Lumbar drain placement lowers postoperative CSF leak rate for patients undergoing endoscopic endonasal surgery

Winner of the Synthes Skull Base Award, Nathan T. Zwagerman, MD, presented his research, A Prospective, Randomized Control Trial for Lumbar Drain Placement after Endoscopic Endonasal Skull Base Surgery, during the 2016 American Association of Neurological Surgeons (AANS) Annual Scientific Meeting.

Cerebrospinal fluid (CSF) leaks remain a complication after endoscopic endonasal surgery. In this study, subjects were randomized to receive an immediate postoperative lumbar drain or not, with comparison of postoperative leak rates.

The study randomized patients to lumbar drainage or no drain following reconstruction. The inclusion criteria included: 1) extensive arachnoid dissection, 2) dissection into a ventricle or cistern and 3) dural defect greater than 1cm. Demographic data, tumor location, defect size and leak rates were collected. The study was approved by the Institutional Review Board.

The trial was stopped early (170 patients) due to a significant difference in CSF leak rate between the experimental (drain) and control (no drain) groups (p=<0.002). No significant differences were found in the demographic measures between the two groups with an average age of 51.2 years (19-86) and BMI of 31.1. The most significant variable for postoperative leak was not having a drain. A difference in leak rate was found based upon the tumor location (anterior, posterior, suprasellar); however, this difference was not significant when a drain was employed. Defect size was noted to be larger in the group with leaks compared to the control group. 36 patients had anterior pathology (olfactory groove or planum), and their leak rate was 10 percent with and 35 percent without a drain (p=0.04). 50 patients had posterior pathology (clival) with a leak rate of 13 percent with and 30 percent without a drain (p=0.025). Finally, 85 patients had suprasellar lesions and their leak rate was 4.7 percent with and 9.5 percent without a drain (p=0.68).

For patients undergoing endoscopic endonasal skull base surgery, lumbar drain placement lowers the rate of postoperative CSF leak. The impact seems to be greatest in patients with large anterior or posterior cranial base defects.