Options To Manage Low-flow Cerebrospinal Fluid Leak After Neuroendoscopic Endonasal Transsphenoidal Surgery For Pituitary Adenoma—is Continuous Lumbar Drainage Indispensable?

Background:Neuroendoscopic endonasal transsphenoidal approach for pituitary adenoma has been widely applied around the world. Postoperative cerebrospinal fluid leak is a relatively common complication after the surgical procedure. Some investigators incline to apply continuous lumbar drainage in the management of the complication. However, other investigators assert that the effect of continuous lumbar drainage is limited. In addition, continuous lumbar drainage is an invasive procedure with the risk of its own complications. Thus, other investigators object to routine application of continuous lumbar drainage.In the management of postoperative cerebrospinal fluid leaks after the surgical procedure, whether continuous lumbar drainage is necessary or not is still under debate.Methods:To evaluate the effectiveness of continuous lumbar drainage in the management of postoperative cerebrospinal fluid leaks after neuroendoscopic endonasal transsphenoidal approach for pituitary adenoma, we reviewed 473 medical records of patients that admitted to Qilu hospital over the past 3 years (2011.07-2014.06). Among which 42 encountered cerebrospinal fluid leaks after surgery, and they all had low-flow cerebrospinal fluid leaks. Based on whether continuous lumbar drainage was applied, all patients with low-flow cerebrospinal fluid leaks were divided into two groups, lumbar drained group and conservatively managed group. The information reviewed included the age, sex, treatment of cerebrospinal fluid leaks, and related complications. Statistical analyses between the 2 groups were calculated using SPSS 17.0. The differences were deemed statistically significant if the P< 0.05.Results:Postoperative cerebrospinal fluid leaks occurred in 42 of 473 (8.9%) patients, which were all low-flow cerebrospinal fluid leaks. Cure rate of cerebrospinal fluid leaks was 91.3% (21/23) in lumbar drained group and 94.7%(18/19) in conservatively managed group.13.0% (3/23) patients developed intracranial infections in lumbar drained group, while 5.3% (1/19) patient in conservatively managed group. Owning to persistent cerebrospinal fluid leak, there was two patients in lumbar drained group and one patient in conservatively managed group required neuroendoscopic repair of skull base in each of the group (the rate was 8.7%,5.3% respectively). No significant difference was discovered in each rate in both groups.Conclusion:To place continuous lumbar drainage did not significantly affect cure rates of postoperative cerebrospinal fluid leaks after neuroendoscopic endonasal transsphenoidal approach for pituitary adenoma. However, the incidence of intracranial infections was relatively higher, which might be significant if the sample size wasn’t limited. The incidence of postoperative cerebrospinal fluid leaks was relatively low. Once happened, postoperative cerebrospinal fluid leaks could usually be treated successfully by conservative management. Thus, the protocol of reconstruction of skull base adopted is reliable. To sum up, in the management of low-flow postoperative cerebrospinal fluid leaks after neuroendoscopic endonasal transsphenoidal approach for pituitary adenoma, the placement of continuous lumbar drainage may be dispensable.