- Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA
- Department of Otorhinolaryngology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA
Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA
DOI:10.4103/2152-7806.151259Copyright: © 2015 Reinard K. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Reinard K, Basheer A, Jones L, Standring R, Lee I, Rock J. Surgical technique for repair of complex anterior skull base defects. Surg Neurol Int 11-Feb-2015;6:20
How to cite this URL: Reinard K, Basheer A, Jones L, Standring R, Lee I, Rock J. Surgical technique for repair of complex anterior skull base defects. Surg Neurol Int 11-Feb-2015;6:20. Available from: http://sni.wpengine.com/surgicalint_articles/surgical-technique-for-repair-of-complex-anterior-skull-base-defects/
Background:Modern microsurgical techniques enable en bloc resection of complex skull base tumors. Anterior cranial base surgery, particularly, has been associated with a high rate of postoperative cerebrospinal fluid (CSF) leak, meningitis, intracranial abscess, and pneumocephalus. We introduce simple modifications to already existing surgical strategies designed to minimize the incidence of postoperative CSF leak and associated morbidity and mortality.
Methods:Medical records from 1995 to 2013 were reviewed in accordance with the Institutional Review Board. We identified 21 patients who underwent operations for repair of large anterior skull base defects following removal of sinonasal or intracranial pathology using standard craniofacial procedures. Patient charts were screened for CSF leak, meningitis, or intracranial abscess formation.
Results:A total of 15 male and 6 female patients with an age range of 26–89 years were included. All patients were managed with the same operative technique for reconstruction of the frontal dura and skull base defect. Spinal drainage was used intraoperatively in all cases but the lumbar drain was removed at the end of each case in all patients. Only one patient required re-operation for repair of persistent CSF leak. None of the patients developed meningitis or intracranial abscess. There were no perioperative mortalities. Median follow-up was 10 months.
Conclusion:The layered reconstruction of large anterior cranial fossa defects resulted in postoperative CSF leak in only 5% of the patients and represents a simple and effective closure option for skull base surgeons.
Keywords: Cerebrospinal fluid leak, reconstruction, skull base defect
Advances in diagnostic tools and microsurgical techniques have enabled multidisciplinary teams of otolaryngologists and neurosurgeons to treat complex skull base lesions [
A standard bicoronal incision is made with great attention to preserving the pericranial layer. The scalp flap is then reflected and dissected in the subgaleal plane to the level of the supraorbital rims. The pericranium is incised at the level of the incision and bluntly dissected forward while avoiding electrocautery to preserve the blood supply from the supratrochlear and supraorbital arteries. The harvested pericranium is then wrapped in a moist sponge to prevent desiccation and over-manipulation during this several hours long procedure. After tumor resection and basal-frontal osteotomies by both the neurosurgical and otolaryngology teams, a primary closure of the resected dura is performed by taking a generous piece of tensor facia lata, covering the dural defect, and leaving a 3-cm extension of graft material to overlap the posterior aspect of the frontal fossa. The tensor fascia is sutured to the dural defect in an “in-out-in” fashion beginning at the inferior midline and continuing bilaterally around the defect. The novelty of this approach centers on leaving a small cuff of dura anterior to the optic chiasm during tumor resection. Preserving this small cuff of dura allows the surgeon to suture the graft securely to a stationary piece of tissue on the floor of the anterior fossa, thereby ensuring a successful closure [Figures
After satisfactory watertight closure is achieved, a piece of cadaveric bone or titanium mesh is fastened with screws to the medial orbital bone, thereby providing a scaffold for separation of the intracranial and nasal compartments [
In accordance with the Institutional Review Board at our hospital, we identified 21 patients who underwent craniotomies for resection of disparate primary pathologies followed by reconstruction of their large anterior skull base and dural defects using the senior author's proposed technique. This was the only surgical reconstruction technique utilized at our institution by the senior author, regardless of the pathology or extent of dural and cranial defects. The rate of postoperative CSF leak, meningitis, or intracranial abscess formation was calculated by screening patient charts for complications.
