Cerebrospinal Fluid Overdrainage Research Articles

Incidence of Rebleed Following Cerebrospinal Fluid (CSF) Drainage in Poor Grade Subarachnoid Hemorrhage: An Institutional Experience.

The outcome of poor grade subarachnoid hemorrhage (SAH) is dismal. Some of these patients need cerebrospinal fluid (CSF) drainage procedure for the hydrocephalus and intraventricular hemorrhage (IVH) which may precipitate rebleeding. However, aneurysmal rebleed following CSF drainage procedure is controversial. Our study aimed at analyzing the effect of CSF drainage procedure on aneurysmal rebleeding. We retrospectively analyzed the records of all the consecutive patients diagnosed with poor grade aneurysmal SAH over three year period. Patients initially requiring either external ventricular drainage (EVD) or lumbar drain (LD) were included in the study group, and the rest (not requiring drainage) were included in the control group. Rebleeding was confirmed on computed tomography. The factors affecting rebleeding were analyzed. Overall 194 patients with poor grade SAH were enrolled in the study (91 males: 103 females; mean age: 50.6 years). The study group had 91 patients (83 EVD and 8 LD) while 103 patients were in the control group. Posterior circulation aneurysms, poor grade SAH, hydrocephalus, and IVH were more common in the study group P < 0.001. The rebleeding rate was 7.6% in the study group and 8.7% in the control group. On univariate analysis size >1 cm, multiplicity, multilobularity, vasospasm, and CSF drainage were significant risk factors for rebleeding (P < 0.001). On multivariate analysis aneurysm size >1 cm, CSF overdrainage >250 ml/day were significantly associated with risk of rebleeding. Ventricular drainage is essential to relieve acute hydrocephalus and drain IVH in SAH and we found no significant association between CSF drainage and rebleeding. However, rapid overdrainage of CSF can lead to aneurysm rupture, hence controlled controlled CSF drainage should be undertaken.

Management of Cerebrospinal Fluid Leakage by Pump-Regulated Volumetric Continuous Lumbar Drainage Following Anterior Cervical Decompression and Fusion for Ossification of the Posterior Longitudinal Ligament.

Cerebrospinal fluid (CSF) leakage is a major concern related to anterior cervical decompression and fusion for ossification of the posterior longitudinal ligament (OPLL). We propose a management algorithm for CSF leakage following anterior cervical decompression and fusion for OPLL involving the use of pump-regulated volumetric continuous lumbar drainage. We retrospectively reviewed patients who underwent anterior cervical decompression and fusion for OPLL and were managed with the proposed algorithm between March 2018 and July 2022. The proposed management algorithm for CSF leakage by pump-regulated volumetric continuous lumbar drainage was as follows. On exposure of the arachnoid membrane with or without CSF leakage, a dural sealant patch was applied to manage the dural defect. In case of persistent CSF leakage despite application of the dural sealant patch, patients underwent pump-regulated volumetric continuous lumbar drainage. Fifty-one patients were included in the study. CSF leakage occurred in 14 patients. Of these 14 patients, 9 patients underwent lumbar drain insertion according to the proposed management algorithm. Successful resolution of CSF leakage was observed in 8 of the 9 patients who underwent lumbar drainage. All patients were encouraged to ambulate without concern of CSF overdrainage due to gravity, because it could be avoided with pump-regulated volumetric continuous CSF drainage. Therefore, complications associated with absolute bed rest or CSF overdrainage were not observed. The proposed management algorithm with pump-regulated volumetric continuous lumbar drainage showed safety and efficacy for management of CSF leakage following anterior decompression and fusion for OPLL.

