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Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus
Published on: October 14, 2022
Reducing CSF shunt placement in patients with spinal myelomeningocele
1Department of Neurosurgery, Dr. Balabhai Nanavati Hospital, Mumbai, India.
Insights
Strict clinical criteria can reduce shunt placement in children with myelomeningocele (MMC) and hydrocephalus. Shunt insertion is best reserved for severe cases with elevated intracranial pressure, avoiding unnecessary interventions.
Area of Science:
- Pediatric Neurosurgery
- Spinal Cord Defects
- Hydrocephalus Management
Background:
- Hydrocephalus is common in myelomeningocele (MMC) patients, often requiring shunt placement.
- Shunt complications contribute significantly to morbidity and mortality in this population.
- Minimizing shunt placement is a critical therapeutic goal.
Purpose of the Study:
- To evaluate the efficacy of strict clinical selection criteria in reducing shunt placements for hydrocephalus in pediatric myelomeningocele patients.
- To report the outcomes of a conservative management approach for hydrocephalus in MMC.
Main Methods:
- Retrospective study of 23 myelomeningocele patients treated from 2000-2007.
- Patients underwent primary surgical closure without immediate CSF diversion.
- Exclusion criteria included severe hydrocephalus requiring immediate shunt and no significant hydrocephalus.
Main Results:
- Ventricular size decreased or stabilized in 81% of patients postoperatively.
- Head circumference reduced or stabilized in 73% of patients with initial head enlargement.
- 13 patients (56.5%) ultimately required shunt placement due to raised intracranial pressure or CSF leak.
Conclusions:
- Strict clinical and radiographic criteria can significantly reduce shunt placement in pediatric myelomeningocele.
- Shunt insertion should be reserved for severe hydrocephalus with clear signs of elevated intracranial pressure.
- Mild to moderate ventricular dilatation may be managed successfully without shunts.
Object:
The incidence of hydrocephalus requiring shunts in children with myelomeningocele (MMC) is reported to be very high. Shunt-related complications are a significant cause of morbidity and mortality in this population. In order to minimize shunt placements, we used very rigid clinical selection criteria and followed them in all patients who had myelomeningocele and enlarged ventricles. The follow-up outcome of this retrospective study is reported.
Methods:
From 2000 to 2007, 23 patients with myelomeningocele and variable degree of hydrocephalus were treated at our institute with primary surgical closure of their myelomeningoceles without a CSF diversion procedure. Patients with severe hydrocephalus who required immediate shunt insertion, and those with no significant associated hydrocephalus were not included in this study. Data regarding the surgical results and complications, postoperative management, and the outcome at follow-up were obtained from their hospital records.
Results:
Initially increased size of the ventricular system was found to have decreased or stabilized in 17 (81%) patients postoperatively. However, ventriculomegaly continued to progress further in 4 (19%) out of 21 patients. Of 11 patients who presented with enlarged head, eight (73%) patients showed reduction or stabilization in their head circumference. Three (27%) children continued to have progressive head enlargement in the postoperative period and required shunt placement. Signs of raised intracranial pressure observed in six patients on admission, improved in two (33%) and persisted or worsened in four (67%) patients who eventually improved after the insertion of a shunt. Eight (35%) patients experienced wound-related complications following closure of the MMC, including CSF leak in four, wound infection in three, wound breakdown in three, and pseudomeningocele in two patients. Shunt placement was required in the postoperative period in 13 (56.5%) patients to treat raised intracranial pressure in 11 and CSF leak from the wound in two patients.
Conclusions:
Our experience suggests that the placement of shunts can be reduced by adopting a policy with strict clinical and radiographic criteria. Shunt insertion should be reserved for only those patients who have severe hydrocephalus with clinical features of elevated intracranial pressure. Mild to moderate ventricular dilatation, persistent ventriculomagaly, and some increase in ventricular size after myelomeningocele repair can be treated successfully without a shunt.
