Bhagavatula Sweta, Chan Justin, Gomez David, Shah Ishan, Cote David J, Briggs Robert G, Lopez Joshua, Pangal Dhiraj J, Bove Ilaria, Wrobel Bozena B, Ference Elisabeth H, Ruzevick Jacob, Carmichael John D, Peterson Racheal, Zada Gabriel
Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
Oper Neurosurg. 2025 Aug 8. doi: 10.1227/ons.0000000000001739.
Cerebrospinal fluid (CSF) leaks are common after endoscopic endonasal approach (EEA). Opioid-induced emesis in the acute postoperative period may play a role in causing these leaks. The purpose of this study was to understand the associations between opioid use, postoperative emesis, and CSF leak occurrence after EEA.
A retrospective review of relevant clinical variables among patients who underwent EEA for tumor resection.
In total, 285 patients underwent EEA for tumor resection. Intraoperative CSF leak was significantly associated with a higher incidence of postoperative emesis (51.5% vs 30.6%, P = .002). Sixteen patients (5.6%) developed postoperative CSF leaks (9 in extended EEA cases and 7 in direct EEA cases), which was associated with significantly greater incidence of postoperative emesis (56.3% vs 21.1%, P = .003), greater opioid use per day (24.3 mg vs 15.1 mg, P = .022), and longer mean hospital stay (7.4 days vs 3.2 days, P < .001). Opioid consumption and length of stay were also significantly higher in patients who experienced an intraoperative CSF leak (P = .020) and postoperative emesis (P < .001). In patients with an intraoperative CSF leak, postoperative emesis was associated with a higher postoperative CSF leak rate, but this did not reach statistical significance (20.6% vs 10.4%, P = .139). After initiating an opioid-sparing analgesia protocol (P < .001), incidence of emesis was significantly lower; however, this did not translate to reduced postoperative CSF leak rates (P = .92).
Intraoperative CSF leaks serve as an exacerbating factor for postoperative emesis, both of which are associated with increased opioid use and patient length of stay. After implementing an opioid-sparing protocol, emesis rates were lower; however, this did not translate to reduced postoperative CSF rhinorrhea. Future research is necessary to better characterize the causal relationship between these perioperative complications, including the role of opioid minimization to prevent postoperative CSF leaks.
内镜鼻内入路（EEA）术后脑脊液（CSF）漏很常见。术后急性期阿片类药物引起的呕吐可能在导致这些漏液中起作用。本研究的目的是了解EEA术后阿片类药物使用、术后呕吐与CSF漏发生之间的关联。
回顾性分析接受EEA进行肿瘤切除患者的相关临床变量。
共有285例患者接受EEA进行肿瘤切除。术中CSF漏与术后呕吐发生率较高显著相关（51.5%对30.6%，P = 0.002）。16例患者（5.6%）发生术后CSF漏（扩大EEA病例9例，直接EEA病例7例），这与术后呕吐发生率显著更高（56.3%对21.1%，P = 0.003）、每日阿片类药物使用量更大（24.3毫克对15.1毫克，P = 0.022）以及平均住院时间更长（7.4天对3.2天，P < 0.001）相关。术中发生CSF漏的患者以及术后呕吐的患者，阿片类药物消耗量和住院时间也显著更高（P = 0.020和P < 0.001）。在术中发生CSF漏的患者中，术后呕吐与术后CSF漏率较高相关，但未达到统计学意义（20.6%对10.4%，P = 0.139）。启动阿片类药物节约镇痛方案后（P < 0.001），呕吐发生率显著降低；然而，这并未转化为术后CSF漏率降低（P = 0.92）。
术中CSF漏是术后呕吐的加重因素，两者均与阿片类药物使用增加和患者住院时间延长相关。实施阿片类药物节约方案后，呕吐率较低；然而，这并未转化为术后脑脊液鼻漏减少。未来有必要进行研究，以更好地描述这些围手术期并发症之间的因果关系，包括将阿片类药物用量减至最低对预防术后CSF漏的作用。