Bifrontal–Parietal Ratio: A Novel Risk Factor for Cerebrospinal Fluid Overdrainage after Ventriculoperitoneal Shunting

Abstract Objective This study aimed to examine potential risk factors associated with cerebrospinal fluid overdrainage after ventriculoperitoneal (VP) shunting. Materials and Methods We retrospectively examined the medical records of hydrocephalus patients who underwent VP shunting at a single institution between January 2011 and December 2017 and had a minimum 3-year follow-up. Variables studied included age, gender, hydrocephalus etiology, symptoms, shunt valve, ventricular catheter entry point, and neurosurgical history, including history of external ventricular drainage. Radiographic variables included Evans index, bicaudate index, callosal angle, measurements of frontal lobe thickness, and bifrontal–parietal ratio. Results Among the 182 study patients, 11 experienced overdrainage. Age, gender, etiology, symptoms, and surgical history did not significantly differ between patients who experienced overdrainage and those who did not. Evans index, bicaudate index, and callosal angle did not significantly differ between the groups. Measurements of frontal lobe thickness and bifrontal–-parietal ratio were significantly lower in the overdrainage group. Conclusion Bifrontal–parietal ratio may be useful to predict overdrainage after VP shunt surgery.

Cervical Myelopathy Caused by a Ventriculoperitoneal Shunt: A Case Report

Intracranial hypotension is a rare cause of cervical myelopathy. Cerebrospinal fluid (CSF) shunt surgery, which belongs to the broader category of ventriculoperitoneal shunt surgery, is commonly chosen as the primary treatment option for hydrocephalus. However, such surgery can potentially lead to CSF overdrainage, resulting in the occurrence of intracranial hypotension. In the present case, spinal surgery was performed twice for cervical myelopathy; however, there was no improvement in symptoms such as gait disturbance. After the readjustment of the shunt valve pressure, the symptoms improved.

Addressing the Devil Within: Normal Pressure Hydrocephalus—A Narrative Review

AbstractNormal pressure hydrocephalus (NPH) is the most frequently occurring form of hydrocephalus among adults. It is characterized clinically by the classical triad, called Hakim's triad, comprising gait issues, cognitive impairment, and urinary problems. NPH may be primary or idiopathic (iNPH) or secondary. Characteristic neuroimaging features occur, which are vital to diagnosis. Diagnostic criteria in the form of Japanese guideline and Congress of Neurological Surgeons 2005 guidelines have been devised, and broadly, are based on a constellation of clinical and neuroimaging features, in association with cerebrospinal fluid (CSF) testing. CSF tap test, extended lumbar drainage, and CSF infusion tests are invasive diagnostic tests. CSF tap test and extended lumbar drainage are used to demonstrate clinical reversibility with CSF drainage, and patients who demonstrate this are candidates for CSF shunting. However, due to the low negative predictive value of these tests, potential response to shunting cannot be negated among patients who do not respond to CSF drainage. Various shunting procedures are used for treatment, including ventriculoperitoneal, lumboperitoneal, and ventriculoatrial shunts. Endoscopic third ventriculostomy has also been attempted with limited success. Among the clinical features, gait abnormalities are most responsive to shunting. Persistent long-term response to shunting has been reported. Patients need to be meticulously followed up after the shunting procedure, to assess clinical and neuroimaging response, and detect possible shunt-related complications, especially CSF over-drainage. Early treatment is associated with better prognosis, and it is crucial to recognize and treat this condition before the development of severe symptoms.

Shunt technology for infants and a lifetime.

The use of cerebrospinal fluid (CSF) shunts remains a fundamental therapeutic modality in the management of hydrocephalus. Nowadays, neurosurgeons have an arsenal of different shunt technologies on their hands, with several companies producing many different configurations of them. The greatest difficulty of treating a child with hydrocephalus is to deal with a brain that will enormously change its size and hydrodynamic conditions and a body that will multiply its height and weight in a short time. Detailed knowledge of the hydrodynamic properties of shunts is mandatory for any neurosurgeon and much more for those taking care of pediatric patients. It is necessary to know that these properties of the valve may influence the evolution of the patient after shunting and it is recognized that a patient physiology-specific valve selection may yield better outcomes and decrease complications. This article provides a summary of the most common available CSF valves and overdrainage control devices, their technology, and possible combinations. The objective is to offer a quick overview of the armamentarium to facilitate the recognition of the implanted device and improve the selection of the most suitable valve for each patient.

