Skull base repair following resection of vestibular schwannoma: a systematic review (Part 1: The Retrosigmoid Approach)

Abstract

Objective: Despite advances in skull-base reconstruction techniques, CSF leaks remain a common complication following retrosigmoid (RS) vestibular schwannoma (VS) surgery. We aimed to review and classify the available strategies used to prevent CSF leaks following RS VS surgery. Methods: A systematic review, including studies of adults undergoing RS VS surgery since 2000, was conducted. Repair protocols were synthesised into a narrative summary, and a taxonomic classification of techniques and materials was produced. Additionally, the advantages, disadvantages, and associated CSF leak rates of different repair protocols were described. Results: All 42 studies were case series, of which 34 were retrospective, and eight were prospective. Repair strategies included heterogeneous combinations of autografts, xenografts, and synthetic materials. A repair taxonomy was produced considering seven distinct stages to CSF leak prevention, including intraoperative approaches to the dura, internal auditory canal (IAC), air cells, RS bony defect, extra-cranial soft tissue, post-operative dressings, and CSF diversion. Notably, there was significant heterogeneity among institutions, particularly in the dural and IAC stages. The median postoperative incidence of CSF leaks was 6.3% (IQR 1.3%-8.44%). Conclusions: The intra-operative strategies used to prevent CSF leaks during RS VS surgery vary significantly between and within institutions. As a result of this heterogeneity and inconsistent reporting of CSF leak predictive factors, a meaningful comparative analysis of repair protocols was not feasible. Instead, we propose the development of a prospective multi-centre service evaluation designed to accurately capture a comprehensive dataset of potential CSF risk factors, including all stages of the operative repair protocol.