1990 年至 2019 年 11 月期间在 PubMed、Cochrane 图书馆和 Web of Science 上搜索了出版物。我们定义了一个从内到外的重建层次结构，共七个级别：脂肪移植、颅内硬脑膜内（衬里）、颅内硬脑膜外（覆盖）、支撑物、黏膜瓣、鼻腔填塞和腰椎引流。对术后 CSF 漏率这一主要结局进行了单臂分析。
在 3641 条记录中，有 48 项研究符合纳入标准。与其他疾病相比，垂体瘤患者术后 CSF 漏率较低（1.8% vs. 6.5%，RD=-4.7%[-7.1%，-2.1%]）。在高 CSF 流量组中，应用黏膜瓣可降低术后漏率（4.3% vs. 无黏膜瓣时的 12.8%，RD=-8.5%[-15.1%，-1.9%]）。使用衬里有降低术后漏率的潜力（5.0% vs. 7.2%，RD=-2.2%[-7.7%，3.3%]）。在低 CSF 流量组中，与球囊相比，填塞物用于鼻腔填塞效果更好（1.0% vs. 10.5%，RD=-9.5%[-16.5%，-2.4%]）。
对于高流量术中 CSF 漏，应用黏膜瓣和衬里，对于低流量术中 CSF 漏，应用填塞物（与球囊相比），可改善术后 CSF 漏率。需要进一步的研究来建立更可靠的证据。
