腰大池腹腔分流.

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Topics1. Historical background of LP shunting LP分流的历史背景2. Benefits and complications of LP shunting Experience in u

2、sing LP shunting LP 分流的优势及并发症使用经验3. 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4. 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? 为什么为什么LP分流曾经不是标准而现在广泛分流曾经不是标准而现在广泛使用？使用？ First introdu

3、ction of LP shunt was 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.很多的神很多的神经经外科大夫由于外科大夫由于术术后太多的并后太多的并发发症，而放弃症，而放弃LP分流分流Improvement 改良改良1. Material & Equipment 材料和设备2. “Diagnosis

4、” 诊断History of LP shunt LPLP 分流的历史分流的历史 1950s first introduction Material : polyethylene 聚乙烯 - induce arachnoiditis and scoliosis 引起蛛网膜炎和脊柱侧凸 1975 Selman et.al. Material : Silicone 硅树脂 - less arachnoiditis and scoliosisComplication : LP shunt VP shunt postural overdrainage : SDFC & SDH Etc.Diagn

5、osis & Treatment difficult ! favorable indication: communicating 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MRIMRICTAntisiphon deviceAdjustable ValveAccurate diagnosis & less complication in shunt surgery准确诊断、

6、并发症少准确诊断、并发症少Before making guideline of iNPH Hebb and Cusimano Neurosurgery: 49, No. 5, 2001Shunting 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 s

7、urgery 22% (range, 047%) permanent neurological deficit and death: 6% (range, 035%)life-threatening intraparenchymal or subdural hematomas requiring surgical evacuation.Diagnosis Evolution诊断的发展诊断的发展 Diagnostic radiological equipment:CT, MRI Clarify of the pathophysiology: iNPH guideline放射诊断设备：CT， MR

8、I明确的病理生理： INPH方针Before 2000 iNPH “Treatable dementia”Shunt responder only 29% 在2000年之前，INPH“可治疗老年痴呆症”分流治疗者只有29Disease dementia(Alzheimer type)老年痴呆症Neurodegenerative disease神经退行性疾病Complication 38%iNPHShunt responder80%complication 20%NowComplications of LP shunting.LP分流的并发症分流的并发症 Wang VY et. al. USCF

9、 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 cases (4%) No

10、serious complicationOnly 30%Recent report of LP shunt LP shunt equally effective as VP shuntComplication rate significant reduceno incidence of subdural hematoma hygroma & low complication Obstruction 1 (1%) Lumber catheter Migration 3 (9%) Pseudomeningocele 2 (6%) Infection 2 (6%) Overdrainage

11、2 (6%) Peritoneal catheter Migration 1 (3%) Abdominal pain 1 (3%) Lumboperitoneal shunts for the treatment of normal pressure hydrocephalusO. Bloch, M.W. McDermott / Journal of Clinical Neuroscience 19 (2012) 11071111Benefits of LP shunting “Avoid intraparenchymal hematoma with ventricular catheter

12、placement.”Benefits of LP shuntingLP分流的优势分流的优势 “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 22% (rang

13、e, 047%) permanent neurological deficit and death: 6% (range, 035%) Serious complication : VP shuntComplications of LP shunting1. Shunt over drainage:过度分流 CSF leakage subdural fluid collection subdural hematoma2. Shunt malfunction: obstruction migration of shunt catheter flipping the shunt valve3. I

14、nfection阀门压力和腹腔压力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 fi

15、xation系住导管、固定阀门For avoiding severe complication如何避免严重的并发症如何避免严重的并发症1. Appropriate shunt pressure setting 设定适当的分流压力2. Avoid unintentional valve pressure change 防止阀门设定压力意外改变3. LP shunting (no puncture brain) LP分流（无穿刺大脑）Polaris is effective. I have not experienced a unintentional pressure change.The ma

16、nner of initial Valve Pressure decision阀门压力的调节方法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 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

17、pressure 肥胖患者，可以选择低一点的压力Bergsneider M et al. Neurosurgery. 2004; 55 :851-8Even very high opening valve pressure setting (170mmH2O)resulted in a significant reduction ICPPredicted shunt under 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

18、 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肥胖会使脑脊液压力上升 Risk factor for intraabdominal hypertension腹内高血压的风险因素腹内高血压的风险因素Reintam Blaser A et.al. Acta Anaesthesiol Scand. 2011 55(5):607-14Risk factors for

19、 intra-abdominal hypertension in mechanically ventilated patients.Quick Refererence Tablefor suitable shunt pressure Concept: obesity = IAP suitable valve pressure 理念： 肥胖=IAP 适合的阀门压力Hydrostatic pressureValve Pressure CSF flow volumeIntra-abdominal Pressure (IAP)腹内压Intracranial Pressure (ICP)Ref) Miy

