Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 21362  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (595 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

  In this Article
 »  Abstract
 »  Materials and Me...
 » Results
 » Discussion
 » Conclusions
 »  References
 »  Article Tables

 Article Access Statistics
    PDF Downloaded93    
    Comments [Add]    
    Cited by others 8    

Recommend this journal


Table of Contents    
Year : 2018  |  Volume : 66  |  Issue : 1  |  Page : 133-138

A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas

1 Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Anesthesia, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
4 Department of Otolaryngology, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication11-Jan-2018

Correspondence Address:
Dr. Ari George Chacko
Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.222823

Rights and Permissions

 » Abstract 

Background: Intraoperative cerebrospinal fluid (CSF) leaks are a frequent cause of morbidity in patients undergoing transsphenoidal surgery. This prospective study was performed to examine the impact of intraoperative lumbar subarachnoid drainage (LSAD) on the incidence of this complication and on the extent of resection in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas.
Materials and Methods: This prospective study was conducted in a single large academic medical center. All patients with pituitary adenomas who had not undergone prior transsphenoidal surgery were eligible for inclusion in the study. Patients were randomly assigned to undergo transsphenoidal surgery with intraoperative lumbar drain insertion (LSAD group) or no lumbar drain insertion (no LSAD group). An otolaryngologist independently determined the occurrence of an intraoperative CSF leak. Extent of tumor resection was determined by volumetric analysis of postoperative magnetic resonance images in patients with nonfunctional tumors or functional adenomas with a large suprasellar component.
Results: Sixty patients were eligible for inclusion, of which 30 were assigned to the LSAD group and 30 to the no LSAD group. There were no statistically significant differences in patient demographics, tumor pathology, or radiology between the two groups. The LSAD catheter was successfully inserted in all patients in the LSAD group. Intraoperative CSF drainage significantly reduced the incidence of CSF leak from 46.7% in the no LSAD group to 3.3% in the LSAD group (P < 0.001). However, there were no statistically significant differences in the incidence of postoperative CSF rhinorrhea between the two groups. There were no major catheter-related complications. There was no statistically significant difference in the extent of resection between the two groups.
Conclusions: Controlled intraoperative CSF drainage significantly reduces the incidence of intraoperative CSF leakage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas.

Keywords: Cerebrospinal fluid leak, endoscopic transsphenoidal surgery, lumbar subarachnoid drain, pituitary adenoma
Key Message:
In a randomized trial, the efficacy of lumbar subarachnoid drainage in reducing the incidence of intraoperative CSF leaks following an endoscopic transsphenoidal approach to pituitary adenomas was evaluated. The extent of resection was determined by magnetic resonance volumetric analysis. The incidence of intraoperative CSF leakage reduced significantly utilizing a controlled intraoperative lumbar CSF drainage.

How to cite this article:
Jonathan GE, Sarkar S, Singh G, Mani S, Thomas R, Chacko AG. A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Neurol India 2018;66:133-8

How to cite this URL:
Jonathan GE, Sarkar S, Singh G, Mani S, Thomas R, Chacko AG. A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Neurol India [serial online] 2018 [cited 2022 Jan 17];66:133-8. Available from:

Pituitary adenomas are the most common brain tumors after gliomas and meningiomas,[1] and the transsphenoidal approach is preferred for these tumors because of the lower morbidity compared to transcranial surgery.[2] Intraoperative cerebrospinal fluid (CSF) leak due to arachnoid tears commonly complicates transsphenoidal surgery, requiring meticulous dural repair to prevent postoperative CSF rhinorrhea and meningitis. Postoperative CSF leaks occur due to failure to recognize an intraoperative CSF leak or a failure of the primary repair.[3] The incidence of intraoperative CSF leak ranges from 18% to 52% in most contemporary reports.[2],[4],[5],[6],[7],[8],[9],[10],[11],[12]

