What is Lumbar-peritoneal Shunt ?
Lumbar-peritoneal Shunt (LP Shunt) is used to divert excess cerebrospinal fluid into the abdominal cavity from the subarachnoid space. The shunt is available in two types. Valve mediated and Valve less. The fact that it can get accessed to a large cerebrospinal space in the thecal sac and that it enables the draining of cerebrospinal fluid (CSF) is a winning element to correct the excess production of CSF in the brain.
Patients with intracranial tumor or subdural hematoma cannot have the LP shunt as they are prone to develop downward brain herniation. Excess CSF may shunt in the spine creating pressure in the brain.
The possible complications thus involved are divided in to three types. It depends on the catheter used. It could be lumbar, peritoneal or general oriented complications surrounding the LP shunt. If you are using a catheter system with the valve there are chances that you will develop complications. The Lumbar catheter complications include :
- Over draining of cerebral spinal fluid
- Irritation in the spinal nerve
- Catheter misplacement
- Catheter migration
- Catheter obstruction
What are the symptoms generally involved from Lumbar-Peritoneal shunt ?
Symptoms that cause complications from lumbar peritoneal shunting include :
The most common symptom or complication from LP shunt is excess drainage of cerebra spinal fluid. Hence, the surgeons in any of the best hospital in Hyderabad for neurology advocate the use of shunts with valve as it allows only a fixed volume of cerebra spinal fluid to drain into the peritoneal cavity.
What are the complications from Lumbar peritoneal shunt and how can they be prevented ?
The complications from the implantation of the LP Shunt and methods to prevent include :
- Radiculopathy : The lumbar-peritoneal catheter is kept in close contact with the spinal nerves. There is a possibility of a spinal injury. This condition is called as Radiculopathy.
- Post-operative CSF Leak : Multiple attempts on the spine can cause CSF leak after the procedure. Hence, fluoroscopy can be used to do the placement safely without too many spinal punctures.
- Catheter Migration : The catheter may move out of the area within the spinal and the peritoneal cavity. This can be secured with the anchors and suture which basically comes along with the shunt equipment adopting the intraoperative procedural method. Despite all measures there are cases of the movement of the catheter.
- Shunt Infections : Chances of the infection in the shunt is the most common complication. Careful draping, proper pre-operative surgical site disinfection and lessening the operative time. Start antibiotics an hour soon after the surgery.
What forms the LP Shunt equipment ?
The LP Shunt equipment includes :
- The basic surgical instruments that opens in to the peritoneal cavity and outside.
- A tuohy needle
A tuohy needle has a curved tip that directs the catheter to access the spinal compartment while a catheter is a blunt hollow metal tube that is used to dissect the sub cutaneous tissue.
How is the LP Shunt procedure conducted ?
Preparing the patient for the procedure : Basic tests are conducted to see if his body is able to handle the surgery. The patient is informed about the dos and don’ts of the procedure. He is cross checked if he has adhered to them.
Anaesthesia : A general anaesthesia is given by an anaesthetist. Although the other options are available anaesthesia is given for a LP shunt procedure.
Placing of the shunt : Best Brain surgery hospitals in Hyderabad explain the importance of the positioning of the patient prior procedure as it enables the surgeon to access both the spinal and peritoneal compartments of the brain. He is placed in decubitus position where in his arms are raised above the shoulders. Soft gel pads are used so that he remains in the same position allowing him to easy access of the cavities.
The position allows the surgeon to have a wide access of the region from one spinal level to another where in the catheter is passed through or a valve is placed and the peritoneal cavity on the abdomen in accessed. The catheter is system is preserved in an antibiotic solution and is not removed until it is ready for use. For a proper understanding of the procedure a visible superior iliac crest is considered as the landmark.
Follow up after the procedure for monitoring its function : The LP Shunt requires extreme care and regular follow up to monitor for any return of symptoms. CT scans and Lumbar Puncture is used to measure the Cerebra spinal pressure.
Complications : There is a possibility of the failure of the shunt system. The statistics state that shunt revision due to obstructions range from 14%– 62% are mostly reported as against 1% -10% of the shunt infections and meningitis.
There is a 3% to 20% chance of the shunt catheters moving away from its position : the peritoneal catheter out of the peritoneum and the lumbar catheter to the thecal sac. It is more common in the children. The result is a collection of CSF in the cavity.
A condition called arachnoiditis where an inflammation or the catheter is migrated causing severe pain. The shunt may have to be re-positioned. 5% to 6% of such cases are reported.
Over drainage (5%-10%) is yet another complication that causes head aches and inter- cranial hypotension. Hence, there are valves that can be programmed and the drainage of the CSF can be set thereby avoiding excess drainage. There are also chances of under drainage (9%-12%) of CSF.
The Arnold-Chiari tosillar herniation is the most commonly reported complication post the LP shunt procedure. Subdural hematomas, intraparenchymal hemorrhages, abdominal haemorrhages are also the complications of post shunt replacement.
Approaches of LPShunts : There are mainly two types of shunts as discussed earlier. The valve mediated and the valve-less types. The positioning of the shunts remain the same.
The Lumboperitoneal Shunt Placement : LP Shunt surgery in Hyderabad is conducted by placing the patient in the lateral decubitus position. With the aid of fluoroscopy the shunt and the iliac crest as the landmark L4-5 spinal level the shunt is placed. Only in case of a haemorrhage the LP shunt is placed at L5-S1 level.
An incision is made in that includes the lumbar area , the skin, flank, abdomen in the midline and the dissection is made down till the fascia layer. Sufficient place is made for the catheter to pass through with the help of the tuohy needle is inserted in to the thecal sac well within the space.
Passing of the catheter in to the abdominal and dorsal incision : The tuohy needle is aligned to rostral-caudal direction. The LP catheter is sent through the thecal sac. The width of the incision may wary between 6-8cm.However the catheter is not withdrawn from the needle to avoid shearing off of the catheter’s end.
Pulling of the shunt of the catheter tunnelling instrument : the laparoscopic approach is better than the traditional one as the catheter is inserted through the incision in the flank while the other approach would have involved the dissection of the scarpa fascia, innominate fascia, muscle layers and traversalis fascia till you reach the peritoneal area.
If you are using a LP catheter with a valve then the flank incision has to be made. The catheter tunnelling instrument is connected to the lumbar and to the incision made in the flank. If there is no valve involved then tunnelling process is conducted through the lumbar region and until the abdomen. Sometimes you may need another intervening incision. Spinal catheter can now be exposed till the flank but should be made sure it is not moved out of the thecal sac. To avoid movement or any displacement anchoring device can be sutured to secure to the lumbar fascia. Finally the valve is then connected to the spinal catheter and an additional tube is placed from the flank to the abdomen incision. The catheter tunnelling instrument is now removed as the LP shunt has been placed.
Why KIMS ?
KIMS is the best Brain surgery hospital in Hyderabad as the neurosurgeons they have on their team have had years of experience in handling patients suffering from hydrocephalus condition that involves the placement of LP and VP shunts to correct it. The surgery is delicate, requires extra care and regular monitoring. A close follow up is advised by the surgeons here that allows them to treat, heal, recover and relieve their patients from such a medical condition.