• Rick F Nelson, Joseph P Roche, Bruce J Gantz, and Marlan R Hansen.
• *Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana†Division of Otolaryngology, Department of Surgery, School of Medicine and Public Health, The Univeristy of Wisconsin-Madison, Madison, Wisconsin‡Department of Otolaryngology-Head and Neck Surgery§Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
• Otol. Neurotol. 2016 Dec 1; 37 (10): 1625-1629.

ObjectiveTo determine the efficacy and morbidity of repairing spontaneous cerebrospinal fluid (CSF) leaks with the middle cranial fossa (MCF) approach without the use of a lumbar drain (LD), as perioperative use of LD remains controversial.Study DesignRetrospective review from 2003 to 2015.SettingUniversity of Iowa Hospitals and Clinics and Indiana University Health Center.PatientsThose with a confirmed lateral skull base spontaneous CSF leaks and/or encephaloceles.InterventionMCF approach for repair of spontaneous CSF leak and/or encephalocele without the use of lumbar drain. Assessment of patient age, sex, body mass index (BMI), and medical comorbidities.Main Outcome MeasureSpontaneous CSF leak patient characteristics (age, sex, BMI, obstructive sleep apnea) were collected. Length of stay (LOS), hospital costs, postoperative complications, CSF leak rate, and need for LD were calculated.ResultsSixty-five operative MCF repairs were performed for spontaneous CSF leaks on 60 patients (five had bilateral CSF leaks). CSF diversion with LD was used in 15 of 60 patients, mostly before 2010. After 2010, only three of 44 patients (6.7%) had postoperative otorrhea requiring LD. The use of LD resulted in significantly longer LOS (3.6 ± 1.6 versus 8.7 ± 2.9 d) and hospital costs ($29,621). There were no postoperative complications in 77% (50 of 65) of cases. Three cases required return to the operating room for complications including frontal subdural hematoma (1), subdural CSF collection (1), and tension pneumocephalus (1). No patients experienced long-term neurologic sequelae or long-term CSF leak recurrence with an average length of follow-up of 19.5 months (range 3-137 mo). The average patient BMI was 37.5 ± 8.6 kg/m. The average age was 57.5 ± 11.4 years and 68% were female. Obstructive sleep apnea was present in 43.3% (26 of 60) of patients.ConclusionThe morbidity of the MCF craniotomy for repair of spontaneous CSF leaks is low and the long-term efficacy of repair is high. Universal use of perioperative lumbar drain is not indicated and significantly increases length of stay and hospital costs. Obesity and obstructive sleep apnea are highly associated with spontaneous CSF leaks.

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