Management of lumbar shunt site swelling in children

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The aim of this study was to define the origin and management of lumbar shunt site swelling/cerebrospinal fluid (CSF) leak seen in children who underwent placement of a percutaneous lumbar shunt due to recurrent problems with a ventricular shunt. Fifty-seven children with a lumbar shunt were analyzed. Episodes of swelling along the lumbar shunt site, presenting symptoms, origin of the CSF leak, and surgical outcome were recorded. Twenty patients had 30 episodes of CSF leak/swelling at a mean interval of 92 +/- 233 days (+/- standard deviation) after placement or revision. There were 7 episodes of an external CSF leak; 5 of marked swelling; and 18 episodes of headache, dizziness, and swelling. In 4 patients, the cause of CSF leakage was a fracture/disconnection or dislocation of the proximal catheter. In the remaining patients, CSF leakage was from around the proximal catheter entry point into the spinal dura (with a rate of 16.9% for placement and 15.7% for revision/reinsertion). Interlaminar removal of the existing catheter, microsurgical repair of the leak, and replacement through an opening made with the stylet of a 14-gauge Tuohy needle (Medtronic Neurosurgery) was most effective compared with percutaneous blood patch, pericatheter fascial suture, and percutaneous repositioning of the proximal catheter or downgrading valve pressure. Lumbar shunt site swelling is predominantly a consequence of pericatheter CSF leakage from the mismatch in the dural opening, which corresponds to the outer diameter of the 14-gauge Tuohy needle and the smaller proximal lumbar catheter. It is best managed by direct repair of the defect through a microsurgical interlaminar approach and recannulation of the dura by using only the stylet of a 14-gauge Tuohy needle.