Efficacy and safety of endoscopic compared with open surgical repair of cerebrospinal fluid fistulas: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE

Cerebrospinal fluid leaks or fistulas are a relatively common neurosurgical pathology. Classically, this condition has been managed through an open surgical approach, but endoscopic surgery has emerged as a less invasive alternative with several advantages. Despite this, no meta-analysis has yet directly compared the clinical outcomes of these two management strategies.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. The PubMed, Embase, LILACS and Web of Science databases were rigoursly searched. Post-operative repair success rate, risk of recurrence and the risk of presenting any operation-related compilation and the all-cause mortality rate were analyzed. Data were analyzed using a common-effects meta-analysis, and statistical heterogeneity was assessed. The study was registered with PROSPERO (CRD42024606877).

RESULTS

Seven studies comprising 360 patients (140 endoscopic, 220 open) were included. Although the point estimate suggested a higher success rate with endoscopic repair, the difference was not statistically significant OR 1.32 (95% CI 0.55-3.16, I2 = 4.4%). The complication rate was significantly lower in the endoscopic group OR 0.26 (95% CI 0.10-0.67, I2 = 38%) and a leave-one-out analysis excluding the study by Gassner et al. found OR 0.10 (95% CI 0.03-0.32, I2 = 0%). Recurrence of CSF fistulas showed a trend favoring endoscopic repair (OR 0.78, 95% CI 0.42-1.43, I2 = 0%). No mortality was reported.

CONCLUSIONS

Endoscopic CSF fistula repair demonstrates a superior safety profile and is non-inferior in terms of efficacy compared to open surgery. Given the limited number of high-quality studies, further research is needed and larger, well-designed studies are recommended to refine clinical decision-making and optimize patient care.