Shunt complications in the first postoperative year in children with meningomyelocele

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.

Comparison of simultaneous shunting to delayed shunting in infants with myelomeningocele in terms of shunt infection rate

“…Some researchers (3,18) are reluctant to place shunting in same session with MM sac repair in HCP cases and they offer shunt placement after elimination of meningitis or ventriculitis. Researchers that suggest shunt placement in postoperative first week, having the infection eliminated following to MM sac repair.…”

“…According to them, in patients with HCP and MM, insertion of shunt in same session would provide a swift recovery of back, avoid a second operation, protect the brain from deterious effects of progressive HCP resulting from delayed shunting and decrease duration of hospitalization (7,10,15,20,23). However, there is also an opposite view; concurrent shunt surgery, in same session, may cause an increased shunt infection risk, which is a common complication of shunting in the patients with MM, observed between the rates of 2-39% (18), because ventricular shunt placement reverses cerebrospinal fluid (CSF) flow from the lumbar region to ventricles (3,9,18). Therefore, shunt placement performed within a week of closure of infected myelomeningocele sac could increase the risk of shunt infection.…”

Hydrocephalus in spina bifida

“…[15,17] The open nature of myelomeningocele (with the potential for CSF contamination via the defect) increases the risk of shunt infection. Central nervous system infection in this young patient group is known to have potentially devastating and profound consequences with regard to neurological development and long-term outcome, which is of deep concern.…”

First Trimester Anomaly Scan—The Last Redoubt Won: Open Spina Bifida

“…This often needs to be replaced as the child grows because of problems with blockage and infection. [53][54][55][56][57] The prognosis for babies born with OSB depends on the location, size and extent of the defect and the presence of hydrocephalus, and the range of disability caused is variable. Still, it often leads to severe disability.…”

“…Generally, abnormalities higher on the spine produce a greater risk of paralysis and other debilitating complications. [53][54][55][56][57] Nowadays, all women are advised to take a supplement of 400 mg of folic acid for at least 3 months before preg nancy and up to the end of the 12th week of pregnancy. 58 Women who have a family history of NTDs are advised to take a higher dose of 5 mg of folic acid, as this has been shown to reduce their chances or having another baby with an NTD.…”