Mehta and Oldfield [13] reported a marked reduction in intraoperative CSF leaks in a retrospective cohort of 114 patients with pituitary macroadenomas and intraoperative lumbar drainage. However, there remain concerns regarding the safety of lumbar drain insertion, which is an invasive procedure with infrequent complications. In addition, the insertion of a drain into the subarachnoid space may be challenging, particularly in obese patients, thereby prolonging anesthesia and operating times. Thus, the current standard of care varies among pituitary surgeons, and there is no consensus on whether intraoperative lumbar drainage should be used routinely.[3] We sought to evaluate the efficacy of intraoperative lumbar drainage by performing a randomized controlled trial at our institution. Furthermore, we hypothesized that CSF drainage could prevent bulging of the arachnoid pouches into the operating field, thus enabling enhanced resection of the suprasellar component of the tumor.

 » Materials and Methods Top

Study design

The protocol for this randomized controlled study was evaluated and approved by the Institutional Review Board of our institution. The trial was registered with the Clinical Trial Registry of India (CTRI/2014/09/005021). An informed written consent was taken from all the patients participating in the study.

Inclusion and exclusion criteria

All patients with pituitary adenomas and planned for endoscopic transsphenoidal surgery were eligible for inclusion. Patients who had undergone previous transsphenoidal surgery or radiation therapy were excluded from the study. We also excluded patients undergoing extended transsphenoidal surgery in which case an intraoperative CSF leak was obligatory.

Randomization of patients

Patients were assigned to the LSAD or no LSAD group using permuted block randomization of sizes 2, 4, or 6 using SAS 9.1.3 software(version 9.1.3; SAS Institute, Inc., Cary, NC, USA). Allocation was concealed using serially numbered opaque sealed envelopes.

Patient profile

Between June 2013 and June 2014, 80 consecutive patients underwent endoscopic transsphenoidal surgery for pituitary adenomas at the Christian Medical College Vellore. All procedures were performed by the senior author (A.G.C.). Twenty cases were excluded from the study, leaving 60 patients eligible for recruitment in the study. All patients underwent a thorough neurological examination and preoperative endocrinological evaluation prior to surgery.

Radiological assessment was performed in all patients using a 3-Tesla magnetic resonance imaging (MRI) scanner. All patients underwent preoperative MRI of the brain with gadolinium contrast. All patients with nonfunctional pituitary macroadenomas and those with functional adenomas with a large suprasellar component underwent early nonenhanced postoperative MRI within 6 hours after surgery. Volumetric analysis was performed by an experienced neuroradiologist (S.M.). The volume of the tumor was calculated on contiguous post-gadolinium MRI sections by outlining the tumor on all slices that showed the tumor and the sum of the areas was calculated. This was multiplied by the slice thickness to calculate the tumor volume. Extent of resection was classified as radical, when there was no evidence of residual tumor on the postoperative imaging done after 3 months at follow-up; subtotal, when tumor residue was <10% of the preoperative tumor volume; and partial, when >10% of tumor was left behind. Tumors were classified as microadenomas or macroadenomas, and their size was denoted by the maximum anteroposterior, craniocaudal, or transverse dimension. Hardy's system graded suprasellar extension, and Knosp grades of 3 and 4 defined cavernous sinus (CS) invasion.

Surgical technique

In patients assigned to the LSAD group, the patient was positioned lateral after induction of anesthesia and a lumbar subarachnoid catheter was inserted under sterile conditions by the anesthetist. A 16-G epidural catheter with a 16-G Tuohy needle (16-G Portex Epidural Catheter Set; Smiths Medical ASD Inc., Keene, NH) was inserted at the L3-L4 interspace. After positioning the patient supine for the pituitary surgery, the lumbar subarachnoid catheter with a 100-cm extension, and a three-way cannula was connected to a burette set and left at ground level to drain. After draining an initial 30 ml of CSF, the drain was temporarily closed and re-opened when the surgeon began the sellar stage of the surgery. The ETCO2 was maintained constantly at 35 mmHg throughout the procedure. After performing a posterior septectomy and removing the vomer, we used the binostril technique to enter the sphenoid sinus through both sphenoid ostia. The sphenoid sinus septae along with the sellar floor were drilled using a high-speed drill up to the edge of the internal carotid arteries on both sides but stopped just short of the tuberculum sellae. The dura was opened as a flap based superiorly. CSF was drained if the arachnoid bulged into the field obscuring view of the tumor or if the surgeon felt that it was at a risk of tearing during the dissection.

