腰大池腹腔分流（课堂PPT）

St.MariannaUniversitySchoolofMedicineDepartmentofNeurosurgeryKotaroOshioM.D.PhD.Thepreparationandpracticalsurgicaltechniqueoflumboperitonealshunts

腰大池-腹腔分流术前准备及临床手术方法12TopicsHistoricalbackgroundofLPshuntingLP分流的历史背景BenefitsandcomplicationsofLPshuntingExperienceinusingLPshuntingLP分流的优势及并发症——使用经验IndicationofLPshuntingDiagnosisiNPHaccordancewiththeguidelinesLP分流的适应症——自发性正常颅压脑积水的诊断VideoseminarThedetailedprocedureofLPshunt手术视频——LP分流的具体步骤22023/1/13

WhyLPshuntwasnotstandard?

AndWhyLPshuntnow?为什么LP分流曾经不是标准而现在广泛使用？

FirstintroductionofLPshuntwas1950’s.Fortreatmentofhydrocephalus.LP分流最早于1950年推出，以治疗脑积水Simpletechnique但技术很简单MostneurosurgeonhesitatetodoLPshunt.Because“Toomuchcomplication”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32023/1/13Improvement改良Material&Equipment材料和设备“Diagnosis”

诊断42023/1/13HistoryofLPshuntLP

LP分流的历史1950’sfirstintroductionMaterial:polyethylene聚乙烯->Xinducearachnoiditisandscoliosis

引起蛛网膜炎和脊柱侧凸1975Selmanet.al.Material:Silicone硅树脂->OlessarachnoiditisandscoliosisComplication:

LPshunt＞VPshunt

posturaloverdrainage:SDFC&SDHEtc.

Diagnosis&Treatmentdifficult!

favorableindication:communicatinghydrocephalus给诊断和治疗带来困难Improvementofthematerial材料的改进Unfortunately, NOadjustablevalve! NOCTscan,NOMRI!没有可调压阀门，没有CT，没有MRIMRICTAntisiphondeviceAdjustableValveAccuratediagnosis&lesscomplicationinshuntsurgery准确诊断、并发症少52023/1/13BeforemakingguidelineofiNPHHebbandCusimanoNeurosurgery:49,No.5,2001ShuntingINPHsystematicreview:Suggest:CriteriaforiNPHisnotunified

(没有统一的标准

iNPH)significantimprovement:only29%(range10-100%)Complicationsoccurredin38%(range,5–100%)Requiredadditionalsurgery22%(range,0–47%)permanentneurologicaldeficitanddeath:6%(range,0–35%)

life-threateningintraparenchymalorsubdural hematomasrequiringsurgicalevacuation.⇒ThispaperisFoundationofguideline62023/1/13DiagnosisEvolution

诊断的发展Diagnosticradiologicalequipment:

CT,MRIClarifyofthepathophysiology:iNPHguideline放射诊断设备：CT，MRI

明确的病理生理：INPH方针Before2000

iNPH“Treatabledementia”Shuntresponderonly29%

在2000年之前，INPH“可治疗老年痴呆症”分流治疗者只有29％Diseasedementia(Alzheimertype)老年痴呆症Neurodegenerativedisease神经退行性疾病Complication38%iNPHShuntresponder80%complication20%Now72023/1/13ComplicationsofLPshunting.

LP分流的并发症

WangVYet.al.USCFgroupNeurosurgery.2007;60:1045-874Patients(Average47.6y)NPH(14)19%Communicatinghydrocephalus(8)11%Pseudotumorcerebri(26)35%Pseudomeningocele(15)20%CSFleak(11)15%ComplicationRevision:27cases(36.5%)Overdrainagesymptoms:11cases(14.8%)infection:3cases(4%)NoseriouscomplicationOnly30%82023/1/13RecentreportofLPshuntLPshuntequallyeffectiveasVPshuntComplicationratesignificantreduce

noincidenceofsubduralhematoma

hygroma&lowcomplicationObstruction1(1%)LumbercatheterMigration3(9%)Pseudomeningocele2(6%)Infection2(6%)Overdrainage2(6%)PeritonealcatheterMigration1(3%)Abdominalpain1(3%)

Lumboperitonealshuntsforthetreatmentofnormalpressurehydrocephalus

O.Bloch,M.W.McDermott/JournalofClinicalNeuroscience19(2012)1107–1111BenefitsofLPshunting“Avoidintraparenchymalhematomawithventricularcatheterplacement.”92023/1/13BenefitsofLPshunting

