Perfusion-based human cadaveric specimen as a simulation training model in repairing cerebrospinal fluid leaks during endoscopic endonasal skull base surgery

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Competency in endoscopic endonasal approaches (EEAs) to repair high-flow cerebrospinal fluid (CSF) leaks is an essential component of the neurosurgical training process. The objective of this study was to demonstrate the feasibility of a simulation model for EEA repair of anterior skull base CSF leaks.


Human cadaveric specimens were utilized with a perfusion system to simulate a high-flow CSF leak. Neurological surgery residents (postgraduate year 3 or greater) performed a standard EEA to repair a CSF leak using a combination of fat, fascia lata, and pedicled nasoseptal flaps. A standardized 5-point Likert questionnaire was used to assess the knowledge gained, techniques learned, degree of safety, benefit of CSF perfusion during repair, and pre- and posttraining confidence scores.


Intrathecal perfusion of fluorescein-infused saline into the ventricular/subarachnoid space was successful in 9 of 9 cases. The addition of CSF reconstitution offered the residents visual feedback for confirmation of intraoperative CSF leak repair. Residents gained new knowledge and a realistic simulation experience by rehearsing the psychomotor skills and techniques required to repair a CSF leak with fat and fascial grafts, as well as to prepare and rotate vascularized nasoseptal flaps. All trainees reported feeling safer with the procedure in a clinical setting and higher average posttraining confidence scores (pretraining 2.22 ± 0.83, posttraining 4.22 ± 0.44, p < 0.001).


Perfusion-based human cadaveric models can be utilized as a simulation training model for repairing CSF leaks during EEA.

ABBREVIATIONS CSF = cerebrospinal fluid; EEA = endoscopic endonasal approach; LAC = Los Angeles County; PGY = postgraduate year; USC = University of Southern California.

Article Information

Correspondence Joshua Bakhsheshian, Department of Neurological Surgery, University of Southern California, Keck School of Medicine, 1200 North State St., Ste. 3300, Los Angeles, CA 90033. email:

INCLUDE WHEN CITING Published online November 3, 2017; DOI: 10.3171/2017.5.JNS162982.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Intrathecal insertion of a pediatric extracorporeal membrane oxygenation (ECMO) cannula after cervical laminectomy and durotomy. Figure is available in color online only.

  • View in gallery

    Suprasellar CSF leak. Figure is available in color online only.

  • View in gallery

    Repair of CSF leak: Step 1, fascia lata (A); Step 2, Surgicel (B); Step 3, nasoseptal flap (C). Figure is available in color online only.


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