1、St. Marianna University School of Medicine Department of Neurosurgery Kotaro Oshio M.D. PhD.,The preparation and practical surgical technique of lumboperitoneal shunts 腰大池-腹腔分流术前准备及临床手术方法,Topics,Historical background of LP shunting LP分流的历史背景 Benefits and complications of LP shunting Experience in us
2、ing LP shunting LP 分流的优势及并发症使用经验 Indication of LP shunting Diagnosis iNPH accordance with the guidelines LP分流的适应症自发性正常颅压脑积水的诊断 Video seminar The detailed procedure of LP shunt 手术视频LP分流的具体步骤,Why LP shunt was not standard? And Why LP shunt now? 为什么LP分流曾经不是标准而现在广泛使用？,First introduction of LP shunt was
3、1950s. For treatment of hydrocephalus. LP分流最早于1950年推出，以治疗脑积水 Simple technique但技术很简单,Most neurosurgeon hesitate to do LP shunt.Because “Too much complication” then. 很多的神经外科大夫由于术后太多的并发症，而放弃LP分流,Improvement 改良,Material & Equipment 材料和设备 “Diagnosis” 诊断,History of LP shunt LP LP 分流的历史,1950s first introdu
4、ction Material : polyethylene 聚乙烯 - X induce arachnoiditis and scoliosis引起蛛网膜炎和脊柱侧凸 1975 Selman et.al. Material : Silicone 硅树脂 - O less arachnoiditis and scoliosis Complication : LP shunt VP shunt postural overdrainage : SDFC & SDH Etc.,Diagnosis & Treatment difficult !favorable indication: communic
5、ating hydrocephalus 给诊断和治疗带来困难,Improvement of the material 材料的改进,Unfortunately, NO adjustable valve !NO CT scan, NO MRI ! 没有可调压阀门，没有CT，没有MRI,MRI,CT,Accurate diagnosis & less complicationin shunt surgery 准确诊断、并发症少,Before making guideline of iNPH,Hebb and Cusimano Neurosurgery: 49, No. 5, 2001 Shuntin
6、g INPH systematic review : Suggest : Criteria for iNPH is not unified (没有统一的标准 iNPH) significant improvement: only 29% (range 10-100%) Complications occurred in 38% (range, 5100%) Required additional surgery 22% (range, 047%) permanent neurological deficit and death: 6% (range, 035%)life-threatening
7、 intraparenchymal or subdural hematomas requiring surgical evacuation., This paper is Foundation of guideline,Diagnosis Evolution 诊断的发展,Diagnostic radiological equipment: CT, MRI Clarify of the pathophysiology: iNPH guideline 放射诊断设备：CT， MRI 明确的病理生理： INPH方针,Complications of LP shunting. LP分流的并发症,Wang
8、 VY et. al. USCF group Neurosurgery. 2007 ;60 :1045-8 74 Patients (Average 47.6 y) NPH (14) 19% Communicating hydrocephalus (8) 11% Pseudotumor cerebri (26) 35% Pseudomeningocele (15) 20% CSF leak (11) 15%Complication Revision : 27 cases (36.5%) Over drainage symptoms: 11 cases (14.8%) infection : 3
9、 cases (4%) No serious complication,Only 30%,Recent report of LP shunt,LP shunt equally effective as VP shunt Complication rate significant reduceno incidence of subdural hematoma hygroma & low complicationObstruction 1 (1%) Lumber catheter Migration 3 (9%) Pseudomeningocele 2 (6%) Infection 2 (6%)
10、Overdrainage 2 (6%) Peritoneal catheter Migration 1 (3%) Abdominal pain 1 (3%),Lumboperitoneal shunts for the treatment of normal pressure hydrocephalus O. Bloch, M.W. McDermott / Journal of Clinical Neuroscience 19 (2012) 11071111,Benefits of LP shunting“Avoid intraparenchymal hematoma with ventric
11、ular catheter placement.”,Benefits of LP shunting LP分流的优势,“Avoid intraparenchymal hematoma with ventricular catheter placement.” 避免脑室导管穿刺部位发生脑实质血肿Hebb and Cusimano Neurosurgery: 49, No. 5, 2001 Shunting INPH systematic review : Complications occurred in 38% (range, 5100%) Required additional surgery
12、 22% (range, 047%) permanent neurological deficit and death: 6% (range, 035%)Serious complication : life-threatening intraparenchymal or subdural hematomas,VP shunt,Complications of LP shunting,Shunt over drainage:过度分流 CSF leakage subdural fluid collection subdural hematomaShunt malfunction: obstruc
