Comparison of the lumbar drain and the hydroxyapatite methods for cerebrospinal fluid leakage after endoscopic skull base surgery

Abstract This study aimed to compare the clinical outcomes and risk of two skull base reconstruction methods after expanded endoscopic skull base approach (EEA), viz. postoperative cerebrospinal fluid (CSF) lumbar drainage (L-method) and injectable hydroxyapatite cement without lumbar drainage (H-method). We enrolled 211 consecutive patients with grade 2 or 3 CSF leakage after EEA. The most common preoperative diagnoses were pituitary adenoma (n=62, 29%), meningioma (n=50, 24%), and craniopharyngioma (n=28, 13%). Vascularized nasoseptal flaps were used in most cases (98%). We used the L-method and H-method in 83 (39%) and 103 patients (49%), respectively. The overall reconstruction-related complication and CSF leakage rates were 8% (18/211) and 6% (12/211), respectively. The complications included CSF leakage (n=12), infection (n=4), postoperative compression (n=2), and brain herniation (n=1). The complication and CSF leakage rates did not differ significantly between the L-method (12% and 10%, respectively) and H-method (8% and 4%, respectively) (P=0.326 and 0.112, respectively). All infections occurred in the H-method (P=0.070). Postoperative hospital stay was significantly shorter with the H-method (6.9 days) compared to the L-method (10.0 days) (p<0.001). Skull base reconstruction using hydroxyapatite effectively prevented CSF leakage and ensured patient comfort and shorter hospitalization without postoperative lumbar drainage, although postoperative infection requires consideration.