{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,6]],"date-time":"2026-11-06T18:17:53Z","timestamp":1793989073578,"version":"4.8.0"},"reference-count":35,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2019,3]]},"abstract":"\n OBJECTIVE<\/jats:title>\n The authors previously described a graded approach to skull base repair following endonasal microscopic or endoscope-assisted tumor surgery. In this paper they review their experience with skull base reconstruction in the endoscopic era.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n A retrospective review of a single-institution endonasal endoscopic patient database (April 2010\u2013April 2017) was undertaken. Intraoperative CSF leaks were graded based on size (grade 0 [no leak], 1, 2, or 3), and repair technique was documented across grades. The series was divided into 2 epochs based on implementation of a strict perioperative antibiotic protocol and more liberal use of permanent and\/or temporary buttresses; repair failure rates and postoperative meningitis rates were assessed for the 2 epochs and compared.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n In total, 551 operations were performed in 509 patients for parasellar pathology, including pituitary adenoma (66%), Rathke\u2019s cleft cyst (7%), meningioma (6%), craniopharyngioma (4%), and other (17%). Extended approaches were used in 41% of cases. There were 9 postoperative CSF leaks (1.6%) and 6 cases of meningitis (1.1%). Postoperative leak rates for all 551 operations by grade 0, 1, 2, and 3 were 0%, 1.9%, 3.1%, and 4.8%, respectively. Fat grafts were used in 33%, 84%, 97%, and 100% of grade 0, 1, 2, and 3 leaks, respectively. Pedicled mucosal flaps (78 total) were used in 2.6% of grade 0\u20132 leaks (combined) and 79.5% of grade 3 leaks (60 nasoseptal and 6 middle turbinate flaps). Nasoseptal flap usage was highest for craniopharyngioma operations (80%) and lowest for pituitary adenoma operations (2%). Two (3%) nasoseptal flaps failed. Contributing factors for the 9 repair failures were BMI \u2265 30 (7\/9), lack of buttress (4\/9), grade 3 leak (4\/9), and postoperative vomiting (4\/9). Comparison of the epochs showed that grade 1\u20133 repair failures decreased from 6\/143 (4.1%) to 3\/141 (2.1%) and grade 1\u20133 meningitis rates decreased from 5 (3.5%) to 1 (0.7%) (p = 0.08). Prophylactic lumbar CSF drainage was used in only 4 cases (< 1%), was associated with a higher meningitis rate in grades 1\u20133 (25% vs 2%), and was discontinued in 2012. Comparison of the 2 epochs showed increase buttress use in the second, with use of a permanent buttress in grade 1 and 3 leaks increasing from 13% to 55% and 32% to 76%, respectively (p < 0.001), and use of autologous septal\/keel bone as a permanent buttress in grade 1, 2, and 3 leaks increasing from 15% to 51% (p < 0.001).<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n A graded approach to skull base repair after endonasal surgery remains valid in the endoscopic era. However, the technique has evolved significantly, with further reduction of postoperative CSF leak rates. These data suggest that buttresses are beneficial for repair of most grade 1 and 2 leaks and all grade 3 leaks. Similarly, pedicled flaps appear advantageous for grade 3 leaks, while CSF diversion may be unnecessary and a risk factor for meningitis. High BMI should prompt an aggressive multilayered repair strategy. Achieving repair failure and meningitis rates lower than 1% is a reasonable goal in endoscopic skull base tumor surgery.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2017.11.jns172141","type":"journal-article","created":{"date-parts":[[2018,5,11]],"date-time":"2018-05-11T09:59:16Z","timestamp":1526032756000},"page":"861-875","source":"Crossref","is-referenced-by-count":184,"title":["Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients"],"prefix":"10.3171","volume":"130","author":[{"given":"Andrew","family":"Conger","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fan","family":"Zhao","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fudan University, Shanghai, China;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaowen","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fudan University, Shanghai, China;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amalia","family":"Eisenberg","sequence":"additional","affiliation":[{"name":"Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John\u2019s Health Center, Santa Monica, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chester","family":"Griffiths","sequence":"additional","affiliation":[{"name":"Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John\u2019s Health Center, Santa Monica, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Felice","family":"Esposito","sequence":"additional","affiliation":[{"name":"Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, Division of NeuroSurgery, Universit\u00e0 degli Studi di Messina, Messina, Italy; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ricardo L.","family":"Carrau","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology\u2013Head & Neck Surgery, The Ohio State University Medical Center, Columbus, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Garni","family":"Barkhoudarian","sequence":"additional","affiliation":[{"name":"Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John\u2019s Health Center, Santa Monica, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel F.","family":"Kelly","sequence":"additional","affiliation":[{"name":"Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John\u2019s Health Center, Santa Monica, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"Otolaryngol Head Neck Surg","doi-asserted-by":"publisher","first-page":"52","DOI":"10.1177\/0194599816670370","article-title":"Efficacy of perioperative lumbar drainage following endonasal endoscopic cerebrospinal fluid leak repair","volume":"156","author":"Ahmed OH","year":"2017","unstructured":"Ahmed OH, Marcus S, Tauber JR, Wang B, Fang Y, Lebowitz RA: Efficacy of perioperative lumbar drainage following endonasal endoscopic cerebrospinal fluid leak repair. 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