Are lumbar drains necessary in endoscopic trans-sellar surgery with an intraoperative high-flow leak? A systematic review and meta-analysis

Background: Cerebrospinal fluid (CSF) leaks are a serious complication of endoscopic trans-sphenoidal surgeries that can lead to meningitis, pneumocephalus and a risk to life. Neurosurgeons have used perioperative lumbar drains to facilitate the healing of the dura and prevent postoperative CSF leaks. However, the use of lumbar drains is controversial and has primarily been left to individual surgeon preference. Sellar and suprasellar lesions form most pathologies treated by skull base surgeons using the endoscopic trans-nasal approach. Through meta-analysis, we aim to determine whether lumbar drains effectively reduce the risk of postoperative CSF leak in the context of a high-flow intraoperative leak in trans-sellar and trans-tuberculum approaches.

Method: A systematic review using PRISMA guidelines was conducted. Databases used in literature searching include PubMed, Ovid (including Embase and Medline), Scopus and Cochrane Library. De-duplication, title and abstract screening were performed on the Rayyan platform. Studies were selected according to the inclusion and exclusion criteria. The random-effects model was used in statistical analysis.

Results: A total of 2623 non-duplicated articles were identified. After screening and full-text reviews, 21 studies were included. Lumbar drains did not significantly lower the rates of postoperative CSF leaks (p = 0.65; 95 % CI 1.24–0.78).

Conclusion: Lumbar drains are not proven to be beneficial for patients who undergo endoscopic endonasal trans-sellar surgery with a concurrent intraoperative high-flow leak. For trans-sellar pathologies, a meticulous repair is sufficient. As repair techniques continue to improve, the role of the lumbar drain is likely to be further diminished.