Lee Shin Heon, Ha Chang-Min, Hong Sang Duk, Choi Jung Won, Seol Ho Jun, Nam Do-Hyun, Lee Jung-Il, Kong Doo-Sik
Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea.
Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
Front Oncol. 2022 May 4;12:906162. doi: 10.3389/fonc.2022.906162. eCollection 2022.
Despite recent advances in skull base reconstructive techniques, including the multilayer technique during the last decade, complete reconstruction of grade 3 intraoperative high-flow cerebrospinal fluid (CSF) leak remains challenging. This study was designed to investigate the role of injectable hydroxyapatite (HXA) used in the multilayer technique on the clinical outcome of skull base reconstruction for intraoperative high-flow CSF leak.
This study enrolled 187 patients who experienced intraoperative high-flow CSF leak after endoscopic endonasal surgery for anterior skull base or suprasellar pathologies between January 2014 and July 2021. All skull base defects were reconstructed using the conventional multilayer technique including a vascularized naso-septal flap (NSF, n = 141) and the combined use of HXA with the conventional multilayer technique (HXA group, n = 46). We retrospectively evaluated the efficacy of the HXA group by 1:2 propensity score matching analysis.
Overall, 17 of 187 patients (9.1%) showed postoperative CSF leaks, resulting in second reconstruction surgery. There were no statistical differences in patient age, sex, body mass index, tumor location, tumor type, and degree of resection, except for the follow-up period between the two groups. The HXA group showed a significantly lower incidence of postoperative CSF leak than the control group (0% vs. 12.1%, p < 0.05). Postoperative lumbar drain (LD) was performed in 8.7% of the HXA group compared to 46.1% of the control group (p < 0.01). CSF leak-related infection rates showed a decreasing tendency in the HXA group compared to the control group (0 vs. 7.1%, p = 0.06). A total of 46 patients in the HXA group were well matched with the control group (92 patients) at a 1:2 ratio. In the propensity score-matched control group, there were higher rates of postoperative CSF leaks than in the HXA group.
The use of HXA combined with the conventional multilayer technique completely reduced postoperative CSF leaks in this study. This technique resulted in reduced CSF leakage, even without postoperative LD, and decreased infection rates. Further randomized comparative studies are required to confirm our findings.
尽管近年来颅底重建技术取得了进展，包括过去十年中的多层技术，但术中3级高流量脑脊液（CSF）漏的完全重建仍然具有挑战性。本研究旨在探讨多层技术中使用的可注射羟基磷灰石（HXA）对术中高流量CSF漏颅底重建临床结果的作用。
本研究纳入了2014年1月至2021年7月期间因前颅底或鞍上病变接受鼻内镜手术后出现术中高流量CSF漏的187例患者。所有颅底缺损均采用传统多层技术重建，包括带血管蒂鼻中隔瓣（NSF，n = 141）以及HXA与传统多层技术联合使用（HXA组，n = 46）。我们通过1:2倾向评分匹配分析对HXA组的疗效进行了回顾性评估。
总体而言，187例患者中有17例（9.1%）出现术后CSF漏，需要进行二次重建手术。除两组的随访时间外，患者年龄、性别、体重指数、肿瘤位置、肿瘤类型和切除程度方面无统计学差异。HXA组术后CSF漏的发生率显著低于对照组（0%对12.1%，p < 0.05）。HXA组8.7%的患者术后进行了腰大池引流（LD），而对照组为46.1%（p < 0.01）。与对照组相比，HXA组CSF漏相关感染率呈下降趋势（0对7.1%，p = 0.06）。HXA组的46例患者与对照组（92例患者）以1:2的比例进行了良好匹配。在倾向评分匹配的对照组中，术后CSF漏的发生率高于HXA组。
在本研究中，HXA与传统多层技术联合使用完全降低了术后CSF漏。该技术即使在无术后LD的情况下也能减少CSF漏，并降低感染率。需要进一步的随机对照研究来证实我们的发现。
