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Published on: October 14, 2022
Tethered brainstem repair and near-fatal ventriculoperitoneal shunt insertion. Case report
Sandeep Mohindra1, Kanchan Kumar Mukherjee
1Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India. satya_sandee@yahoo.com
Insights
This case study highlights primary brainstem tethering, a rare spinal condition. Careful surgical sequencing is crucial to avoid near-fatal complications from traction on the tethered brainstem.
Area of Science:
- Neuroscience
- Pediatric Neurology
- Neurosurgery
Background:
- Spinal dysraphic states can involve complex congenital anomalies.
- Brainstem tethering, though rare, is a serious component of these conditions.
- Associated findings like hydrocephalus and syringomyelia complicate management.
Observation:
- A 13-year-old girl presented with primary brainstem tethering, hydrocephalus, a low-lying tethered cord, and a conus medullaris syrinx.
- Ventriculoperitoneal shunt insertion resulted in near-fatal brainstem traction.
- Imaging of the craniospinal region and head is critical for low-lying tethered cords.
Findings:
- Primary brainstem tethering can lead to severe neurological compromise.
- Traction on a tethered brainstem during surgical interventions, like shunt placement, poses significant risk.
- Comparison with secondary brainstem tethering cases reveals distinct clinical presentations.
Implications:
- Surgical detethering in multiple-level tethered cords requires cautious planning.
- Prioritizing detethering of the most vital neural structures may minimize traction-related complications.
- Understanding brainstem dysfunction from ventricular drainage is essential for patient safety.
Abstract:
The authors report a case of primary brainstem tethering, a component of a spinal dysraphic state, occurring in a 13-year-old girl. This patient also had associated hydrocephalus, a low-lying tethered cord, and a syrinx in her conus medullaris. The significance of imaging surveys of the craniospinal region and head in a case involving a low-lying tethered cord is highlighted. The insertion of a ventriculoperitoneal shunt, leading to traction on the tethered brainstem, proved nearly fatal for this patient. In cases involving a multiple-level tethered cord, the sequence of detethering should be decided on with caution. It seems prudent to detether the vital neural structure first, so as to minimize the traction force on that structure. All four previously reported cases of secondary tethered brainstem and cerebellar vermis in the literature are reviewed and compared with the present case of primary brainstem tethering. The literature describing brainstem dysfunction caused by ventricular drainage is also reviewed.
