Novel Insights from Clinical Practice Pediatr Neurosurg 2013;49:86–88 DOI: 10.1159/000356361
Received: December 5, 2012 Accepted after revision: October 15, 2013 Published online: November 30, 2013
Retroperitoneal, Paraspinal Migration of Distal Ventriculoperitoneal Shunt Catheter: A Peculiar Complication of Cerebrospinal Fluid Shunt Clarence Greene Jr. a Evans Valerie b Departments of a Neurosurgery and b General Surgery, Children’s Hospital New Orleans and LSUHSC, New Orleans, La., USA
Established Facts • Ventriculoperitoneal shunts are the most common of neurosurgical operations. • Persistently high shunt failure rates perplex neurosurgeons everywhere.
Novel Insights
Key Words Ventriculoperitoneal shunt · Catheter migration · Paraspinal migration
ings on physical examination and the results of the imaging made to make the diagnosis are presented. No prior report of migrating shunt tubing into this anatomic area was found in the literature. This curiosity is added to the list of organs or spaces shunts are capable of wandering into.
Abstract We describe a case of a ventriculoperitoneal shunt malfunction in which the tip of the peritoneal catheter found its way to the paraspinal subcutaneous tissues. The specific find-
© 2013 S. Karger AG, Basel
© 2013 S. Karger AG, Basel 1016–2291/13/0492–0086$38.00/0 E-Mail [email protected] www.karger.com/pne
Clarence Greene Jr., MD Neurosurgery, Children’s Hospital 200 Henry Clay Avenue New Orleans, LA 70118 (USA) E-Mail cgreene @ chnola.org
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:30:34 PM
• Distal ventriculoperitoneal shunt catheters can migrate through previously considered impenetrable anatomic barriers. • General surgeons and their laparoscopic techniques can mitigate some distal shunt malfunctions.
a
b
c
An 18-month-old male was admitted to our oncology service for adjunctive treatment of posterior fossa medulloblastoma. The child had presented for medical attention due to irritability and vomiting in his homeland of Egypt. A cerebellar tumor and hydrocephalus were found. He successfully underwent suboccipital craniectomy for gross total resection of the tumor, and a subsequent ventriculoperitoneal shunt. He did well, and the family was able to make their way to the USA for further care.
Ten days after admission, it was noted on examination that there was an approximately 10-cm slightly raised soft tissue mass in the right paraspinal area. This was tender but not inflamed. The parents reported that the size of the mass had slowly increased since admission to hospital. In addition the child was irritable, more ‘clingy’ to mom, and at times somnolent. The differential diagnosis included metastasis and infection. Contrast MRI of the brain and spinal canal upon hospital admission had not demonstrated evidence of metastasis. Conventional radiography and subsequent noncontrast CT 3-dimensional imaging surprisingly revealed that the tip of the
Retroperitoneal, Paraspinal Migration of Distal Ventriculoperitoneal Shunt Catheter
Pediatr Neurosurg 2013;49:86–88 DOI: 10.1159/000356361
Case Report
87
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:30:34 PM
Fig. 1. a–c Radiography and 3-dimensional CT imaging showing the ventriculoperitoneal shunt in a subcutaneous location.
ventriculoperitoneal shunt had found its way through the paraspinal muscles to a subcutaneous location (fig. 1a–c). Brain CT imaging was now consistent with ventriculoperitoneal shunt malfunction. Laparoscopic examination of the abdomen was performed via a single incision in the umbilicus using a 10-mm operative endoscope. Visual inspection showed a fibrous encasement of the distal shunt extending from the anterior abdominal wall down into the posterior abdomen and retroperitoneum. The fibrous tissue was incised; the shunt was grasped and pulled out of the fibrous sheath. The intra-abdominal portion of the sheath was then excised and the shunt repositioned into the pelvis with restoration of proper shunt function and resolution of all symptoms.
Discussion
In the early days of ventriculoperitoneal shunting (around the 1950s), injury to the abdominal viscera was not uncommon given the less pliable nature of the shunt tubing. A once popular wire-reinforced tube (Raimondi
shunt) was especially prone to this problem. After the introduction of improved, more pliable silicone materials, abdominal organ injuries with penetration, laceration and erosion became less common. Yet the literature continues to expand with reports of migrating tubes. Common escape routes are retrograde anywhere along the shunt tract [1–4], the gastrointestinal tract [5, 6], the genitourinary system [7] and through the diaphragm into the thoracic cavity. Other exotic wanderings include some into the vascular system to the heart [8] and the lung. Our report is the only case we can find that the catheter was making its way through the retroperitoneum to the paraspinal musculature. Clearly, other than the surgical mishap of actually placing the distal catheter into an unintended organ/ space, these migrations can neither be anticipated nor prevented. One can only marvel at the propensity of CSF shunts to continue to perplex neurosurgeons everywhere.
