Abstract

Background: Spinal catheter migration into the subcutaneous tissue is common after lumboperitoneal shunt (LPS) placement. This study proposed a new method (i.e., wrapping fascia around the catheter like a sheath) to prevent LPS spinal catheter migration.

Methods: After a LPS spinal catheter was inserted under routine fluoroscopic guidance, and the paravertebral muscle fascia was closed, the fascia was sutured to wrap the catheter like a sheath using intermittent sutures.

Results: Before the introduction of this technique, the rate of LPS spinal catheter subcutaneous migration was 4.6%. In this study, following LPS shunt placement in 18 consecutive patients with normal pressure hydrocephalus, no further spinal catheter migrations were observed.

Conclusion: This novel method of “wrapping the LPS catheter with intermittent suture like a sheath” was found to be safe and effective for preventing further spinal catheter subcutaneous migration.

Keywords: Complication, Lumboperitoneal shunt, Normal pressure hydrocephalus, Spinal catheter, Subcutaneous migration

INTRODUCTION

A recent randomized and controlled trial reported that lumboperitoneal shunt (LPS) placement can be beneficial for patients with idiopathic normal pressure hydrocephalus (iNPH).[ 2 ] However, LPS spinal shunt catheter subcutaneous shunt migration is a common complication, we previously observed the incidence of 4.6%, whereas other studies reported the incidence of 1.1–1.9%.[ 1 , 2 ]

Here, we introduce a novel method of wrapping the subcutaneous shunt catheter with intermittent fascial sutures to create a protective “sheath” for preventing LPS shunt migration.

MATERIALS AND METHODS

Overall, 18 consecutive patients underwent LPS placement for iNPH through our modified technique between 2018 and 2019. Based on our previous experience, LPS spinal catheter subcutaneous migration occurred in 4.6% of cases (five of 107 patients; 2011–2017) [ Table 1 ]. One patient presented with gradual spinal catheter subcutaneous migration after >1 year of surgery [ Figure 1 ]. In this study, LPS (i.e., pressure-programmable valves with anti-siphon devices) was routinely placed under fluoroscopic guidance. A programmable valve was then connected to the spinal catheter and implanted in the subcutaneous tissue above the paravertebral muscle/fascia [ Figure 2a ]. Subsequently, using intermittent sutures, the fascia was wrapped around the catheter to create a “sheath” to prevent future catheter migration [ Figures 2b and c ]. Postprocedural imaging of LPS placement was conducted using X-rays or computed tomography for a minimum of 1 postoperative year.

Table 1:

Summary of clinical manifestations of five patients.

Figure 1:

Case 4 - Postoperative three-dimensional computed tomography on day 50 shows correct placement of the spinal catheter (a). Postoperative anterior-posterior (AP) radiograph on day 295 shows catheter migration (b, arrow). Postoperative AP radiograph on day 502 shows catheter coiling (c, arrowhead).

Figure 2:

The spinal catheter and the valve system posteriorly on the patient’s paravertebral spinal muscle are connected after achieving a lumbar puncture (a). The fascia is sutured to wrap the catheter with intermittent sutures like a sheath (b and c).

Preoperative clinical data

Overall, 10 enrolled patients were females and eight were males, and the mean age of the participants was 73.6 (45–85) years. Of these, 12, four, one, and one patients presented with iNPH, communicating hydrocephalus after subarachnoid hemorrhage, communicating hydrocephalus caused by dural arteriovenous fistula, and communicating hydrocephalus after head trauma.

RESULTS

No spinal catheter-related complications were observed after the use of our method.

DISCUSSION

Spinal catheter migration after LPS placement for NPH is a common complication occurring in 4.6% of patients based on our previous experience and 1.1–1.9% of patients according to the relevant literature.[ 1 , 2 ] Proposed mechanisms underlying catheter migration are as follows: (i) increased intraspinal canal pressure, pushing the tube out of the spinal canal; (ii) a wide subcutaneous free space surrounding the catheter, allowing for catheter redundancy and coiling; and (iii) retraction of the catheter by subcutaneous tissue during the movement of the trunk.

Our modified technique allows for the correct placement of the spinal catheter under fluoroscopic guidance to avoid the direct ejection force due to hyperflexion exerted on the catheter. In addition, we can minimize excessive dissection of the subcutaneous tissue, thereby reducing dead space and better anchoring the catheter to the paravertebral muscle/ fascia using a protective sheath (i.e., interrupted sutures in the fascia) around the catheter itself.[ 3 , 4 ]

Notably, after the use of this modified “sheath technique” after LPS shunt placement in 18 consecutive patients with NPH, no further spinal catheter migrations were observed.

CONCLUSION

We created a sheath around subcutaneous LPS spinal catheters for patients with NPH, and this prevented spinal catheter subcutaneous migration in the present case series.

Declaration of patient consent

Patients’ consent not required as patients’ identities were not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

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2. Kazui H, Miyajima M, Mori E, Ishikawa M, SINPHONI-2 Investigators. Lumboperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (SINPHONI-2): An open-label randomised trial. Lancet Neurol. 2015. 14: 585-94

3. Tanaka T, Goto H, Momozaki N, Honda E. Incidence of radiculopathy following lumboperitoneal shunt placement without fluoroscopy for normal pressure hydrocephalus. Surg Neurol Int. 2022. 13: 437

4. Tucker A, Kajimoto Y, Ohmura T, Ikeda N, Furuse M, Nonoguchi N. Fluoroscopic-guided paramedian approach for lumbar catheter placement in cerebrospinal fluid shunting: Assessment of safety and accuracy. Oper Neurosurg (Hagerstown). 2019. 16: 471-7