13、tion migration of shunt catheter flipping the shunt valve Infection,Factor: Shunt valve pressure Peritoneal pressure 阀门压力和腹腔压力- What is best ?,Diameter difference between Lumber catheter & TUHOY Needle 导管和腰穿针之间存在直径差,Factor & counterplan 原因及对策,Sterile operation & Appropriate antimicrobial 无菌操作和适当的抗生素
14、,How should we set the appropriate shunt pressure? 应该如何设置相应的分流压力？,Important surgical tips: anchoring catheterShunt valve fixation 系住导管、固定阀门,For avoiding severe complication 如何避免严重的并发症,PointAppropriate shunt pressure setting 设定适当的分流压力Avoid unintentional valve pressure change 防止阀门设定压力意外改变LP shunting (
15、no puncture brain) LP分流（无穿刺大脑）,Polaris is effective. I have not experienced a unintentional pressure change.,The manner of initial Valve Pressure decision 阀门压力的调节方法,Opening Pressure at Implantation植入时设定的压力 To avoid subdural hematomas in older patients, we initially establish a high opening pressure
16、and decrease it step by step when necessary.初始高压，然后根据需要逐步调低Another Factor Obesity; choice a little lower pressure 肥胖患者，可以选择低一点的压力,Bergsneider M et al. Neurosurgery. 2004; 55 :851-8,Even very high opening valve pressure setting (170mmH2O) resulted in a significant reduction ICP,Predicted shunt under
17、drainage did not occur even at the OPV setting of 200 mm H2O 阀门压力设定为200mmH2O也没有发生分流不足,ICP measurement at 11 NPH patients implanted programmable shunt valve without an antisiphon device .,Actual CSF pressure wave form,Obesity makes,CSF pressure 肥胖会使脑脊液压力上升,Risk factor for intraabdominal hypertension
18、腹内高血压的风险因素,Reintam Blaser A et.al. Acta Anaesthesiol Scand. 2011 55(5):607-14 Risk factors for intra-abdominal hypertension in mechanically ventilated patients.,Quick Refererence Table for suitable shunt pressure,Concept: obesity = IAP suitable valve pressure 理念： 肥胖=IAP 适合的阀门压力,Hydrostatic pressure,
19、Valve Pressure CSF flow volume,Intra-abdominal Pressure (IAP)腹内压,Intracranial Pressure (ICP),Ref) Miyake H et.al. Neurol Med Chir (Tokyo) 48, 427432, 2008,Desirable condition,underdrainage,overdrainage,For Avoid unintentional valve pressure change 防止阀门设定压力意外改变,Basic concept of us基本的治疗理念 Loss of adju
20、stability after MRI examination. MRI检查后丧失调节能力 Above all, unintentional changes in pressure setting.设定好的阀门压力发生意外改变,Akbar M. Loss of Adjustability of Codman-Medos Hydrocephalus Valves after Exposure to 3.0T MRI. New England. J. Med. 2005; 353 : 1413 -1414., 6 out of 12 (50%) tested Codman-Medos valves
21、 showed permanent failure of adjustability after exposure to a 3.0 T MRI In contrast, all tested Sophy-SU8 devices could still be re-ajusted after all procedures . 12枚Codman-Medos阀门中6枚在接触3.0T MRI后，被消磁，永久丧失调节能力，而索菲SU8阀门在相同情况下，不受影响。,Loss of adjustability after MRI examination MRI检查后丧失调节能力,Nomura S. Ef
22、fect of cell phone magnetic fields on adjustable cerebrospinal fluid shunt valves. Surgical Neurology, 63(2005), 467-468. 可以改变不同阀门压力的最小磁通密度,Utsuki S. Alteration of the Pressure Setting of a Codman-Hakim Programmable valve by a Television. Neurol. Med. Chir. (Tokyo) 46, 405-407, 2006, we should recog
23、nize that there are many sources of weak magnetic fields that may influence a programmable valve in everyday life . 日常生活中有许多的若磁场，可能造成可调压阀门压力发生意外改变,Daily life magnetic fields (1) 日常生活中的磁场（1）,Zuzak T.J. Magnetic toys: forbidden for pediatric patients with certain programmable valves.? Childs Nervous S
24、yst. 25: 161-164 (2009).,Anderson R. Adjustment and malfunction of a programmable valve after exposure to toy magnets. J. Neurosurg. : Pediatrics 101 : 222-225., Both Codman and Strata programmable valves revealed alterations of pressure settings after exposure to commercially available toy magnets.