Intraventricular Fluid Injection as a Novel Treatment of Subdural Fluid Collection after VP Shunt Overdrainage: A Case Report

Introduction: Subdural fluid collection is one of many complications of ventriculoperitoneal (VP) shunt. Variety of surgical procedures have been applied for the treatment of the post VP shunt subdural fluid collection, but the ideal surgical treatment remains controversial. Case Report: This is a case report of 14 years old boy who had a history of multiple VP shunt revisions for post hemorrhagic hydrocephalus with subdural fluid collections due to cerebrospinal fluid (CSF) overdrainage. Result: The author performed intraventricular fluid injection via shunt valve to expand the brain mantle and drain the subdural fluid through a small craniotomy. This is the first case report using the novel “fluid infusion” technique for the treatment of intractable subdural fluid collection after the VP shunt overdrainage. Conclusion: The technique can bring potentially great impact for the future treatment of symptomatic subdural fluid collection associated with CSF overdrainage after VP shunt.

A case of overshunting‐associated myelopathy that developed 27 years after placement of a ventriculoperitoneal shunt

AbstractOvershunting‐associated myelopathy (OSAM) is a rare complication of ventriculoperitoneal (VP) shunts. Here, we report the case of a 52‐year‐old man who presented with OSAM without positional headache 27 years after the placement of a VP shunt. The patient recovered after shunt ligation and transection. Although rare, chronic cerebrospinal fluid overdrainage can lead to cervical myelopathy due to spinal cord compression by the dilated vertebral veins/epidural venous plexus. Thus, reversible OSAM needs to be differentiated during the diagnosis of cervical myelopathy.

Multiloculated Hydrocephalus: Surgical Techniques

Objective: Hydrocephalus shunt remains as the most common treatment choice for nonobstructive hydrocephalus, but in some cases multiloculated hydrocephalus (MH) remains a difficult neurosurgical disease despite of the different therapeutic options available. In children with MH multiple shunt procedures combined with neuroendoscopy may be required.(1) The rationale for neuroendoscopy in such complex cysts and multiloculated hydrocephalus is also to open several compartments to the normal fluid-filled spaces, minimize the number of isolated/loculated CSF spaces, and decrease shunt dependency and the number of proximal shunt catheters.(2) In such cases our major objective is keep the children with one or no one shunt and with one normal intracranial pressure (ICP).&#x0D; Most patients with multiloculated hydrocephalus are infants with a severe disability who present with high intracranial pressure. Multiple shunting was a routine practice so far to normalize the intracranial pressure, but in these cases shunt complications could be quite common including shunt infection, malposition and malfunction which needed more shunt revision surgeries.(1, 3)&#x0D; Neuroendoscopy has changed the treatment options for complex multiloculated hydrocephalus. The possibility to do several fenestrations and change multiples cysts in one simple cyst or ventricle was one important improvement in MH treatment.(4-6)&#x0D; In this review we will discuss aspects related to etiology, surgical techniques, and results in multiloculated hydrocephalus.&#x0D; &#x0D; Methods: The authors carried out a literature review on multiloculated hydrocephalus and evaluated a series of personal cases operated in the recent years.&#x0D; The keywords loculated hydrocephalus and surgical technique were used in Pubmed database website. Fifty-two articles were obtained and reviewed. From these publications we select the most relevant ones for the presentation. The articles were divided according to the main subject, with articles on etiology, surgical techniques and outcomes were selected.&#x0D; We also reviewed some difficult cases with MH from personal experience. In all of those cases endoscopy procedures were performed associated to shunt procedures in all cases. The authors described some different techniques of cyst fenestration and the association to shunt or not.&#x0D; Results/Discussion: Neuroendoscopy has changed the treatment in MH. This is a very difficult and interesting disease. Common risk factors for the development of MH include intraventricular hemorrhage, bacterial meningitis, shunt infection, and cerebrospinal fluid (CSF) overdrainage from shunt placement (rare). The magnetic resonance imaging (MRI) or computerized tomography (CT) scan with evidence of septations causing marked nonuniform compartmentalization and enlargement within the ventricular system are the most important ways to do the diagnosis of MH. Predisposing factors include low birth weight, prematurity, perinatal complications, and congenital malformation.&#x0D; Although the full pathogenesis of MLH remains unclear, it is known that inflammation leads to subependymal gliosis, which produces glial tufts and septations that occlude the normal ventricle system. Septations also develop via organization of intraventricular exudate and debris from ventriculitis.&#x0D; Despite os clinical history of poor outcome, head circuference increase and prior infection or brain bleeding, we need image to perform the diagnosis. Types of loculated hydrocephalus could be divided in: multiloculated and uniloculated. The most important classification was done by Spennato.(5) He divided in five types:&#x0D; 1) hydrocephalus with multiple intraventricular septations;&#x0D; 2) isolated lateral ventricle/unilateral hydrocephalus;&#x0D; 3) entrapped temporal horn;&#x0D; 4) isolated fourth ventricle;&#x0D; 5) expanding cavum septi pellucidi/cavum vergae&#x0D; Using the endoscope to treat MH has some advantages.(7, 8) This is a less invasiveness and this is very important in kids.(6) Avoidance of brain retraction, less blood loss, faster operation time, and shorter hospital stay. But endoscopy has some risk and possible complications. It also has several disadvantages. A subdural hematoma and/or hygroma may form, but the incidence of this is lower than with open craniotomy. The risk of ventriculitis, CSF leakage (subcutaneous CSF collection), and hemorrhage are reported to be like that with open craniotomy. Intraoperative bleeding can usually be easily managed by irrigation or coagulation. However, handling of significant intraoperative bleeding is not as easy in endoscopy as in open craniotomy.(9)&#x0D; Some new technologies could improve the outcome and avoid risk and complications.(10, 11) Navigation could be used in two forms:&#x0D; &#x0D; Navigation system is used to planning the entry point and the endoscopy trajectory&#x0D; Endoscopy guided and navigation during all surgical time.&#x0D; &#x0D; The evaluation of results is presented in different ways in the literature. The main outcomes observde for measuring results were: hydrocephalus control or not, number of surgery performed and number of catheters used.(4) Shunt Independence is rare.&#x0D; Conclusion: Multiloculated hydrocephalus is one difficult disease to treat.(4) Neuroendoscopy cyst fenestration was one great improvement in treatment of MH, but after this new procedure the clinical outcome still no so good. Endoscopy is important to decrease the number of shunts and surgeries.&#x0D;

