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Management of lumbar shunt site swelling in children
Sandeep Sood1, Holly Gilmer-Hill, Steven D Ham
1Department of Neurosurgery, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan, USA. ssood@med.wayne.edu
Insights
Lumbar shunt site swelling in children is often due to cerebrospinal fluid (CSF) leaks from the dural opening. Direct microsurgical repair and re-cannulation using a Tuohy needle stylet is the most effective management strategy.
Area of Science:
- Neurosurgery
- Pediatric Surgery
- Biomedical Engineering
Background:
- Recurrent ventricular shunt problems in children often necessitate lumbar shunt placement.
- Lumbar shunt sites can develop swelling and cerebrospinal fluid (CSF) leaks, posing management challenges.
Purpose of the Study:
- To investigate the origin of lumbar shunt site swelling and CSF leaks in pediatric patients.
- To evaluate the effectiveness of different management strategies for these complications.
Main Methods:
- A retrospective analysis of 57 children with lumbar shunts was conducted.
- Data collected included episodes of swelling, CSF leak origin, symptoms, and surgical outcomes.
Main Results:
- 30 episodes of CSF leak/swelling occurred in 20 patients, with leaks often originating from the dural entry site.
- The mismatch between the 14-gauge Tuohy needle and the lumbar catheter was identified as a primary cause.
- Microsurgical repair and re-cannulation with the Tuohy needle stylet proved most effective.
Conclusions:
- Lumbar shunt site swelling is primarily caused by pericatheter CSF leakage due to dural opening mismatch.
- Direct microsurgical repair and dural recannulation using the Tuohy needle stylet is the optimal management approach.
Object:
The aim of this study was to define the origin and management of lumbar shunt site swelling/cerebrospinal fluid (CSF) leak seen in children who underwent placement of a percutaneous lumbar shunt due to recurrent problems with a ventricular shunt.
Methods:
Fifty-seven children with a lumbar shunt were analyzed. Episodes of swelling along the lumbar shunt site, presenting symptoms, origin of the CSF leak, and surgical outcome were recorded.
Results:
Twenty patients had 30 episodes of CSF leak/swelling at a mean interval of 92 +/- 233 days (+/- standard deviation) after placement or revision. There were 7 episodes of an external CSF leak; 5 of marked swelling; and 18 episodes of headache, dizziness, and swelling. In 4 patients, the cause of CSF leakage was a fracture/disconnection or dislocation of the proximal catheter. In the remaining patients, CSF leakage was from around the proximal catheter entry point into the spinal dura (with a rate of 16.9% for placement and 15.7% for revision/reinsertion). Interlaminar removal of the existing catheter, microsurgical repair of the leak, and replacement through an opening made with the stylet of a 14-gauge Tuohy needle (Medtronic Neurosurgery) was most effective compared with percutaneous blood patch, pericatheter fascial suture, and percutaneous repositioning of the proximal catheter or downgrading valve pressure.
Conclusions:
Lumbar shunt site swelling is predominantly a consequence of pericatheter CSF leakage from the mismatch in the dural opening, which corresponds to the outer diameter of the 14-gauge Tuohy needle and the smaller proximal lumbar catheter. It is best managed by direct repair of the defect through a microsurgical interlaminar approach and recannulation of the dura by using only the stylet of a 14-gauge Tuohy needle.
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