A Reliable Closure Technique for Retromastoid Craniotomy to Avoid Cerebrospinal Fluid Leaks and Meningitis.

Neurosurgery practice Pub Date : 2024-06-27 eCollection Date: 2024-09-01 DOI:10.1227/neuprac.0000000000000086
Garni Barkhoudarian, R Justin Garling, Regin Jay Mallari, Walavan Sivakumar, Daniel F Kelly
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Abstract

Background and objectives: Postoperative cerebrospinal fluid (CSF) leaks and meningitis are well-known risks of retromastoid craniotomy. Use of abdominal fat grafts, collagen allografts, and rigid or semirigid buttresses have demonstrated efficacy in preventing CSF leaks and meningitis in endoscopic endonasal surgery. This study aims to determine the utility of a similar multilayered reconstruction technique for retromastoid craniotomy.

Methods: We retrospectively reviewed 212 consecutive patients who underwent retromastoid craniotomy for tumor removal or microvascular decompression from 2007 to 2022. Scalp incisions were linear or slightly curved, muscle and facia opening was performed sharply avoiding monopolar cautery; craniotomies had a maximum dimension of 3 cm. A primary water-tight dural closure was rarely achieved favoring collagen sponge overlay often augmented with autologous fat. Clinical factors including pathology, mastoid air cell entry, and reconstruction material were analyzed. Outcomes including postoperative CSF leakage and meningitis were assessed.

Results: Of 212 patients (mean age 56 ± 16 years; 60% female; 10% with prior surgery), 148 (70%) had tumor resection and 64 (30%) had microvascular decompression. Mastoid air cells were breached in 67%. Collagen sponge dural overlay was used in 201/212 (95%). A fat graft was placed in 116 (55%) cases: 69% with air cell entry, 27% without air cell entry; 158 (75%) patients had their bone flap replaced, 46 (21%) had titanium mesh cranioplasty, 8 (4%) had no bone flap or titanium mesh. There were no CSF leaks or meningitis. One patient had a lumbar drain placement preoperatively, none postoperatively. Median length of stay was 2 days.

Conclusion: Retromastoid craniotomy multilayered reconstruction with liberal use of collagen sponge and abdominal fat grafts seems to reliably avoid postoperative CSF leaks and meningitis including in the setting of nonwatertight dural closure and mastoid cell entry. Use of shorter incisions, avoidance of monopolar cautery, and a relatively small craniotomy may contribute to the absence of CSF leaks in this series.

避免脑脊液外漏和脑膜炎的可靠的开颅手术闭合技术
背景和目的:乳突后开颅术后脑脊液(CSF)渗漏和脑膜炎是众所周知的风险。使用腹部脂肪移植、同种异体胶原移植和刚性或半刚性支撑在内窥镜鼻内手术中预防脑脊液泄漏和脑膜炎已被证明有效。本研究旨在确定类似的多层重建技术在乳突后开颅术中的应用。方法:我们回顾性分析了2007年至2022年连续212例接受乳突后开颅手术切除肿瘤或微血管减压的患者。头皮切口呈线状或微弯曲,肌肉和面膜切口锋利,避免单极烧灼;开颅手术的最大尺寸为3cm。初级水密硬脑膜封闭很少实现,胶原海绵覆盖通常增加自体脂肪。临床因素包括病理、乳突空气细胞进入、重建材料等。结果包括术后脑脊液漏和脑膜炎。结果:212例患者(平均年龄56±16岁;60%的女性;10%的患者既往手术),148例(70%)行肿瘤切除术,64例(30%)行微血管减压。67%的乳突空气细胞破裂。201/212(95%)采用胶原海绵硬膜覆盖。116例(55%)患者接受了脂肪移植,其中69%的患者进入了空气细胞,27%的患者没有进入空气细胞;158例(75%)行骨瓣置换,46例(21%)行钛网颅骨成形术,8例(4%)不行骨瓣或钛网成形术。没有脑脊液渗漏或脑膜炎。1例患者术前有腰椎引流管放置,术后无。中位住院时间为2天。结论:乳突后开颅多层重建与自由使用胶原海绵和腹部脂肪移植似乎可靠地避免了术后脑脊液泄漏和脑膜炎,包括在非水密硬脑膜封闭和乳突细胞进入的情况下。使用较短的切口,避免单极烧灼和相对较小的开颅可能有助于在本系列中没有脑脊液泄漏。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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