Our strategy was to achieve intracapsular resection of the tumor while preserving pituitary function. In patients with CS invasion, aggressive tumor removal was attempted using 30 and 45-degree endoscopes. However, no attempt was made to go lateral to the intracavernous segment of the internal carotid artery. At the end of the tumor resection, the otolaryngologist independently determined if there was an intraoperative CSF leak. If doubtful, this was confirmed by injecting fluorescein dye through the lumbar subarachnoid drain in patients assigned to the LSAD group. In the no LSAD group, this was confirmed by a Valsalva maneuver.

If no CSF leak was noted at surgery, the drain was removed on the operating table immediately after extubation in the LSAD group. In the event of a CSF leak in the LSAD group, the sella was packed with fat and the drain was left in-situ for 5 days. For patients suffering CSF leaks in the no LSAD group, a lumbar drain was inserted within 6 hours of surgery after transfer to the postoperative intensive care unit.

Postoperative management

All patients underwent an endoscopic inspection by the otolaryngologist (R.T.) 1 week after surgery. All patients were advised a 3-month postoperative follow-up. Functional tumors were assessed with fasting and postsuppression human growth hormone (HGH) levels, insulin-like growth factor-1 (IGF-1) levels for growth hormone (GH) adenomas, and serum cortisol and adrenocorticotrophic hormone (ACTH)levels for the Cushing's disease. If there was biochemical evidence of residual disease based on current remission criteria, a gadolinium-enhanced MRI was done. All patients with nonfunctional tumors were followed with a contrast brain MRI.

Outcome measures

The primary outcome was the incidence of intraoperative CSF leak determined by endoscopic inspection at the end of the surgery. Secondary outcome measures included the occurrence of postoperative CSF leaks and extent of tumor resection using volumetric analysis on MRI.

Statistical analysis

Data is presented as mean ± standard deviation (SD) for continuous variables and as frequencies for categorical variables. Continuous and categorical variables were examined for statistically significant differences using the Student t-test and the Fisher's exact test respectively. A P value <0.05 was considered significant. was considered significant. Analysis was performed using the Statistical Package for the Social Sciences (SPSS version 22.0, CA).

 » Results Top

All 60 patients initially recruited completed the study protocol. Baseline demographics and preoperative variables are summarized in [Table 1]. With the exception of 1 patient with pediatric Cushing's disease who was 16 years old, all were adults and there was an equal distribution of males and females. The mean preoperative body mass index (BMI) was 27.9 ± 5.9 kg/m2. Most tumors were macroadenomas with significant suprasellar extension, and functional tumors were more common. There were no statistically significant differences in the patients' age, sex, BMI, tumor size, extrasellar extension, tumor consistency, or pathology when the LSAD group was compared with the no LSAD group, demonstrating adequate randomization.
Table 1. Comparison between the LSAD and no LSAD groups

Click here to view

Intraoperative CSF leak was seen in a quarter of cases overall, occurring in both microadenomas (n = 5) and macroadenomas (n = 10). There was no significant difference in the frequency of intraoperative CSF leaks in microadenomas when compared to macroadenomas (35.7% versus 21.7%; P = 0.309). The intraoperative CSF leak rate in the LSAD group was 3.3%, which was significantly lower when compared to the no LSAD group, where the leak rate was 46.7% (P< 0.001). There were no cases of postoperative CSF rhinorrhea in the LSAD group, whereas 3.3% of patients suffered this complication in the no LSAD group.

Thirty patients were eligible to undergo postoperative MRI. The overall extent of tumor resection in this subcohort was 94.73 ± 9.9%. Insertion of a drain did not impact resection rates (P = 0.541). There were no instances of catheter-related complications, including meningitis, retained catheter fragments, and epidural or subdural hematomas. However, two patients in the LSAD group complained of low-pressure headache, which was managed conservatively without an epidural blood patch.