25、 Surgeons should warn the families of patients with programmable valves to avoid toy magnets., It was shown that the magnetic properties of magnetic toys are of sufficient strength to alter programmable Strata and Codman valves. ,Daily life magnetic fields (2) 日常生活中的磁场（2）,headphones 14.0 mTearphones
26、 (Walkman) 23.0 mTcordless telephone 34.0 mTcellular telephone 17.5 mTtoy magnet 67 82 mTDe Schneider et al. J.Neurosurgery 96:331-334, 2002,Potential sources of dysadjustment daily life,Indication of LP shunting,Communicating hydrocephalus 交通性脑积水 idiopathic Normal Pressure Hydrocephalus (iNPH) 自发性正
27、常颅压脑积水Secondary Normal Pressure Hydrocephalus继发性正常颅压脑积水Contraindication: obstructive hydrocephalus禁忌症：梗阻性脑积水Exclusion! : Intracranial solid occupying lesion (+)Queckenstedt test positive,It is important to diagnose in accordance with the guidelines,idiopathic Normal Pressure Hydrocephalus (iNPH),Age
28、 : 60 y.o. (Japanese iNPH GL) ref) 40 y.o. ( Relkin N et.al. Neurosurgery 2005, iNPH guideline US & Euro) Symptom (Triad) 1： gait disturbance, urinary incontinence, dementia Radiological findings: Ventricle dilatation (Evans index 0.3), CSF pressure Improvement = Probable iNPH Treatment: Shunt surge
29、ry (V-P shunt, L-P shunt)- Improvement = Definite iNPH,Improvement symptom:Gait UI Dements,SINPHONI (The study of iNPH on neurological improvement),iNPH specific radiological feature :VentriculomegalyTight high-convexity and medial subarachnoid spaceExpanded sylvian fissure,Hashimoto M et. al. Cereb
30、rospinal Fluid Res. 2010 7:18. Diagnosis of idiopathic normal pressure hydrocephalus is supported by MRI-based scheme: a prospective cohort study.,Different with brain atrophy,DESH (Disproportionately Enlarged Subarachnoid-space Hydrocephalus),Shunt effective rate 80%,Classification of Normal Pressu
31、re Hydrocephalus (NPH),DESH (Disproportionately Enlarged Subarachnoid-space Hydrocephalus), 60 y.o. (Japanese iNPH GL),80%,20%,Etiology of iNPH,Probable iNPH is estimated: a minimum prevalence of iNPH in our population of 21.9/100,000.,Prevalence of probable idiopathic normal pressure hydrocephalus
32、in a Norwegian population. Brean A, Eide PK. Acta Neurol Scand 2008: 118: 4853,MRI feature of iNPH,Why LP shunt?,before iNPH guideline (20th century) Once relinquish surgery for iNPH secondary hydrocephalus (relatively young ) hydrocephalus in childrenmostly adapt the VP shunt. 2004 iNPH guidelines
33、the proportion of elderly patients LP shunt is preferred than VP shunt Avoid intraparenchymal hematoma with ventricular catheter placement., iNPH patients : Age 74.5 + 5.1 Y.O.,Video seminar The detailed procedure of lumboperitoneal shunt,Introduction of Surgical materials & Design 手术耗材和设计介绍 Preoper
34、ative preparation: 术前准备 shunt valve adjusting 阀门调节 Operation room arrangement 手术室安排 Positioning 摆体位 Surgical procedure (video) 手术过程（视频）,Lumbo-peritoneal Catheter 腰大池-腹腔导管 The Sophysa Lumbo-Peritoneal Catheter Set 索菲萨LP分流导管套装,- Lumbar catheter（腰椎管）, 0.76 mm ID,1.6 mm OD, length 60 cm, multi-perforate
35、d proximal tip, radiopaque, depth markings at 11, 16, 21, 26 cm from the proximal tip. - Intermediary catheter（中间管）, 1.1 mm ID, 2.5 mm OD, length 10 cm, with integrated proximal asymmetric step-down connector for attachment to lumbar catheter, radiopaque stripe.（在腰椎管和阀门中间过度连接） - Peritoneal catheter（
36、腹腔管）,1.1 mm ID,2.5 mm OD, length 70 cm, multiperforated open end, radiopaque stripe. - Tuohy needle 14 Gauge, length 9 cm. - Female Luer-Lock connector（Luer 接头）.,Adjustment for valve pressure Polaris,SPVA : Polaris Adjustable Valve, 30-200, Antechamber,Preoperative preparation,Design of LP shunt,Pol
37、aris valve,Peritoneal catheter,Lumbar catheter,Intermediary catheter,* Design : Shunt valve would place above iliac crest for pumping.,Design of LP shunt,Operating room arrangement,Apparatus & nurse,Positioning & skin incision Lateral position,Arm stand,Fixation Sternum & Pubis,Fixation Thoracic spi
38、ne & Sacrum,For lumber puncture,Open the operative field,LP shunting is simple!,Lumbar puncture , insert lumbar catheter Open the abdomen place the shunt valve above the iliac bone(髂骨). connect the catheter each parts & implant and closing.,The main steps of the procedure,LP shunt simple 4 steps,Vid
39、eo time!,Postoperative follow up 术后随访,observation point 观察点 Overdrainage symptoms Underdrainage symptoms check CT scan & adjust valve pressure 检查CT并调节阀门压力Mostly in a couple of month !(also reported in a couple of year),Headache, nausea 头痛，恶心,Thank you for your attention. I hope you learned something
40、 today.感谢您的关注。 我希望你今天学到了一些东西。,Dont hesitate to do LP shunt !,Lumbo-Peritoneal Catheter Set (Sophysa),The tips of lumbar puncture,Direction for Tuohy Needle,Height : L3/4 L4/5,Placement of lumbar catheter,Lumbar catheter length : once insert until 3rd marker （=27cm） remove TUOHY needle carefully remove 5-6cm from 3rd marker,
