Should the Impact of Postural Change of Intracranial Pressure After Surgical Repair of Skull Base Cerebrospinal Fluid Leaks Be Considered? A Preliminary Survey.

Introduction: Managing skull base cerebrospinal fluid (CSF) leaks is often challenging. Postoperative care, especially regarding postural restrictions and bedrest recommendations, is variable and continues to be based on empirical habits.

Methods: An electronic survey was submitted to French experts in skull base surgery to evaluate current practice of postoperative postural recommendations in patients treated for skull base CSF leaks.

Results: Thirty-nine experts completed the survey. Postoperative recommendations were heterogenous. They depended on the size of defects: half of the surgeons did not recommend any constraints of posture for small defects; 84% recommended bed rest for large defects. The most preferred bed-rest modality was Fowler's position (20°-30° tilt). Standing/walking during short periods was allowed in up to 73%. From a physiological viewpoint, head elevation decreases ICP and thus limits the risk of recurrence of CSF leak. However, ICP can fall below 0 in the standing position, favouring pneumocephalus.

Discussion: These results confirmed that postural recommendations for patients surgically treated for skull base CSF leaks remain variable. Recommendations should take into consideration the postural change in ICP. Fowler's position may represent the best compromise between risk of recurrence of CSF leak and the risk of pneumocephalus in large CSF leaks.