Shunt Complications - Staying Out of Trouble.

BACKGROUND AND OBJECTIVE: To analyze the common problems in shunt surgery and measures to avoid them. Management of hydrocephalus takes up as much as 50% of a pediatric ' 'neurosurgeon's time, and these are notoriously prone to complications. In this article, the author analysis his series of ventriculoperitoneal shunts and discusses his technique, nuances and avoidance of shunt complications. METHODS AND MATERIALS: The author will review common issues related to hydrocephalus shunt management with a review of 549 procedures and associated complications. RESULTS: Key features and basic principles of complication avoidance in shunt surgery is provided. The analysis looks into the complications and ways to avoid them based on the author's experience. CONCLUSIONS: Specific measures may be adopted to minimize or avoid these complications. These will be discussed based on the author's series and experiences.

Rosette-forming Glioneuronal Tumor in the Optic Pathway of a Child.

Rosette-forming glioneuronal tumor is a rare World Health Organization grade I neoplasm, primarily involving the posterior fossa. Most cases have been reported in young adults. Although maximal surgical resection is advocated, a precise treatment modality is yet to be established. We describe an unusual presentation of rosette-forming glioneuronal tumor occurring in the optic pathway in a child. As the site of the tumor was not amenable to resection, he underwent radiotherapy and is currently well on follow-up.

Unique mishap following transfacial pin fixated midface distraction and successful management using nasal endoscopy.

A 2-year-old female child with craniosynostosis was referred to our unit for definitive management. She presented with a turricephalic head, hypoplastic midface and obstructive sleep apnoea. Routine preoperative workup included radiographs, CT and polysomnography. She was provisionally planned for calvarial remodelling and midface advancement using transfacial pin fixated distractor (TPF). This involves insertion of a K-wire from one zygoma to the other, a few millimetres below the orbits, traversing across maxilla and nasal cavity. The ends of K-wire are then connected to the distractor anchored firmly to the temporal bone. During insertion, the K-wire transected the nasogastric tube. This technical disaster was circumvented by endoscopic-guided disengagement prior to recovery. The purpose of this paper is to discuss the probable causes that lead to such untoward instances and strategies to avoid and manage the same.

Shunt infections: a review and analysis of a personal series.

INTRODUCTION AND PURPOSE: CSF diversion shunts are notoriously prone to complications. The most difficult to manage among them is shunt infection, which warrants a prolonged hospital stay. The aim of this paper is to review the pattern of infections, the pathology, and management of shunt infections with special reference to a tertiary pediatric center in a developing country. MATERIALS AND METHODS: This is a review of shunt infections in general and a retrospective study of all cases operated in the hospital from 2000 to 2015. RESULTS: The authors analyze the data and try to discern patterns, which may enable newer interventions to treat as well as decrease the burden of shunt infections in the future. CONCLUSION: It is difficult to determine the true incidence of shunt infections as there is no definition of what constitutes a shunt infection. There are no standardized international guidelines as to how to deal with an infected shunt. Though the ability to treat shunt infection has improved and the incidence of shunt infection has decreased over time, there is still no consensus on the best way to manage it. The prevention is predominantly based on common sense and has helped but a more scientific algorithm is the need of the hour.

Acute onset of postoperative syringohydromyelia.

Syringohydromyelia is a frequent finding in cases of tethered cord syndrome. The classical teaching is that the development and progression of a syrinx is a chronic process. We present a case report of an acute onset syringomyelia in an infant, who underwent an excision of a lumbosacral transitional lipoma and detethering of the cord. Immediately after recovery, the infant was found to have flaccid paraplegia. An emergency magnetic resonance imaging revealed a large acute onset syringomyelia for which he underwent an emergency midline myelotomy and release of fluid from the syrinx. Though the eventual recovery was good, this made us re-visit our understanding of the concept of syringohydromyelia. The case details and a plausible hypothesis for the rapid development of the syrinx are presented.

Remote delayed recurrence of craniopharyngioma after radiotherapy.

The aim was to present a rare case of recurrent craniopharyngioma remote from the primary site of origin. A young girl was operated for sellar region craniopharyngioma. For a small residual tumor, she underwent radiotherapy. Follow-up imaging did not reveal any residual tumor or recurrence. Surveillance magnetic resonance imaging after 5 years revealed a recurrence in the right Sylvian fissure. This tumor was totally excised. Recurrence of craniopharyngioma is well-known, but recurrence at a site remote from the original site after radiotherapy is extremely rare. One such case is being presented.

Craniostenosis: a neurosurgeon's perspective.

In pediatric neurosurgery departments in India, craniosynostosis is being increasingly identified and dealt with during the past several years. The management of this problem is well established in units that have a strong pediatric bias, whereas it is still in infancy in certain departments. Some misconceptions exist regarding this condition with reference to clinical, genetic aspects and management-in particular, the surgical indications. The experience gained for more than 2 decades of treating this condition as well as the problems faced in the management of this condition will be discussed. Although the terms craniostenosis and craniosynostosis do not mean quite the same thing, the terms are used interchangeably and will be done so in this communication.

Management of CSF leak following spinal surgery.

PURPOSE: Postoperative CSF leak is a known complication of spinal surgery especially after surgery for neural tube defects (NTD). The problem can metamorphose into a severe infection. This article hopes to shed some light on the management of these problems and suggests precautions so as to reduce their occurrence. MATERIALS AND METHODS: A retrospective analysis of 102 children, between the ages of 1 day and 12 years, operated for various spinal pathologies, over the past 2.5 years by the same surgeon (CB) was done. The various methods of dural closure were noted. The methods of management of postoperative CSF leaks were analysed, and the patients were followed till discharge. RESULTS: The incidence of CSF leak was found to be 12.7%. The methods of management included lumbar drain only (n = 7), lumbar drain with re-exploration (n = 3), lumbar drain followed by lumboperitoneal shunt (n = 2) and only lumboperitoneal shunt (n = 1). The use of fibrin glue did not seem to significantly prevent the incidence of CSF leak in cases. CONCLUSIONS: Primary and meticulous dural closure is sine qua non in preventing postoperative CSF leak. A lumbar drain is a convenient and economical method of managing the problem initially failing which more invasive methods like re-exploration may be employed.

Craniostenosis.

Craniostenosis is a common problem in the pediatric neurosurgery departments. The management of this problem is still evolving. Some misconceptions exist regarding this condition particularly regarding the indications for surgery. The author started performing this surgery nearly two decades ago. The experience gained over time as well as the problems encountered are discussed.