Lumbar Drains Decrease the Risk of Post-Operative Cerebrospinal Fluid (CSF) Leak Following Extended Endonasal Endoscopic Surgery for Suprasellar Meningiomas in Patients with High BMI

Object: Post-operative cerebrospinal fluid leak (CSF) is a persistent, albeit much less prominant, complication following extended endonasal endoscopic surgery. The pathology with highest risk is suprasellar meningiomas. Post-operative lumbar drainage (LD) is used to decrease the risk of CSF leak but is not universally accepted.

Methods: A consecutive series of newly diagnosed suprasellar meningiomas was drawn from a prospectively acquired database of endonasal surgeries at Weill Cornell Medical College-New York Presbyterian Hospital. An intra-operative, pre-resection LD was placed and left open at 5 cc/hr for ~48 hours. Closure was with a gasket seal and nasoseptal flap. In a subset of patients the lumbar drain could not be placed. Rates of post-operative CSF leak were compared between patients with and without LD.

Results: A total of twenty-five patients underwent extended endoscopic endonasal transsphenoidal surgical resection of supasellar meningiomas. LD could not be placed in two patients, There were two post-operative CSF leaks (8%), both of which occurred in the patients who did not have an LD (p = 0.0033). The average BMI of the patients in whom the LD could not be placed was 39.1 kg/m2, compared with 27.6 kg/m2 in whom LD could be placed (p = 0.009).. When placement was possible, LDs were left in place for a mean of 45 hours (SD, 37.7 hours). There were four (16%) patients with spinal headaches, all of which resolved with conservative management. Both post-operative CSF leaks stopped with post-operative LD placement.

Conclusion: The inability to place a lumbar drain in patients with high BMI is a risk factor for post-operative CSF leak. LD may be useful to prevent post-operative CSF leak, particularly in patients with elevated BMi.