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Posture related in-vitro characterization of a flow regulated MEMS CSF valve.

Overdrainage in upright position is one of the most prevalent issues in treating hydrocephalus with a cerebrospinal fluid (CSF) shunt. Anti-siphon devices (ASDs) are employed to reduce this problem. A novel microelectromechanical system (MEMS)-based valve, termed Chronoflow device, aims to regulate CSF drainage indifferently of the body posture. With this study, the suitability of this MEMS-based valve is evaluated regarding its use for the treatment of hydrocephalus, particularly for the prevention of overdrainage and blockage. In total, four Chronoflow devices were tested. An established in-vitro hardware-in-the-loop (HIL) test bed was used to investigate the valves regarding their pressure-flow characteristics, their behaviors towards CSF dynamics, and their capabilities to prevent CSF overdrainage in upright position. Additionally, a contamination test was conducted to evaluate the susceptibility of the device to blockage due to particles. All valves tested regulated the drainage rate at similar nominal flows and independently of posture. The pressure-flow relation measured, however, was notably higher than numerically calculated. Regarding the CSF dynamics, the first three valves tested led to a decreased steady-state intracranial pressure in supine position and showed stable drainage rate in upright position. During the transitional phase from supine to upright and vice versa, the valves continuously adjusted the outflow resistance, which resulted in a stable transitional phase preventing overdrainage. Yet, the fourth valve showed continuous overdrainage in upright position due to an increased nominal flow. However, after several test iterations the nominal flow decreased and stabilized at a level similar to that of the first three valves tested. The contamination test showed that most particles initially adhere to the pillars and spread throughout the cavity of the valve as the concentration of particles increases, thereby affecting the displacement of the membrane. The devices generally provide a stable flow regulation and prevent overdrainage in upright position. Specifically, their drainage behaviors during the posture changes are very effective. However, they also showed high hysteresis and sensitivity towards particle contamination, which resulted in initial increased and altering nominal flows after many test iterations. This result suggests that the MEMS design presented lacks robustness. Yet, an upstream filter and specific coatings on the fluid pathway may increase significantly its reliability.

