2018 Section 5 - Rhinology and Allergic Disorders

Reprinted by permission of Otolaryngol Head Neck Surg. 2017; 156(1):52-60.

Systematic Review/Meta-analysis

Otolaryngology– Head and Neck Surgery 2017, Vol. 156(1) 52–60 American Academy of Otolaryngology—Head and Neck

Efficacy of Perioperative Lumbar Drainage following Endonasal Endoscopic Cerebrospinal Fluid Leak Repair: A Meta-analysis

Surgery Foundation 2016 Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599816670370 http://otojournal.org

Omar H. Ahmed, MD 1 , Sonya Marcus, MD 1 , Jenna R. Tauber 2 , Binhuan Wang, PhD 3 , Yixin Fang, PhD 4 , and Richard A. Lebowitz, MD 1

Keywords cerebrospinal fluid leak, cerebrospinal fluid rhinorrhea, lumbar drains, cerebrospinal fluid diversion, endoscopic skull base surgery Received June 6, 2016; revised August 16, 2016; accepted August 31, 2016. C erebrospinal fluid (CSF) rhinorrhea results from an abnormal communication between the subarachnoid and sinonasal spaces. Surgical repair of CSF leaks that do not respond to conservative management is indicated to seal a potentially infectious conduit. The risk of ascend- ing meningitis in the setting of anterior skull base defects has been reported to be 10% to 37%. 1,2 Since its introduc- tion in the early 1980s, endonasal endoscopic repair has emerged as the preferred modality of treatment for anterior skull base CSF leaks. 3 Numerous studies have corroborated the safety, efficacy, and low morbidity associated with the procedure, and success rates of primary repair have been reported to be . 90%. 2-5 Lumbar drains (LDs) are commonly used as an adjunct in the perioperative period to reduce intracranial pressure 1 Department of Otolaryngology–Head and Neck Surgery, New York University, New York, New York, USA 2 School of Medicine, New York University, New York, New York, USA 3 Department of Population Health, Division of Biostatistics, New York University, New York, New York, USA 4 Department of Mathematical Sciences, New Jersey Institute of Technology, Newark, New Jersey, USA This article was presented as an oral presentation for the American Rhinologic Society at the Combined Otolaryngology Spring Meetings; May 20, 2016; Chicago, Illinois. Corresponding Author: Omar H. Ahmed, MD, Department of Otolaryngology–Head and Neck Surgery, New York University, 550 First Ave, NBV 5E5, New York, NY 10016, USA. Email: Omar.Ahmed@nyumc.org

No sponsorships or competing interests have been disclosed for this article.

Abstract Objective. Perioperative lumbar drain (LD) use in the setting of endoscopic cerebrospinal fluid (CSF) leak repair is a well- established practice. However, recent data suggest that LDs may not provide significant benefit and may thus confer unnecessary risk. To examine this, we conducted a meta- analysis to investigate the effect of LDs on postoperative CSF leak recurrence following endoscopic repair of CSF rhinorrhea. Data Sources. A comprehensive search was performed with the following databases: Ovid MEDLINE (1947 to November 2015), EMBASE (1974 to November 2015), Cochrane Review, and PubMed (1990 to November 2015). Review Method. A meta-analysis was performed according to PRISMA guidelines. Results. A total of 1314 nonduplicate studies were identified in our search. Twelve articles comprising 508 cases met inclusion criteria. Overall, use of LDs was not associated with significantly lower postoperative CSF leak recurrence rates following endoscopic repair of CSF rhinorrhea (odds ratio: 0.89, 95% confidence interval: 0.40-1.95) as compared with cases performed without LDs. Subgroup analysis of only CSF leaks associated with anterior skull base resections (6 studies, 153 cases) also demonstrated that lumbar drai- nage did not significantly affect rates of successful repair (odds ratio: 2.67, 95% confidence interval: 0.64-11.10). Conclusions. There is insufficient evidence to support that adjunctive lumbar drainage significantly reduces postopera- tive CSF leak recurrence in patients undergoing endoscopic CSF leak repair. Subgroup analysis examining only those patients whose CSF leaks were associated with anterior skull base resections demonstrated similar results. More level 1 and 2 studies are needed to further investigate the efficacy of LDs, particularly in the setting of patients at high risk for CSF leak recurrence.

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