Valentin Favier1, Louis Crampette1, Laurent Gergelé2, Generoso De Cristofaro3, Emmanuel Jouanneau4, Romain Manet5. 1. Department of ENT-Head and Neck Surgery, Gui de Chauliac Hospital, University Hospital of Montpellier, Montpellier, France. 2. Intensive Care, Ramsay Générale de Santé, Hôpital Privé de la Loire, Saint Etienne, France. 3. Department of Mental and Physical Health and Preventive Medicine, ENT Unit of University of Campania "Luigi Vanvitelli"-University Hospital "Luigi Vanvitelli", Naples, Italy. 4. Skull Base Unit, Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, University Hospital of Lyon, Lyon, France. 5. Skull Base Unit, Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, University Hospital of Lyon, Lyon, France. romain.manet@neurochirurgie.fr.
Abstract
INTRODUCTION: Managing skull base cerebrospinal fluid (CSF) leaks is often challenging. Postoperative care, especially regarding postural restrictions and bedrest recommendations, is variable and continues to be based on empirical habits. METHODS: An electronic survey was submitted to French experts in skull base surgery to evaluate current practice of postoperative postural recommendations in patients treated for skull base CSF leaks. RESULTS: Thirty-nine experts completed the survey. Postoperative recommendations were heterogenous. They depended on the size of defects: half of the surgeons did not recommend any constraints of posture for small defects; 84% recommended bed rest for large defects. The most preferred bed-rest modality was Fowler's position (20°-30° tilt). Standing/walking during short periods was allowed in up to 73%. From a physiological viewpoint, head elevation decreases ICP and thus limits the risk of recurrence of CSF leak. However, ICP can fall below 0 in the standing position, favouring pneumocephalus. DISCUSSION: These results confirmed that postural recommendations for patients surgically treated for skull base CSF leaks remain variable. Recommendations should take into consideration the postural change in ICP. Fowler's position may represent the best compromise between risk of recurrence of CSF leak and the risk of pneumocephalus in large CSF leaks.
INTRODUCTION: Managing skull base cerebrospinal fluid (CSF) leaks is often challenging. Postoperative care, especially regarding postural restrictions and bedrest recommendations, is variable and continues to be based on empirical habits. METHODS: An electronic survey was submitted to French experts in skull base surgery to evaluate current practice of postoperative postural recommendations in patients treated for skull base CSF leaks. RESULTS: Thirty-nine experts completed the survey. Postoperative recommendations were heterogenous. They depended on the size of defects: half of the surgeons did not recommend any constraints of posture for small defects; 84% recommended bed rest for large defects. The most preferred bed-rest modality was Fowler's position (20°-30° tilt). Standing/walking during short periods was allowed in up to 73%. From a physiological viewpoint, head elevation decreases ICP and thus limits the risk of recurrence of CSF leak. However, ICP can fall below 0 in the standing position, favouring pneumocephalus. DISCUSSION: These results confirmed that postural recommendations for patients surgically treated for skull base CSF leaks remain variable. Recommendations should take into consideration the postural change in ICP. Fowler's position may represent the best compromise between risk of recurrence of CSF leak and the risk of pneumocephalus in large CSF leaks.
Entities:
Keywords:
CSF leak; Intracranial pressure; Posture; Skull base surgery