Cerebrospinal Fluid Disorders by David D. Limbrick & Jeffrey R. Leonard

Author:David D. Limbrick & Jeffrey R. Leonard
Language: eng
Format: epub
ISBN: 9783319979281
Publisher: Springer International Publishing

Surgical Management of Hydrocephalus Secondary to Myelomeningocele

Ventriculoperitoneal Shunting

The treatment of hydrocephalus in this population has undergone a significant evolution over the last several decades. The rate of VPS insertion has diminished significantly for several reasons. First, establishment of a definitive role for folate in neural tube development has led to massively successful nutritional supplementation campaigns for women of childbearing age worldwide, particularly in high and upper middle-income countries [13, 39]. Second, the number of children in high-resourced countries born with MM is probably waning partly as a result of prenatal diagnosis and subsequent elective termination [34]. While the spinal defect alone may not trigger disruption of pregnancy, sonographic evidence of severe ventriculomegaly or other significant cerebral malformation may. As a result, fewer women are giving birth to babies with MM. Third, the perception of CSF shunts in this population has changed among the neurosurgical community, both in relation to shunt-related complications and also to differing theories regarding the indications for CSF diversion in these infants.

As with other forms of hydrocephalus, catheter-based CSF shunting has been the mainstay for hydrocephalus management since shunts were popularized more than half a century ago. The rate of VPS insertion in MM infants ranges from 78% to 86% in older series [6, 33, 40, 43, 54]. This relatively high rate of shunting is the consequence of three concepts. First, it became evident with other variants of hydrocephalus that insertion of a VPS was followed by a reliable and immediate decrease in ventricle size. Thus, when a child with MM was noted to be developing progressive ventriculomegaly, the instinctual treatment algorithm led the surgeon to recommend a shunt be inserted. Over time, as shunt-related morbidity, including the risks associated with shunting and the need for revisions became more apparent, this paradigm was reevaluated. Second, the third ventriculostomy, while developed even prior to the VPS, had fallen out of favor in the decades following the advent of shunt catheters. As pediatric neurosurgeons became more comfortable with the endoscope, the ETV came to be recognized as a safe, minimally invasive alternative to VPS for select patients [4]. The utility of ETV for MM-HC is discussed later in this chapter. Finally a high rate of VPS insertion in the MM population reflected an effort by surgeons to avoid CSF leakage, infection, and wound breakdown at the site of the spinal defect repair. Rather than wait for the patient to develop true refractory elevated intracranial pressure following MM repair, surgeons frequently placed a VPS “prophylactically” to ensure that spinal intrathecal hypertension would not compromise the integrity of the defect closure [2, 28]. In the discussion that follows, the timing of CSF diversion in relation to MM repair is discussed, including the pros, cons, and current consensus on the topic. Today, the rate of VPS insertion in patients with MM-HC has decreased as a result of changing surgical perceptions as well as the maturation of long-term clinical outcomes data. Nonetheless, even some recent series still describe a high rate of VPS

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