 » Discussion Top

The goal of transsphenoidal surgery for pituitary adenomas is maximal resection of tumor to decompress the optic apparatus while preserving endocrine function. Postoperative outcomes after surgery for pituitary adenomas are intimately related to the extent of resection because it allows remission of hormone excess in functional tumors, while delaying recurrence in nonfunctional tumors.[14] Most pituitary surgeons use the endoscopic endonasal transsphenoidal approach effectively, with excellent outcomes and low perioperative morbidity.[2],[14],[15],[16],[17],[18] In an earlier study, using the microscopic transsphenoidal technique, we showed that the extent of resection depends on the configuration of the suprasellar component of the tumor. If a greater part of the tumor was not visible through the transsphenoidal trajectory, radical resection was less likely.[16]

To enable more complete tumor resection, various strategies have been described to elevate intracranial pressure to force the suprasellar portion of the tumor inferiorly into the sella. Nath et al.,[19] studied the effect of injecting saline and air through the lumbar subarachnoid catheter to increase the intracranial pressure, thereby aiding the descent of the suprasellar component into the sella. They noted improvements in the extent of tumor resection but report an intraoperative CSF leak rate of 25%. Korula et al.,[20] achieved similar results solely by increasing the end tidal carbon di oxide (ETCO2) to 50 mmHg. These methods of raising the intracranial pressure often resulted in bulging of the arachnoid pouch, which can obscure the surgeon's view of the tumor, leading to inadvertent arachnoid injury. The incidence of postoperative CSF leak in endoscopic and microscopic series of transsphenoidal surgery for pituitary adenomas described in literature varies from 0% to as high as 27%.[3],[4],[6],[15],[21],[22],[23],[24],[25],[26],[27]

A recent study [13] recommended the use of a lumbar subarachnoid catheter to drain CSF intraoperatively. They arrived at this conclusion from a retrospective analysis of 114 transsphenoidal operations for pituitary macroadenoma performed without intraoperative CSF drainage. They compared this with findings from 44 cases in which CSF was drained through a lumbar subarachnoid catheter. They noted a dramatic decrease in the intraoperative CSF leak rate from 41% to less than 5% in patients who underwent intraoperative lumbar subarachnoid catheter. They did not report any catheter-related complications in their series, but did not comment on the extent of tumor resection. They [13] postulated that lumbar CSF diversion reduces the turgor of the suprasellar arachnoid that is typically expanded in pituitary adenomas and makes it less susceptible to tearing during surgery. The results of our randomized trial confirm this finding, and strongly favor the routine use of intraoperative lumbar drainage in transsphenoidal surgery.

The incidence of intraoperative CSF leak in the no LSAD group was 46.7%, which is in the higher end of the ranges described in the literature. In our country, we commonly deal with large and invasive tumors; this combined with our aggressive surgical strategy may be responsible for the relatively high incidence of this complication. Nevertheless, extent of resection did not differ significantly between the two groups, confirming that the surgeon was not biased towards a more conservative resection in the LSAD group.

As with any invasive procedure, there are certain risks associated with lumbar drain placement, although most are minor and can be managed conservatively. The placement of lumbar drains in patients with normal pressure hydrocephalus is associated with a 1.7% risk of subdural hygroma and subdural hemorrhage and 0.8% risk of developing meningitis. Approximately 5% of patients experience minor complications such as low pressure headache, local site infection, and nerve root irritation.[28] Ransom et al.,[29] in their study on prospective placement of lumbar drain for different pathologies reported a complication rate of 12.3% in their series. They reported persistent peritubal CSF leak around the insertion site in 7.7% of their patients. Other complications included retained catheter fragments in 1.5%, significant overdrainage in 1.5%, and inadvertent disconnection in 1.5% patients. In our series, we had no catheter-related complications, similar to the results published by other authors.[13],[30],[31] Insertion of the catheter may be theoretically problematic in obese patients, where localization of the interspinous space may be difficult, especially if fluoroscopy is avoided. In such patients, we advocate catheter insertion following induction of general anesthesia, which allows administration of an intravenous muscle relaxant that may facilitate easier insertion of the lumbar drain. Despite the fact that most of our patients had elevated BMI values, we did not encounter any difficulties in inserting lumbar drains in overweight patients. This should, in particular, encourage the use of lumbar drainage in overweight patients, who may be at a higher risk for postoperative CSF rhinorrhea following endoscopic transsphenoidal surgery.[4]

