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Comparison of simultaneous versus delayed ventriculoperitoneal shunt insertion in children undergoing
P D Miller1, I F Pollack, D Pang
1Department of Neurological Surgery, University of Pittsburgh School of Medicine, PA, USA.
Insights
Simultaneous myelomeningocele repair and cerebrospinal fluid shunt insertion in neonates with hydrocephalus may reduce hospital stay and wound complications. This approach appears safe, with no significant increase in shunt-related issues compared to delayed shunting.
Area of Science:
- Pediatric Neurosurgery
- Neonatal Care
- Spinal Cord Defects
Background:
- Hydrocephalus is a common complication in neonates with myelomeningocele.
- The optimal timing for cerebrospinal fluid (CSF) shunt insertion in these patients is debated.
- Two approaches exist: simultaneous repair and shunting, or sequential repair followed by delayed shunting.
Purpose of the Study:
- To compare complication rates and hospital stay between simultaneous and sequential myelomeningocele repair and CSF shunt insertion.
- To evaluate hydrocephalus-related complications within the first six months post-procedure.
Main Methods:
- Retrospective review of 69 neonates undergoing both myelomeningocele closure and CSF shunt insertion between 1987 and 1993.
- Patients were divided into two groups: simultaneous (n=21) and sequential (n=48) procedures.
- Comparison of complication types (wound leak, CSF infection, shunt malfunction) and mean hospital stay.
Main Results:
- No significant difference in overall complication frequency, CSF infection, shunt malfunction, or symptomatic Chiari malformation between groups.
- Significantly higher rate of myelomeningocele wound leak in the sequential group (8 vs. 0; P = .05).
- Significantly longer mean hospital stay in the sequential group (22 days) compared to the simultaneous group (13 days; P = .05).
Conclusions:
- Simultaneous myelomeningocele repair and ventriculoperitoneal shunt insertion can reduce hospital stay.
- This combined approach lowers back wound morbidity in neonates with hydrocephalus.
- The simultaneous strategy does not lead to an increased risk of shunt-related complications.
Abstract:
The timing of cerebrospinal fluid shunt insertion for those neonates with hydrocephalus in association with myelomeningocele remains controversial. To examine whether there was a difference in either the complication rate or mean hospital stay for neonates undergoing myelomeningocele repair and shunting under the same anesthetic (simultaneous group) versus those in whom shunt insertion was delayed for several days after myelomeningocele closure (sequential group), we reviewed the results obtained with these two approaches in a series of 69 consecutive patients who underwent both myelomeningocele closure and shunt insertion at our institution between 1987 and 1993. Twenty-one infants underwent simultaneous myelomeningocele repair and shunting, and 48 underwent sequential procedures. The decision to shunt concurrently with myelomeningocele repair rather than in a delayed fashion was based primarily on surgeon preference rather than initial head circumference, which did not differ significantly between the two groups. The frequency and type of hydrocephalus-related complications (e.g., wound leak, cerebrospinal fluid infection, or shunt malfunction) that occurred during the first 6 months after myelomeningocele closure were compared between the two groups. Neither the overall frequency of complications nor the frequency of cerebrospinal fluid infection, shunt malfunction, or symptomatic Chiari malformation differed significantly between the two groups. In contrast, there was a significantly higher rate of myelomeningocele wound leak in the sequential group versus the simultaneous group (eight versus zero; P = .05). Mean hospital stay for the sequential group was also significantly longer than the simultaneous group (22 days versus 13 days; P = .05). These results suggest that simultaneous myelomeningocele repair and ventriculoperitoneal shunt insertion reduces hospital stay and back wound morbidity in those patients with evidence of hydrocephalus at birth, without an inordinate increase in shunt-related complications.