Cerebrospinal Fluid Leakage in Pediatric Supratentorial Intradural Surgery and the Modified Twist-Drill Drainage Technique.

OBJECTIVE: To characterize cerebrospinal fluid (CSF) leakage after selected pediatric supratentorial intradural procedures requiring drainage and to evaluate whether the modified twist-drill drainage technique, which separates the drain route from the primary dural suture line, was associated with lower leakage and revision burden. METHODS: Among 464 screened pediatric supratentorial intradural procedures, 90 patients met the inclusion criteria of arachnoid opening, communication with CSF spaces, and selective intradural drain placement. The first 45 underwent conventional drainage through the dural suture line, and the next 45 underwent modified twist-drill drainage through an independent mini-craniostomy. The primary outcome was 30-day CSF leakage, defined as incisional leakage or pseudomeningocele. RESULTS: CSF leakage occurred in 23 patients (26%). Leakage was less frequent with the modified technique than with conventional drainage (p=0.003), as was incisional leakage (p=0.027); the difference in pseudomeningocele was not significant (p=0.197). Reoperation was required in 3 versus 11 patients (p=0.039). Among reoperated patients, median revision duration was 12 versus 124 minutes, and median post-revision stay was 1 versus 4 days. In separate models adjusted for ventricular opening and drain location, the modified technique remained associated with lower odds of overall leakage. CONCLUSIONS: In this selected cohort, postoperative CSF leakage frequently required active management. The modified route was associated with lower leakage and reoperation burden and, when leakage required revision, with a more limited surgical approach. These findings are hypothesis-generating. Other institutions are encouraged to evaluate, adapt, and report outcomes and technical refinements with this approach.