Percutaneous lumboperitoneal shunt Technical note
ROBERT F, SPEXZLER, M.D., CHARLES B. WILSON, M.D., ANO JOaN M. GROLLMUS, M.D. Department of Neurological Surgery, University of California School of Medicine, San Francisco, California ~" The authors describe a new catheter for use in percutaneous lumboperitoneal shunting, designed to overcome the problem of kinking. They present their experience with the catheter in 14 patients. KEvWoRos 9 lumboperitoneai shunt 9 c o m m u n i c a t i n g hydrocephalus 9 shunt
HE good results of Eisenberg, et al., 1 with lumboperitoneal (LP) shunts, in which Silastic tubing was placed into the lumbar subarachnoid space by way of hemilaminectomy, established LP shunting as an effective treatment for communicating hydrocephalus. Although percutaneous LP shunting further simplifies the procedure and reduces the complications associated with hemilaminectomy and abdominal surgery, it has not been used extensively for the treatment of communicating hydrocephalus, presumably due to its high complication rate. Jackson and Snodgrass ~ were the first to report a closed LP shunting procedure in 1955. In 1967, Murtaugh and Lehman3 described their procedure using a 16-gauge Touhey spinal needle to introduce a polyethylene catheter into the lumbar subarachnoid space. The tubing was then tunneled subcutaneously around the flank and inserted through a small muscle-splitting inci-
T
770
sion into the peritoneal cavity. Complications of kinking, adhesive arachnoiditis, and migration were reported. In an effort to overcome the drawbacks of percutaneous LP shunting, we have designed a new catheter (Fig. 1).* M a t e r i a l s and M e t h o d s
The subarachnoid portion of the system is of Silastic material with a multiple perforated tip, attached to a 24-cm length of springreinforced tubing. This kink-resistant portion of the tubing prevents occlusion where the catheter emerges between the laminae in its course to the subcutaneous tissues of the flank. *The shunt is manufactured by Heyer-Schulte Corporation, 5377 Overpass Road, Santa Barbara, California 93105. J. Neurosurg. / Volume 43 / December, 1975
Percutaneous lumboperitoneal shunt TABLE 1
Sttrnmary (~/'results lit 14 patie.ts treated by percuta~mous htmboperito.eal shu.t Case Age No. 1
2
3
4
5
6
7
Diagnosis*
60 CH secondary to SAH from basilar artery aneurysm clipped prior to shunting 9 reconstructive surgery for craniofacial dysotosis; CH (failure of previous VP shunt) 44 CH secondary to posterior fossa operation and removal of angle tu,mor 55 CSF leak following surgery and radiation therapy for pituitary tumor
57 CSF leak following operation on poorly differentiated carcinoma located on the cribiform plate 54 bulging posterior lbssa craniectomy site following resection of clivus meningioma 65 LPH
Symptoms
Date of Shunt Surgery
Results
Complications Shunt Function
lethargy, incontinence, difficulty walking
3/74
progressive improvement
none
patent
bulging craniotomy site; CSF drainage; lethargy
3/74
flattening of craniotomy site, cessation of CSF drainage, patient alert
patent
ataxia
4/74
mild improvement
3-day episode of decreased bowel sounds and abdominal distention; resolved spontaneously none
rhinorrhea
5/74
cessation of rhinorrhea
shunt tubing removed 1/75 ; no recurrence of rhinorrhea
rhinorrhea
5/74
cessation of rhinorrhea
headache, revision on 7-19-74 of peritoneal end of shunt with insertion of higher pressure valve none
lethargy, cranial nerve dysfunction
5/74
flattening of craniectomy site
dementia, incontinence, severe ataxia
5/74 mild improvement
patient continued to deteriorate and died during 6th week from progressive tumor enlargement none
patent
patent
shunt patent until death of patient
patent
*CH = communicating hydrocephalus; SAH = subarachnoid hemorrhage; VP = ventriculoperitoneal; CSF = cerebrospinal fluid; LPH = low-pressure hydrocephalus. (See TABLE 1 Continued next page.) The p a t i e n t is placed on the o p e r a t i n g table in a lateral d e c u b i t u s p o s i t i o n with both knees flexed; if low c e r e b r o s p i n a l fluid ( C S F ) pressure is a n t i c i p a t e d , the reverse T r e n d e l e n berg position is e m p l o y e d , p r o m o t i n g expansion of the l u m b a r s u b a r a c h n o i d sac. T h e a b d o m e n , flank, a n d back are p r e p p e d and
J. Neurosurg. / Volume 43 / December, 1975
draped. A 14-gauge T o u h e y needle is i n s e r t e d into the low l u m b a r s u b a r a c h n o i d space, usually with the bevel p o i n t e d s u p e r i o r l y since this angle is m o r e obtuse. A p p r o x i m a t e l y 6 cm of the Silastic t u b i n g is i n t r o d u c e d into the s u b a r a c h n o i d space a n d the T o u h e y n e e d l e is t h e n w i t h d r a w n o v e r the c a t h e t e r . T h e
771
R. F. Spetzler, C. B. Wilson and J. M. Grollmus TABLE 1 (Continued)
Case Age No.