Although we hypothesized that intraoperative CSF drainage reduces the bulging of arachnoid folds into the operative field, thereby facilitating tumor resection, there was no significant difference in the extent of tumor resection between the two groups. Having made a full transition to endoscopic transsphenoidal surgery more than a decade ago, we feel that our increased experience with this technique allowed us to displace the bulging folds of arachnoid using cottonoids to remove seemingly inaccessible tumor. This might have confounded the impact of a lumbar subarachnoid drain on the extent of resection. In addition, in the setting of elevated intracranial pressure, tumor is often forced down into the sella, which may also account for why there was no difference in the extent of resection between the two groups.

Strengths and limitations of this study

Despite its prospective design, our study is limited by its small sample size and by the fact that the surgeon was not blinded to the intervention. Nevertheless, this is the first randomized trial to evaluate the efficacy of lumbar subarachnoid drainage in reducing the incidence of intraoperative CSF leaks following an endoscopic transsphenoidal approach to pituitary adenomas. Moreover, extent of resection was determined in nonfunctional and large functional adenomas by volumetric analysis on MRI as opposed to surgeon's intraoperative impression, which is often inaccurate. As patients were recruited over a relatively short time frame, it is also unlikely that the surgeon experience would have impacted our results.

 » Conclusions Top

Controlled intraoperative drainage of CSF via an LSAD significantly reduces the incidence of CSF leaks during endoscopic transsphenoidal surgery for pituitary adenomas, thereby eliminating subsequent morbidity associated with this complication.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

The Institutional Research Board of the Christian Medical College, Vellore provided financial support in the form of funding the equipment used in this study (Grant No. 8638). The sponsor had no role in the design or conduct of this research.

