Case-specific protocol to reduce cerebrospinal fluid leakage after endonasal endoscopic surgery

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Endoscopic transsphenoidal surgery is expanding in acceptance, yet postoperative CSF leak rates remain a concern. This study presents the Cornell closure protocol, which has yielded significantly lower postoperative CSF leak rates compared with prior reports, as an algorithm that can be used by centers having difficulty with CSF leak.


A single closure algorithm for endoscopic surgery has been used since January 2010 at Weill Cornell Medical College. A prospective database noting intraoperative CSF leak, closure technique, and postoperative CSF leak was reviewed. The authors used a MEDLINE search to identify similar studies and compared CSF leak rates to those of patients treated using the Cornell algorithm.


The retrospective study of a prospectively acquired database included 209 consecutive patients. In 84 patients (40%) there was no intraoperative CSF leak and no postoperative CSF leak. In the 125 patients (60%) with an intraoperative CSF leak, 35 of them with high-flow leaks, there were 0 (0%) postoperative CSF leaks.


It is possible to achieve a CSF leak rate of 0% by using this closure protocol. With proper experience, endoscopic skull base surgery should not be considered to have a higher CSF leak rate than open transcranial or microscopic transsphenoidal surgery.

Abbreviation used in this paper:GPA = giant pituitary adenoma.

Article Information

Address correspondence to: Theodore H. Schwartz, M.D., Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY 10065. email:

Please include this information when citing this paper: published online May 31, 2013; DOI: 10.3171/2013.4.JNS13124.

© AANS, except where prohibited by US copyright law.



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    The Cornell closure algorithm. This protocol has been implemented since January 2010 with minimal variations. This algorithm takes into account the pathological features of the lesion and intraoperative CSF leakage level to determine what closure technique to implement. LD = lumbar drainage; NS = nasoseptal.



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