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Shunt complications in the first postoperative year in children with meningomyelocele
M Caldarelli1, C Di Rocco, F La Marca
1Department of Neurosurgery, Catholic University Medical School, Rome, Italy.
Insights
Cerebrospinal fluid (CSF) shunt complications in children with hydrocephalus and meningomyelocele (MM) are frequent, with shunt malfunction occurring in 45.9% within the first year. Abnormal CSF characteristics significantly increase complication rates, particularly infections.
Area of Science:
- Pediatric Neurosurgery
- Neurology
- Medical Engineering
Background:
- Hydrocephalus and meningomyelocele (MM) are complex congenital conditions often requiring cerebrospinal fluid (CSF) shunting.
- Early complications of CSF shunts in this population include mechanical failures and infections.
- Identifying risk factors is crucial for improving patient outcomes.
Purpose of the Study:
- To analyze the incidence of early mechanical and infective CSF shunt complications in children with hydrocephalus and MM.
- To identify specific risk factors correlated with CSF shunt malfunction in this patient group.
- To propose a management protocol based on identified risk factors.
Main Methods:
- Retrospective analysis of 170 children with hydrocephalus and MM undergoing CSF shunting.
- Investigation of factors including spinal malformation level, age at repair/diagnosis/implantation, ventricular dilatation, surgical modality, and CSF characteristics.
- Assessment of shunt patency and complication rates within the first postoperative year.
Main Results:
- Overall shunt malfunction rate was 45.9% in the first postoperative year, with 75% mechanical and 25% infective.
- High-level meningomyelocele and greater ventricular dilatation correlated with increased shunt malfunction and infection rates.
- Abnormal cerebrospinal fluid characteristics were strongly associated with a significantly higher incidence of overall and infective complications (90.9% vs 39.2%).
Conclusions:
- Meningomyelocele level, degree of ventricular dilatation, and particularly cerebrospinal fluid characteristics are significant risk factors for CSF shunt complications.
- The timing of meningomyelocele repair and CSF shunting influences infective complication rates.
- A protocol for temporary CSF external drainage is proposed for high-risk patients to mitigate complications.
Abstract:
The authors analyze the incidence of early mechanical and infective CSF shunt complications and various factors that might be correlated with the incidence in a series of 170 children affected by hydrocephalus and meningomyelocele (MM), with the aim of the finding to this specific risk factors related to this particular type of hydrocephalus. Factors investigated for correlation with CSF shunt malfunction are the following: level of spinal malformation, age of the patient at MM repair, age at diagnosis of hydrocephalus, degree of ventricular dilatation, age at shunt implantation, modality of the surgical procedure, characteristics of CSF at operation. In the first postoperative year following CSF shunting, 45.9% of the patients presented one shunt malfunction, three-quarters of which were due to mechanical causes, and one quarter to infection. Age of the patient at diagnosis of hydrocephalus and at CSF shunt operation did not significantly influence shunt patency, nor did the surgical modality (programmed vs emergency procedure). On the other hand, MM level did influence the outcome of CSF shunting: a higher percentage of malfunctions (and in particular of infective complications) was observed among the patients with "high level" MMs than in the group with more caudal location of the spinal defect. Similarly, the degree of ventricular dilatation correlated with the incidence of complications (more severe ventricular dilatation was associated with the highest incidence of complications). The order in which MM repair and CSF shunting were carried out and the age of the patients at MM repair did not affect the occurrence of mechanical complications, whereas they had a significant effect on the incidence of infective complications. In fact, the rate of overall complications, and of infective complications in particular, was proportional the age at MM repair. Furthermore, the group of children who underwent to MM repair and CSF shunting simultaneously scored the lowest percentage of complications, although these were mainly infections; the highest incidence of complications (and in particular of infective ones) was observed in the children who underwent CSF shunting first. The most striking correlation, however, was found with the characteristics of CSF. While normal CSF values correlated with an overall incidence of complications of 39.2%, abnormal CSF values were correlated with a rate of complications of 90.9%; in particular, the rates of infective complications were 2.7% and 77.3%, respectively. On the grounds of these observations a protocol is proposed of temporary CSF external drainage in children requiring prompt relief of increased intracranial pressure but at risk for the presence of a leaking spinal defect or of a MM left unrepaired for more than 48 h.