References
88
4 Borkar SA, Satyarethee GD, Khan RN, Sharma BS, Mahapatra AK: Spontaneous extrusion of migrated ventriculoperitoneal shunt catheter through chest wall: a case report. Turk Neurosurg 2008;18:95–98. 5 Wani AA, Ramzan A, Wani MA: Protrusion of a peritoneal catheter through the umbilicus: an unusual complication of a ventriculoperitoneal shunt. Pediatr Surg Int 2002; 18: 171–172.
Pediatr Neurosurg 2013;49:86–88 DOI: 10.1159/000356361
6 Low SW, Sein L, Yeo TT, Chou N: Migration of the abdominal catheter of a ventriculoperitoneal shunt into the mouth: a rare presentation. Malays J Med Sci 2010;17:64–67. 7 Nagulic M, Djordjevic M, Samardzic M: Peritoneo-vulvar catheter extrusion after shunt operation. Childs Nerv Syst 1996; 12: 222– 223. 8 Rizk E, Dias MS, Verbrugge J, Boop FA: Intracardiac migration of a distal shunt catheter: an unusual complication of ventricular shunts. Report of two cases. J Neurosurg Pediatrics 2009;3:525–528.
Greene Jr. /Valerie
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:30:34 PM
1 Martinez-Lage J, Poza M, Izura V: Retrograde migration of the abdominal catheter as a complication of ventriculoperitoneal shunts: the fishhook sign. Childs Nerv Syst 1995; 9: 425– 427. 2 Kim KJ, Wang KC, Cho BK: Proximal migration and subcutaneous coiling of a peritoneal catheter: report of two cases. Childs Nerv Syst 1995;11:428–431. 3 Gan YC, Steinbok P: Migration of the peritoneal tip of a ventriculoperitoneal catheter causing shunt malfunction. J Neurosurg 2006; 105(suppl):153.
Received: December 5, 2012 Accepted after revision: October 15, 2013 Published online: November 30, 2013
Retroperitoneal, Paraspinal Migration of Distal Ventriculoperitoneal Shunt Catheter: A Peculiar Complication of Cerebrospinal Fluid Shunt Clarence Greene Jr. a Evans Valerie b Departments of a Neurosurgery and b General Surgery, Children’s Hospital New Orleans and LSUHSC, New Orleans, La., USA
Established Facts • Ventriculoperitoneal shunts are the most common of neurosurgical operations. • Persistently high shunt failure rates perplex neurosurgeons everywhere.
Novel Insights
Key Words Ventriculoperitoneal shunt · Catheter migration · Paraspinal migration
ings on physical examination and the results of the imaging made to make the diagnosis are presented. No prior report of migrating shunt tubing into this anatomic area was found in the literature. This curiosity is added to the list of organs or spaces shunts are capable of wandering into.
Abstract We describe a case of a ventriculoperitoneal shunt malfunction in which the tip of the peritoneal catheter found its way to the paraspinal subcutaneous tissues. The specific find-
© 2013 S. Karger AG, Basel
© 2013 S. Karger AG, Basel 1016–2291/13/0492–0086$38.00/0 E-Mail [email protected] www.karger.com/pne
Clarence Greene Jr., MD Neurosurgery, Children’s Hospital 200 Henry Clay Avenue New Orleans, LA 70118 (USA) E-Mail cgreene @ chnola.org
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:30:34 PM
• Distal ventriculoperitoneal shunt catheters can migrate through previously considered impenetrable anatomic barriers. • General surgeons and their laparoscopic techniques can mitigate some distal shunt malfunctions.
a
b
c
An 18-month-old male was admitted to our oncology service for adjunctive treatment of posterior fossa medulloblastoma. The child had presented for medical attention due to irritability and vomiting in his homeland of Egypt. A cerebellar tumor and hydrocephalus were found. He successfully underwent suboccipital craniectomy for gross total resection of the tumor, and a subsequent ventriculoperitoneal shunt. He did well, and the family was able to make their way to the USA for further care.