Conflicts of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

 » References Top

Ezzat S, Asa SL, Couldwell WT, Barr CE, Dodge WE, Vance ML, et al. The prevalence of pituitary adenomas. Cancer 2004;101:613-9.  Back to cited text no. 1
Chacko A, Chandy M. Complications of transsphenoidal pituitary surgery. Neurol India 1997;45:224.  Back to cited text no. 2
Rabadán AT, Hernández D, Ruggeri CS. Pituitary tumors: Our experience in the prevention of postoperative cerebrospinal fluid leaks after transsphenoidal surgery. J Neurooncol 2009;93:127-31.  Back to cited text no. 3
Dlouhy BJ, Madhavan K, Clinger JD, Reddy A, Dawson JD, O'Brien EK, et al. Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery. J Neurosurg 2012;116:1311-7.  Back to cited text no. 4
Nishioka H, Haraoka J, Ikeda Y. Risk factors of cerebrospinal fluid rhinorrhea following transsphenoidal surgery. Acta Neurochir 2005;147:1163-6.  Back to cited text no. 5
Sarkar S, Rajaratnam S, Chacko G, Chacko AG. Endocrinological outcomes following endoscopic and microscopic transsphenoidal surgery in 113 patients with acromegaly. Clin Neurol Neurosurg 2014;126:190-5.  Back to cited text no. 6
Wang YY, Kearney T, Gnanalingham KK. Low-grade CSF leaks in endoscopic trans-sphenoidal pituitary surgery: Efficacy of a simple and fully synthetic repair with a hydrogel sealant. Acta Neurochir 2011;153:815-22.  Back to cited text no. 7
Patel KS, Komotar RJ, Szentirmai O, Moussazadeh N, Raper DM, Starke RM, et al. Case-specific protocol to reduce cerebrospinal fluid leakage after endonasal endoscopic surgery. J Neurosurg 2013;119:661-8.  Back to cited text no. 8
Prevedello DM, Pouratian N, Sherman J, Jane Jr JA, Vance ML, Lopes MB et al. Management of Cushing's disease: Outcome in patients with microadenoma detected on pituitary magnetic resonance imaging. J Neurosurg 2008;109:751-9.  Back to cited text no. 9
Rodziewicz GS, Kelley RT, Kellman RM, Smith MV. Transnasal endoscopic surgery of the pituitary gland. Neurosurgery 1996;39:189-93.  Back to cited text no. 10
Baskin DS, Boggan JE, Wilson CB. Transsphenoidal microsurgical removal of growth hormone-secreting pituitary adenomas: A review of 137 cases. J Neurosurg 1982;56:634-41.  Back to cited text no. 11
Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, et al. Endoscopic endonasal skull base surgery: Analysis of complications in the authors' initial 800 patients: A review. J Neurosurg 2011;114:1544-68.  Back to cited text no. 12
Mehta GU, Oldfield EH. Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg 2012;116:1299-303.  Back to cited text no. 13
Gondim JA, Schops M, de Almeida JP, de Albuquerque LA, Gomes E, Ferraz T, et al. Endoscopic endonasal transsphenoidal surgery: Surgical results of 228 pituitary adenomas treated in a pituitary center. Pituitary 2010;13:68-77.  Back to cited text no. 14
Berker M, Hazer DB, Yücel T, Gürlek A, Cila A, Aldur M, et al. Complications of endoscopic surgery of the pituitary adenomas: Analysis of 570 patients and review of the literature. Pituitary 2012;15:288-300.  Back to cited text no. 15
Chacko A, Chandy M. Transsphenoidal line of vision on MRI for pituitary tumor surgery. Neurol India 2002;50:136.  Back to cited text no. 16
Jho H-D, Carrau RL. Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients. J Neurosurg 1997;87:44-51.  Back to cited text no. 17
Mortini P, Losa M, Barzaghi R, Boari N, Giovanelli M. Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 2005;56:1222-33.  Back to cited text no. 18
Nath G, Korula G, Chandy MJ. Effect of intrathecal saline injection and Valsalva maneuver on cerebral perfusion pressure during transsphenoidal surgery for pituitary macroadenoma. J Neurosurg Anesthesiol 1995;7:1-6.  Back to cited text no. 19
Korula G, George SP, Rajshekhar V, Haran RP, Jeyaseelan L. Effect of controlled hypercapnia on cerebrospinal fluid pressure and operating conditions during transsphenoidal operations for pituitary macroadenoma. J Neurosurg Anesthesiol 2001;13:255-9.  Back to cited text no. 20
Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 2002;97:293-8.  Back to cited text no. 21
Gondim JA, Almeida JP, Albuquerque LA, Schops M, Gomes E, Ferraz T, et al. Endoscopic endonasal approach for pituitary adenoma: Surgical complications in 301 patients. Pituitary 2011;14:174-83.  Back to cited text no. 22
Hofstetter CP, Shin BJ, Mubita L, Huang C, Anand VK, Boockvar JA, et al. Endoscopic endonasal transsphenoidal surgery for functional pituitary adenomas. Neurosurg Focus 2011;4:E10.  Back to cited text no. 23
Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for giant pituitary adenomas: Advantages and limitations. J Neurosurg 2013;118:621-31.  Back to cited text no. 24
Sarkar S, Rajaratnam S, Chacko G, Mani S, Hesargatta AS, Chacko AG. Pure endoscopic transsphenoidal surgery for functional pituitary adenomas: Outcomes with Cushing's disease. Acta Neurochir 2016;158:77-86.  Back to cited text no. 25
Sade B, Mohr G, Frenkiel S. Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery: Use of post-operative lumbar drain and sellar reconstruction without fat packing. Acta Neurochir 2006;148:13-9.  Back to cited text no. 26
Van Aken MO, Feelders RA, de Marie S, van de Berge JH, Dallenga AH, Delwel EJ, et al. Cerebrospinal fluid leakage during transsphenoidal surgery: Postoperative external lumbar drainage reduces the risk for meningitis. Pituitary 2004;7:89-93.  Back to cited text no. 27
Governale LS, Fein N, Logsdon J, Black PM. Techniques and complications of external lumbar drainage for normal pressure hydrocephalus. Operative Neurosurgery 2008;63:ONS379-ONS84.  Back to cited text no. 28
Ransom ER, Palmer JN, Kennedy DW, Chiu AG. Assessing risk/benefit of lumbar drain use for endoscopic skull-base surgery. International forum of allergy and rhinology: Wiley Online Library, 2011:173-7.  Back to cited text no. 29
Brown RD, Maxson PM, Schroeder DR. Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: Implications for regional anesthesia. Anesth Analg 1999;88:388-92.  Back to cited text no. 30
Kaptain GJ, Kanter AS, Hamilton DK, Laws ER. Management and implications of intraoperative cerebrospinal fluid leak in transnasoseptal transsphenoidal microsurgery. Neurosurgery 2011;68(1 Suppl Operative):144-51.  Back to cited text no. 31