Of the 21 patients included in this study, 71% were male and 29% female with an age range of 26–89 years. The pathologic diagnosis varied from benign meningioma to pleomorphic rhabdomyosarcoma and included a patient with ballistic trauma to the anterior cranial vault. Only one female patient with a meningocele suffered a postoperative CSF leak early in our experience with this closure technique and required a second, endoscopic transnasal operation for definitive repair [
Hugh Cairns, a British neurosurgeon, was the first to introduce a classification scheme for CSF rhinorrhea in 1937 and differentiated between spontaneous and postoperative CSF leak.[
Ketcham et al.'s initial series reported in 1963 popularized craniofacial resection approaches to neoplasms of the anterior skull base.[
In his series, Ketcham described using only a split-thickness skin graft placed on dura.[
Schafer et al. then described what probably is the most commonly utilized method of reconstructing the anterior skull base today, which involves the pericranial flap.[
The use of temporalis muscle flap has also been described in situations with superior orbital wall involvement. The muscle and its investing fascia are dissected down to their insertion point with preservation of the coronoid process to protect the blood supply. The muscle is then rotated to cover the defect. Additionally, free muscle flaps (such as the rectus abdomenins) are also used for reconstruction of extensive anterior skull base defects.
All these techniques can be combined and augmented with composite split-calvarial grafts and porcine dermis allografts, as well as numerous synthetic material such as titanium mesh and high-viscosity polymethylmethacrylate (PMMA). In some cases, the repaired dural defect is covered with a second layer of fascia applied against the entire surface of frontal fossa. Fibrin glue is used to provide additional protection against CSF leakage.[
Ever since the German otolaryngologist Malte Wigand pioneered the use of intraoperative endoscope for repair of spontaneous CSF rhinorrhea in 1981,[
Here we present our experience with a simple technique for watertight dural reconstruction following repair of large anterior cranial fossa defects. The rationale behind the need for a watertight dural closure is to effectively separate the intradural and extradural compartments to reduce the postoperative morbidity and mortality associated with persistent CSF leak. In our case series of 21 patients, after craniofacial approach for primary pathology resection and/or repair, all patients were left with extensive dural and bony defects. Early in our experience, we reconstructed large anterior cranial fossa dural defects with a smaller tensor fascia lata patch and an abdominal fat graft anterior to the dural repair, and reinforced the floor of the frontal fossa with vascularized pericranium without a scaffold to separate the intracranial and intranasal compartments. The limited flexibility of our tensor fascia lata graft prevented re-expansion of the frontal lobe into the frontal fossa and the continuity between the intranasal and intracranial potential spaces resulted in significant extradural pneumocranium and CSF leaks that necessitated a change in our technique [
We have no strict criteria for selecting cadaveric bone versus a titanium mesh for re-establishment of the anterior cranial fossa floor because our primary objective is to buttress the frontal dural repair. In cases where we could harvest a flat piece of cadaveric bone that would fit the anterior cranial fossa defect relatively snugly, we preferentially used cadaveric bone. Otherwise we used a titanium mesh and shaped it to appropriately fit the frontal fossa floor defect. We understand that the theoretical risk of biologic or cadaveric bone buttress failure may be higher in patients who will receive postoperative radiation, however, thus far in our experience we have not encountered any radiation-induced bone resorption or structural failures.
We think the advantage of our closure technique is that it utilizes multiple layers of tissue to repair the frontal fossa dura, while the underlying reconstructed anterior cranial base provides a solid scaffold and reestablishes separate intracranial and sinus compartments. Using generously sized fascia lata graft allows the brain to relax into its normal anatomical position while the natural weight of the frontal lobe may further fortify this layered closure. Defect size is not a limiting factor because large vascularized pericranium or fascia lata grafts can be easily harvested and sewn into position. More importantly, this technique does not require a significant learning curve and is easily mastered. A potential disadvantage of our technique is that it relies on the integrity of an extension of the posterior frontal dura, which could be compromised during lesion resection or trauma, leaving little to no intact dural cuff to sew the graft. However, with care, a small remnant of dura can almost always be left intact. Another potential disadvantage of this technique is in leaving a possibly tumor-infiltrated piece of dura, which may become a site of recurrence. This has not occurred in our series and if it were to occur, some form of radiation therapy would likely be required.
Reconstruction of complex anterior skull base defects remains a challenge for otolaryngologists and neurosurgeons despite numerous advances in diagnostic capabilities, endoscopic techniques, surgical approaches, and availability of various materials for grafting. Regardless of the reconstruction methods used, the primary goals of any reconstruction should focus on attaining a watertight seal, providing a durable barrier between the sinonasal tract and intracranial compartment, and providing structural integrity to prevent brain herniation into the surgical defect. While this case series of 21 patients is a relatively small cohort, we feel that the 95% success rate heralds a robust technique for reconstruction of large anterior skull base defects.
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