Miyazaki syndrome: Cervical myelo/radiculopathy caused by overshunting. A systematic review

ObjectivesMiyazaki syndrome is a cervical myelopathy or radiculopathy caused by cervical epidural venous congestion, due to cerebrospinal fluid over-drainage by an implanted ventricular shunt. The complex pathophysiology includes CSF pressure-changes consistent with the Monro-Kellie doctrine and a non-functional Starling resistor, leading to spinal epidural venous plexus enlargement and dilation. This venous congestion may be significant enough to exert compression on the spinal cord or nerve roots. The typical clinical and imaging findings together with a history of ventricular CSF shunting may establish the diagnosis, proven by a successful treatment. The aim of treatment is the abrogation of CSF over-drainage. The eligible interventions may be the followings: the increase of the opening-pressure of the valve system by the insertion of a new programmable valve if necessary, closing or removing the shunt. AimWe want to call attention to this rare iatrogenic condition with potentially severe consequences. Patients and MethodsWe perform a systematic literature-review and present our five cases. ResultsOnce recognized in time, Miyazaki syndrome can be well taken care of. ConclusionsPatients with chronic ventricular shunt need monitoring for CSF over-drainage to recognise potential complications such as cervical myelopathy or radiculopathy.

Lumboperitoneal Shunts for the Treatment of Idiopathic Normal Pressure Hydrocephalus: A Comparison of Small-Lumen Abdominal Catheters to Gravitational Add-On Valves in a Single Center

BACKGROUNDTreating idiopathic normal pressure hydrocephalus (iNPH) with lumboperitoneal shunts (LPSs) may cause cerebrospinal fluid (CSF) overdrainage.OBJECTIVETo investigate whether LPSs, including gravitational “add-on” and programmable pressure valves (PPVs/+GVs), reduce complications and improve outcomes.METHODSWe compared PPVs/+small lumen abdominal catheters (SLs) to PPVs/+GVs using different opening pressures for supine and standing positions. We analyzed 115 patients with iNPH in 2 consequent cohorts: 48 patients receiving LPSs with PPVs/+SLs and 67 patients receiving LPSs with PPVs/+GVs. The modified Rankin Scale (mRS), Japan iNPH grading scale, Mini Mental State Examination, Frontal Assessment Battery, and CSF biomarkers were evaluated.RESULTSComparisons of postoperative clinical factors in 64 patients in the PPV/+SL and PPV/+GV groups using 1:1 propensity score matching revealed differences in the mean (±standard deviation) postoperative mRS (2.65 ± 1.07 vs 2.16 ± 1.02, P = .049) and gait disturbance scores (1.97 ± 1.03 vs 1.39 ± 0.92, P = .011). Thus, outcomes improved in the LPS group with the GV. Serious and nonserious adverse event rates for the PPV/+SL and PPV/+GV groups were 22.9% and 19.4% (P = .647) and 38% and 17.9% (P = .018), respectively, indicating higher rates of subdural collections for the PPV/+SL group.CONCLUSIONThis is the first study to examine LPS treatment for iNPH using a GV in tandem with a PPV. Our results suggest that the CSF shunt flow volume is restricted in the standing position and maintained in the supine position, thus improving iNPH symptoms. This may reduce intracranial CSF hypotension-related complications.

Cervical compressive myelopathy caused by malfunction of a programmable cerebrospinal fluid shunt valve

Abstract The primary treatment for hydrocephalus is ventricular shunt placement, and a programmable valve is widely used for ventriculoperitoneal (VP) shunt surgery to reduce over/under drainage of cerebrospinal fluid (CSF). Here, we report a rare case of a patient who developed successive VP shunt malfunction causing spastic muscle weakness in extremities associated cervical epidural venous distension and compressive myelopathy due to over-drainage of CSF through a defective VP shunt valve a decade after the initial shunt was placed. One should be aware and cognizant of this complication and carefully follow the symptoms and potentially utilize brain MRI with and without contrast to look at over drainage stigmata to avoid the development of neurological complications.