Diagnosis*
Symptoms
Date of Shunt Surgery
Results
8
77 LPH
dementia
5/74
no change postoperatively
9
5 CH and bulging posterior fossa at craniectomy site, secondary to pineal tumor removal 50 LPH, probably secondary to SAH
bulging craniectomy defect, lethargy, headache
6/74
flattening of bulging posterior fossa, relief of lethargy and headache
dementia, incontinence, ataxia
8/74
11
55 LPH
dementia incontinence, ataxia
8/74
12
33 hydrocephalus secondary to SAH
dementia, incontinence
8/74
13
62 LPH
unable to walk, dementia, incontinence
1/75
14
58 CH secondary to SAH
posterior fossa bulging craniectomy site secondary to clipping of basilar artery aneurysm; lethargy
2/75
10
Complications
Shunt Function
CSF bloody during attempted lumbar insertion, procedure terminated ; VP shunt inserted following day none
patent
moderate improvement
none
patent
moderate improvement
none
patent
migration of lumbar end from subarachnoid space, revised to VP shunt none
patent
dramatic improvemerit, patient alert, oriented and walking without difficulty flattening of bulging posterior fossa, patient alert and oriented
none
patent
* CH = communicating hydrocephalus; SAH = subarachnoid hemorrhage; VP = veutriculoperitoneal ; CSF = cerebrospmal fluid; LPH = low-pressure hydrocephalus.
catheter is cut a few millimeters beyond the termination of the wire coil; this allows easy attachment of the appropriate connector, Through a small superficial abdominal incision, a trochar is inserted into the peritoneal cavity. Alternatively, the peritoneal end may be inserted through a small incision, under 772
direct observation. An appropriate pressure peritoneal catheter is then passed through the trochar into the peritoneal cavity. A spinal fluid reservoir is placed above the lilac crest, anchored, and connected to the two catheters tunneled subcutaneously around the flank. The reservoir we use is a one-way valve J. Neurosurg. / Volume 43 / December, 1975
Percutaneous lumboperitoneal shunt ing procedure can be employed in the treatment of communicating hydrocephalus. The ease of insertion, short operating time, and lack of complication make it particularly useful for evaluation and treatment of lowpressure hydrocephalus. It is ideal for situations in which there is a temporary absorption defect, for instance, those seen in some posterior fossa craniotomies or subarachnoid hemorrhages, for it eliminates multiple daily taps or external C S F drainage with its associated risk of infection. Furthermore, the shunt can be removed easily with a small incision in the flank under local FIG. 1. Lumbar subarachnoid catheter with anesthesia. We have also employed this multiple perforated tip (arrow) and spring rein- procedure to decrease C S F pressure forced tubing. When the first marker (arrowhead) postoperatively in persistent C S F rhinorrhea. is at the entrance of the Touhey needle the catheter The complications that remain are those of is 5 cm within the lumbar subarachnoid space. The any LP shunting procedure, but the major other two markers are spaced at 5-cm intervals. The large spinal fluid reservoir and the 14-gauge drawback of kinking has been reduced to a Touhey needle are also shown. minimum. References
Silastic dome-shaped flushing device similar to the units used for intracranial shunts, except that it holds a larger volume of CSF in order to make it palpable through the subcutaneous tissue of the flank. The reservoir can be used to flush the tubing, collect a CSF specimen, or inject a radioisotope to check shunt function. Any slack tubing is eliminated by insertion into the peritoneal cavity, after which the trochar is removed. The three small superficial incisions are closed in the usual manner. Comment
Our experience with this system is summarized in Table 1. This percutaneous shunt-
J. Neurosurg. / Volume 43 / December, 1975
1. Eisenberg HM, Davidson RI, Shillito J Jr: Lumbo-peritoneal shunts: review of 34 cases. J Neurosurg 35:427-431, 1971 2. Jackson IJ, Snodgrass SR: Peritoneal shunts in the treatment of hydrocephalus and increased intracranial pressure: a 4-year survey of 62 patients. J Neurosurg 12:216-222, 1955 3. Murtaugh F, Lehman R: Peritoneal shunts in the management of hydrocephalus. JAMA 202:1010-1014, 1967 This work was supported in part by NINDS Training Grant 5593. Address reprint requests to: Robert F. Spetzler, M.D., Department of Neurological Surgery, University of California School of Medicine, San Francisco, California 94143.
773