  [Table 1]

This article has been cited by
1 Impact of Experience on Outcomes After Endoscopic Transsphenoidal Surgery for Acromegaly
Abhijit Goyal-Honavar, Sauradeep Sarkar, Hesarghatta Shyamasunder Asha, Nitin Kapoor, Regi Thomas, Rajesh Balakrishnan, Geeta Chacko, Ari G. Chacko
World Neurosurgery. 2021; 151: e1007
[Pubmed] | [DOI]
2 Commentary: Endoscopic Endonasal Excision of an Optic Pathway Cavernous Malformation: Technical Case Report
Jitin Bajaj, Yad Ram Yadav
Operative Neurosurgery. 2021; 21(2): E143
[Pubmed] | [DOI]
3 Skull base repair following endonasal pituitary and skull base tumour resection: a systematic review
Danyal Z. Khan, Ahmad M. S. Ali, Chan Hee Koh, Neil L. Dorward, Joan Grieve, Hugo Layard Horsfall, William Muirhead, Thomas Santarius, Wouter R. Van Furth, Amir H. Zamanipoor Najafabadi, Hani J. Marcus
Pituitary. 2021; 24(5): 698
[Pubmed] | [DOI]
4 Utilizing a Novel Pituitary Retractor for Early Descent of the Diaphragma Sellae during Endoscopic Transsphenoidal Pituitary Surgery
Jae-Sung Park, Dong-Sup Chung, Wan-Soo Yoon
Journal of Korean Neurosurgical Society. 2021;
[Pubmed] | [DOI]
5 Efficacy and Safety of Intraoperative Lumbar Drain in Endoscopic Skull Base Tumor Resection: A Meta-Analysis
Xiaoming Guo, Yueli Zhu, Yuan Hong
Frontiers in Oncology. 2020; 10
[Pubmed] | [DOI]
6 Effect of Intraoperative Lumbar Drainage on Gross Total Resection and Cerebrospinal Fluid Leak Rates in Endoscopic Transsphenoidal Surgery of Pituitary Macroadenomas
Bolin Liu, Yuan Wang, Tao Zheng, Shujuan Liu, Wenhai Lv, Dan Lu, Lei Chen, Long Chen, Tao Ma, Guodong Gao, Yan Qu, Shiming He
World Neurosurgery. 2020; 135: e629
[Pubmed] | [DOI]
7 Intraoperative lumbar drainage can prevent cerebrospinal fluid leakage during transsphenoidal surgery for pituitary adenomas: a systematic review and meta-analysis
Jiahe Tan, Rui Song, Renzheng Huan, Ning Huang, Jin Chen
BMC Neurology. 2020; 20(1)
[Pubmed] | [DOI]
8 Endoscopic endonasal repair of skull base defects after tumor resection
E.V. Shelesko, D.N. Capitanov, N.A. Chernikova, A.I. Belov, M.V. Nersesyan, D.N. Zinkevich
Endoskopicheskaya khirurgiya. 2020; 26(2): 19
[Pubmed] | [DOI]


Print this article  Email this article
Online since 20th March '04
Published by Wolters Kluwer - Medknow