20、ake H et.al. Neurol Med Chir (Tokyo) 48, 427432, 2008 Desirable conditionunderdrainageoverdrainageFor 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 uLoss of adjustability after MRI examination. MRI检查后丧失调节能力 uAbove all, unintentional changes in pressure setting.设定好

21、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 showed permanent failure of adjustability after exposure to a 3.0 T MRIIn contrast, all tested Sophy-SU

22、8 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 examinationMRI检查后丧失调节能力 Nomura S. Effect of cell phone magnetic fields on adjustable cerebrospinal fluid shunt valves. Surgical Neurology, 63(2

23、005), 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 recognize that there are many sources of weak magnetic fields that may influence a programmable valve in everyday

24、 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 Syst. 25: 161-164 (2009). Anderson R. Adjustment and malfunction of a programmable valve after exposure to toy

25、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.Surgeons should warn the families of patients with programmable valves to avoid toy magnets.It was shown that t

26、he 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）u headphones 14.0 mTu earphones (Walkman) 23.0 mTu cordless telephone 34.0 mTu cellular telephone 17.5 mTu toy magnet67 82 mTDe Schneider et al.

27、 J.Neurosurgery 96:331-334, 2002Potential sources of dysadjustment daily lifeIndication of LP shunting Communicating hydrocephalus 交通性脑积水交通性脑积水a. idiopathic Normal Pressure Hydrocephalus (iNPH) 自发性正常颅压脑积水b. Secondary Normal Pressure Hydrocephalus 继发性正常颅压脑积水 Contraindication: obstructive hydrocephalu

28、s 禁忌症禁忌症：梗阻性脑积水梗阻性脑积水 Exclusion! : Intracranial solid occupying lesion (+) Queckenstedt test positive It is important to diagnose in accordance with the guidelinesidiopathic Normal Pressure Hydrocephalus (iNPH) Age : 60 y.o. (Japanese iNPH GL) ref) 40 y.o. ( Relkin N et.al. Neurosurgery 2005, iNPH g

29、uideline 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 surgery (V-P shunt, L-P shunt)- Improvement = Definite iNPHImprovement symptom: Gait UI

30、 DementsSINPHONI (The study of iNPH on neurological improvement)iNPH specific radiological feature :VentriculomegalyTight high-convexity and medial subarachnoid spaceExpanded sylvian fissure Hashimoto M et. al. Cerebrospinal Fluid Res. 2010 7:18.Diagnosis of idiopathic normal pressure hydrocephalus

31、is supported by MRI-based scheme: a prospective cohort study. (Disproportionately Enlarged Subarachnoid-space Hydrocephalus)Shunt effective rate 80%Classification of Normal Pressure Hydrocephalus (NPH)NPHIdiopathic NPHDESHNon-DESHSecondaryNPHAcquiredetiologiesCongenital/Developmentaletiologies (Disp

32、roportionately 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 in a Norwegian population.Brean A, Eid

33、e PK. Acta Neurol Scand 2008: 118: 4853MRI feature of iNPHWhy LP shunt?before iNPH guideline (20th century) Once relinquish surgery for iNPH secondary hydrocephalus (relatively young ) hydrocephalus in children mostly adapt the VP shunt. 2004 iNPH guidelines the proportion of elderly patients LP shu

34、nt 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 1. Introduction of Surgical materials & Design 手术耗材和设计介绍2. Preoperative preparation: 术前准备A) shunt v

35、alve adjusting 阀门调节B) Operation room arrangement 手术室安排C) Positioning 摆体位3. Surgical procedure (video) 手术过程（视频）Lumbo-peritoneal Catheter腰大腰大池池-腹腔导管腹腔导管 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-perforated proximal tip, radiop

36、aque, 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（腹腔管）,1.1 mm ID,2.5 mm OD

37、, 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 PolarisPositionOperating Pressure (mm H2O) SPVSPV-140SPV-300 SPV-4001301050802704010015031108015023041501102203305200140300400SPVA : P

38、olaris Adjustable Valve, 30-200, AntechamberPreoperative preparation Design of LP shuntPolaris valvePeritoneal catheterLumbar catheterIntermediary catheter* Design : Shunt valve would place above iliac crest for pumping.Design of LP shuntPolaris valvePeritoneal catheterLumbar catheterIntermediary catheterOperating room arrangementAnesthesiologistSurgeonSurgeonBipolar & monopolar coagulatorsuctionApparatus & nurseArm standApparatus & nursePositioning & skin incisionLateral positi