Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery: use of post-operative lumbar drain and sellar reconstruction without fat packing.

BACKGROUND: This study aims at describing primary reconstruction of sella turcica using lyophilized dura graft and fibrin glue without fat packing of the sphenoid sinus, together with postoperative lumbar drain in the management of intraoperative cerebrospinal fluid (CSF) leak.
METHOD: Records of 127 consecutive patients undergoing 129 transnasal transsphenoidal procedures were reviewed retrospectively with respect to intra- and post-operative CSF leak and lumbar drain use. One hundred and ten patients had adenomas (60 secreting adenomas, 48 non-functioning), 10 Rathke's cleft cysts and 9 miscellaneous lesions.
FINDINGS: Intra-operative leak was detected in 43 (33.3%) of 129 procedures: 38 (34.5%) of 110 adenoma related procedures and 5 (26.3%) of 19 non-adenomas. Among adenomas, leak occurred in 35 (41.2%) of 85 patients with suprasellar extension (SSE) and in 3 (12%) of 25 without SSE (p = 0.007). Lumbar drain was used in 61 cases (47.3%): in 34 it was inserted immediately before and in 27 at the end of procedure. In 24 of 34 patients (70.6%) with pre-operative drain (all adenomas), saline infusion was used to mobilize SSE. Only 2 patients (1.6%) developed post-operative leak, requiring an endoscopic procedure with fascia and muscle obliteration of the sphenoid sinus.
CONCLUSIONS: Meticulous duroplasty and routine postoperative lumbar drain has shown satisfactory results in dealing with intra-operative CSF leaks. It compares favorably with other techniques and obviates the need for fat harvesting. In patients with SSE, where leak occurs more frequently, we recommend inserting the lumbar drain before the procedure. As an adjunctive benefit, this allows for the saline-infusion method to mobilize the SSE without producing the venous engorgement of the Valsalva maneuver.