Shunt-dependent hydrocephalus: management style among members of the American Society of Pediatric Neurosurgeons.

OBJECTIVE The authors conducted a survey to evaluate differences in the understanding and management of shunt-dependent hydrocephalus among members of the American Society of Pediatric Neurosurgeons (ASPN). METHODS Surveys were sent to all 204 active ASPN members in September 2014. One hundred thirty responses were received, representing a 64% response rate. Respondents were asked 13 multiple-choice and free-response questions regarding 4 fundamental problems encountered in shunted-hydrocephalus management: shunt malfunction, chronic cerebrospinal fluid (CSF) overdrainage, chronic headaches, and slit ventricle syndrome (SVS). RESULTS Respondents agreed that shunt malfunction occurs most often as the result of ventricular catheter obstruction. Despite contrary evidence in the literature, most respondents (66%) also believed that choroid plexus is the tissue most often found in obstructed proximal catheters. However, free-text responses revealed that the respondents' understanding of the underlying pathophysiology of shunt obstruction was highly variable and included growth, migration, or adherence of choroid plexus, CSF debris, catheter position, inflammatory processes, and CSF overdrainage. Most respondents considered chronic CSF overdrainage to be a rare complication of shunting in their practice and reported wide variation in treatment protocols. Moreover, despite a lack of evidence in the literature, most respondents attributed chronic headaches in shunt patients to medical reasons (for example, migraines, tension). Accordingly, most respondents managed headaches with reassurance and/or referral to pain clinics. Lastly, there were variable opinions on the etiology of slit ventricle syndrome (SVS), which included early shunting, chronic overdrainage, and/or loss of brain compliance. Beyond shunt revision, respondents reported divergent SVS treatment preferences. CONCLUSIONS The survey shows that there is wide variability in the understanding and management of shunt-dependent hydrocephalus and its complications. Such discrepancies appear to be derived partly from inconsistent familiarity with existing literature but especially from a paucity of high-quality publications.

Risk factors and outcomes of cerebrospinal fluid overdrainage in HIV-negative patients with cryptococcal meningitis after the ventriculoperitoneal shunting procedure.

Shunt procedures used to treat cryptococcal meningitis complicated with hydrocephalus and/or increased intracranial pressure (IICP) could result in cerebrospinal fluid (CSF) overdrainage, thereby presenting therapeutic challenges. We analyzed the clinical features and neuroimaging findings after the ventriculoperitoneal (VP) shunt procedure in 51 HIV (Human Immunodeficiency Virus)-negative patients with cryptococcal meningitis, to assess the risk factors associated with post-shunt CSF overdrainage. Symptomatic CSF overdrainage occurred in 12% (6/51) of patients with cryptococcal meningitis who underwent the shunt procedure. Rapid deterioration of neurological conditions was found in 6 patients after the shunt procedure was performed, including disturbed consciousness, quadriparesis, and dysphasia in 5 patients and severe ataxia in 1. The mean duration of CSF overdrainage after the shunting procedure was 2-7 days (mean 4 days). The mean interval between meningitis onset to shunting procedure remained independently associated with CSF overdrainage, and the cut-off value for predicting CSF overdrainage in interval between meningitis onset to shunting procedure was 67.5 days. CSF overdrainage after the VP shunt procedure is not rare, especially in patients with a high-risk of cryptococcal meningitis who also have a prolonged duration of hydrocephalus and/or IICP.

