A Stratified Algorithm for Skull Base Reconstruction With Endoscopic Endonasal Approach

The authors presented our institutional experience with skull base reconstruction techniques and developed a stratified algorithm for different causes of cerebrospinal fluid (CSF) leak. This is a retrospective review of patients who were diagnosed as CSF leak treated with skull base reconstruction or who underwent endoscopic transsphenoidal surgery for sellar and parasellar lesions at our department from August 2012 to April 2017. The authors totally identified 57 (59 operations in total) patients who were divided into 3 groups according to the causes of CSF leak and different reconstruction techniques. All patients underwent skull base reconstruction with specific focus on diagnosis, reconstruction techniques and strategies, and clinical outcome. The reconstruction technique we adopted was the classical multiple-layer technique, as known as "sandwich" technique, with combination of fat tissue, septal bone, autologous fascia lata, artificial dura, and nasoseptal flap (NSF). The NSF was selectively harvested for large defects according to our protocol. The reconstruction failure rate is 4.4% (2 of 45) in patients underwent endoscopic surgery for sellar and parasellar lesions. Reconstruction for postoperative iatrogenic, traumatic, and spontaneous CSF leak achieved 100% success rate; 54.2% (32 of 59) operations were done with "sandwich" plus NSF. The overall failure rate of all reconstructions was 3.4% (2 of 59). A stratified approach with multiple-layer technique and NSF is reliable for skull base reconstruction.