Ten days after admission, it was noted on examination that there was an approximately 10-cm slightly raised soft tissue mass in the right paraspinal area. This was tender but not inflamed. The parents reported that the size of the mass had slowly increased since admission to hospital. In addition the child was irritable, more ‘clingy’ to mom, and at times somnolent. The differential diagnosis included metastasis and infection. Contrast MRI of the brain and spinal canal upon hospital admission had not demonstrated evidence of metastasis. Conventional radiography and subsequent noncontrast CT 3-dimensional imaging surprisingly revealed that the tip of the
Retroperitoneal, Paraspinal Migration of Distal Ventriculoperitoneal Shunt Catheter
Pediatr Neurosurg 2013;49:86–88 DOI: 10.1159/000356361
Case Report
87
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:30:34 PM
Fig. 1. a–c Radiography and 3-dimensional CT imaging showing the ventriculoperitoneal shunt in a subcutaneous location.
ventriculoperitoneal shunt had found its way through the paraspinal muscles to a subcutaneous location (fig. 1a–c). Brain CT imaging was now consistent with ventriculoperitoneal shunt malfunction. Laparoscopic examination of the abdomen was performed via a single incision in the umbilicus using a 10-mm operative endoscope. Visual inspection showed a fibrous encasement of the distal shunt extending from the anterior abdominal wall down into the posterior abdomen and retroperitoneum. The fibrous tissue was incised; the shunt was grasped and pulled out of the fibrous sheath. The intra-abdominal portion of the sheath was then excised and the shunt repositioned into the pelvis with restoration of proper shunt function and resolution of all symptoms.
Discussion
In the early days of ventriculoperitoneal shunting (around the 1950s), injury to the abdominal viscera was not uncommon given the less pliable nature of the shunt tubing. A once popular wire-reinforced tube (Raimondi
shunt) was especially prone to this problem. After the introduction of improved, more pliable silicone materials, abdominal organ injuries with penetration, laceration and erosion became less common. Yet the literature continues to expand with reports of migrating tubes. Common escape routes are retrograde anywhere along the shunt tract [1–4], the gastrointestinal tract [5, 6], the genitourinary system [7] and through the diaphragm into the thoracic cavity. Other exotic wanderings include some into the vascular system to the heart [8] and the lung. Our report is the only case we can find that the catheter was making its way through the retroperitoneum to the paraspinal musculature. Clearly, other than the surgical mishap of actually placing the distal catheter into an unintended organ/ space, these migrations can neither be anticipated nor prevented. One can only marvel at the propensity of CSF shunts to continue to perplex neurosurgeons everywhere.
References
88
4 Borkar SA, Satyarethee GD, Khan RN, Sharma BS, Mahapatra AK: Spontaneous extrusion of migrated ventriculoperitoneal shunt catheter through chest wall: a case report. Turk Neurosurg 2008;18:95–98. 5 Wani AA, Ramzan A, Wani MA: Protrusion of a peritoneal catheter through the umbilicus: an unusual complication of a ventriculoperitoneal shunt. Pediatr Surg Int 2002; 18: 171–172.
Pediatr Neurosurg 2013;49:86–88 DOI: 10.1159/000356361
6 Low SW, Sein L, Yeo TT, Chou N: Migration of the abdominal catheter of a ventriculoperitoneal shunt into the mouth: a rare presentation. Malays J Med Sci 2010;17:64–67. 7 Nagulic M, Djordjevic M, Samardzic M: Peritoneo-vulvar catheter extrusion after shunt operation. Childs Nerv Syst 1996; 12: 222– 223. 8 Rizk E, Dias MS, Verbrugge J, Boop FA: Intracardiac migration of a distal shunt catheter: an unusual complication of ventricular shunts. Report of two cases. J Neurosurg Pediatrics 2009;3:525–528.
Greene Jr. /Valerie
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:30:34 PM
1 Martinez-Lage J, Poza M, Izura V: Retrograde migration of the abdominal catheter as a complication of ventriculoperitoneal shunts: the fishhook sign. Childs Nerv Syst 1995; 9: 425– 427. 2 Kim KJ, Wang KC, Cho BK: Proximal migration and subcutaneous coiling of a peritoneal catheter: report of two cases. Childs Nerv Syst 1995;11:428–431. 3 Gan YC, Steinbok P: Migration of the peritoneal tip of a ventriculoperitoneal catheter causing shunt malfunction. J Neurosurg 2006; 105(suppl):153.
![[The migration of a ventriculoperitoneal shunt catheter].](/assets/img/hold.png)