Severe Remote Cerebellar Hemorrhage with Intracerebral Hemorrhage after Burr-Hole Evacuation for Chronic Subdural Hematoma

Since remote cerebellar hemorrhage, with intracerebral hemorrhage after supratentorial neurosurgery, is rare, its pathophysiology remains elusive. Here, we report a 64-year-old man who had severe bilateral symmetric remote cerebellar hemorrhage with frontal lobe hemorrhage following burr-hole evacuation for supratentorial chronic subdural hematoma. Computed tomography venography showed undeveloped left internal jugular vein and sigmoid sinus. He received 3 weeks of conservative treatment and fully recovered. Overdrainage of cerebrospinal fluid and head rotation with undeveloped internal jugular vein may have resulted in this complication. This case is the first case in the literature with this event sequence and has some significance for revealing the mechanism of remote cerebellar hemorrhage occurrence after other supratentorial surgeries.

Use of Pneumoperitoneal Puncture for Peritoneal Catheter Placement in Lumboperitoneal Shunt Surgery: Technical Note.

In hydrocephalus shunt surgery, a peritoneal catheter is traditionally inserted with laparotomy incision. The abdominal incision length will not be shorter than 3 cm in most cases. A longer incision has to be made in obese patients. The lateral position in lumboperitoneal shunt (LPS) surgery also increases the difficulty of laparotomy. This report introduces a simple technique of pneumoperitoneal puncture for peritoneal catheter placement in LPS surgery. Twenty-eight communicating hydrocephalus cases underwent pneumoperitoneal puncture in an LPS operation. Abdominal incision length, time for peritoneal catheter placement, and postoperative complications were recorded. The length of the abdominal incision was 1cm, and the average time for peritoneal catheter placement was 3.5 minutes. No patient suffered from infection and obstruction. Two cases of subdural hematoma because of cerebrospinal fluid overdrainage occurred. The pneumoperitoneal puncture technique has proven, in our experience, to be a minimally invasive, simple, and reliable method in a peritoneal catheter placement procedure. This technique, which needs to be assessed further by larger case series, may be considered a new method of choice for peritoneal catheter placement in LPS surgery.

Tethered Cord as a Complication of Chronic Cerebral Spinal Fluid Diversion.

The etiology and treatment of tethered cord syndrome remains controversial, especially in adults. We present an unusual case of tethered cord syndrome with an associated epidural lipomatosis likely due to chronic over shunting of cerebrospinal fluid (CSF). A 25-year-old woman had a history of Chiari malformation, hydrocephalus, and a ventriculoperitoneal shunt. She demonstrated progressively worsening gait, which led to a diagnosis of myelopathy and a posterior cervical decompression and fusion was performed. Imaging revealed engorgement of the epidural veins ventral to the spinal cord which was causing cord compression. Magnetic resonance (MR) imaging of the lumbar spine demonstrated a low-lying conus at the level of L2-L3 with an absence of CSF in the lumbar cistern. This was associated with this was a widening of the epidural space with secondary epidural lipomatosis. She underwent a laminectomy of L5 as well as decompression of the inferior aspect of the L4 and superior aspect of the S1 lamina. No free flow of CSF could ever be appreciated as was suggested by postoperative MR imaging. Postoperatively, the patient did well and was discharged in stable condition. Tethering of the spinal cord, associated with epidural lipomatosis, may be secondary to over-drainage of CSF. Symptoms of back pain and tethered cord phenomenon may warrant surgical intervention.

Cervical Myelopathy Caused by Engorgement of the Epidural Venous Plexus due to Cerebrospinal Fluid Overdrainage: Case Report and Review of the Literature

This is a case report of a 33-year-old woman with cervical myelopathy caused by an enlargement of the cervical venous plexus, after she was submitted to a ventriculoperitoneal (VP) shunt that evolved to overdrainage. Magnetic Resonance Imaging (MRI) revealed an epidural venous enlargement within the spinal channel, with a 50% narrowing from C2 to C5, and spinal cord compression. A shunt revision was performed using a programmable drainage system, and a second MRI revealed the absence of the venous enlargement, resulting in cervical spinal cord decompression and remission of neurological symptoms. Compressive myelopathy consequent to the enlargement of the epidural venous plexus related to the overdrainage of the ventriculoperitoneal shunt system without typical signs of intracranial hypotension may result in misleading etiological diagnoses. Acknowledging this disorder is important to distinguish it from neoplastic processes or hematomas, for which surgical intervention may be needed.