LP分流的优势“Avoidintraparenchymalhematomawithventricularcatheterplacement.”避免脑室导管穿刺部位发生脑实质血肿HebbandCusimanoNeurosurgery:49,No.5,2001ShuntingINPHsystematicreview:Complicationsoccurredin38%(range,5–100%)Requiredadditionalsurgery22%(range,0–47%)permanentneurologicaldeficitanddeath:6%(range,0–35%)

Seriouscomplication:

life-threateningintraparenchymalorsubduralhematomasVPshunt102023/1/13ComplicationsofLPshuntingShuntoverdrainage:过度分流

CSFleakagesubduralfluidcollectionsubduralhematomaShuntmalfunction:obstructionmigrationofshuntcatheterflippingtheshuntvalveInfectionFactor:ShuntvalvepressurePeritonealpressure阀门压力和腹腔压力->Whatisbest?DiameterdifferencebetweenLumbercatheter&TUHOYNeedle导管和腰穿针之间存在直径差Factor&counterplan原因及对策Sterileoperation&Appropriateantimicrobial无菌操作和适当的抗生素Howshouldwesettheappropriateshuntpressure?应该如何设置相应的分流压力？Importantsurgicaltips: anchoringcatheter Shuntvalvefixation系住导管、固定阀门112023/1/13Foravoidingseverecomplication

如何避免严重的并发症PointAppropriateshuntpressuresetting设定适当的分流压力Avoidunintentionalvalvepressurechange防止阀门设定压力意外改变LPshunting(nopuncturebrain)

LP分流（无穿刺大脑）Polarisiseffective.Ihavenotexperiencedaunintentionalpressurechange.122023/1/13ThemannerofinitialValvePressuredecision

阀门压力的调节方法OpeningPressureatImplantation植入时设定的压力Toavoidsubduralhematomasinolderpatients,weinitiallyestablishahighopeningpressureanddecreaseitstepbystepwhennecessary.

初始高压，然后根据需要逐步调低AnotherFactorObesity;choicealittlelowerpressure肥胖患者，可以选择低一点的压力BergsneiderMetal.Neurosurgery.2004;55:851-8Evenveryhighopeningvalvepressuresetting(≧170mmH2O)

resultedinasignificantreductionICP132023/1/13PredictedshuntunderdrainagedidnotoccurevenattheOPVsettingof200mmH2O

阀门压力设定为200mmH2O也没有发生分流不足ICPmeasurementat11NPHpatientsimplantedprogrammableshuntvalvewithoutanantisiphondevice.ActualCSFpressurewaveform142023/1/13ObesitymakesCSFpressure肥胖会使脑脊液压力上升

152023/1/13Riskfactorforintraabdominalhypertension

腹内高血压的风险因素ReintamBlaserAet.al.

ActaAnaesthesiolScand.201155(5):607-14Riskfactorsforintra-abdominalhypertensioninmechanicallyventilatedpatients.162023/1/13QuickRefererenceTable

forsuitableshuntpressureConcept:obesity=IAPsuitablevalvepressure

理念：肥胖=IAP适合的阀门压力HydrostaticpressureValvePressure＝CSFflowvolumeIntra-abdominalPressure(IAP)腹内压IntracranialPressure(ICP)Ref)MiyakeHet.al.NeurolMedChir(Tokyo)48,427~432,2008Desirableconditionunderdrainageoverdrainage172023/1/13ForAvoidunintentionalvalvepressurechange

防止阀门设定压力意外改变

Basicconceptofus基本的治疗理念LossofadjustabilityafterMRIexamination.MRI检查后丧失调节能力

Aboveall,unintentionalchangesinpressuresetting.设定好的阀门压力发生意外改变182023/1/13AkbarM.LossofAdjustabilityofCodman-MedosHydrocephalusValvesafterExposureto3.0TMRI.NewEngland.J.Med.2005;353:1413-1414.«

6outof12(50%)testedCodman-Medosvalvesshowedpermanentfailureofadjustabilityafterexposuretoa3.0TMRI…Incontrast,alltestedSophy-SU8devicescouldstillbere-ajustedafterallprocedures

».12枚Codman-Medos阀门中6枚在接触3.0TMRI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。LossofadjustabilityafterMRIexaminationMRI检查后丧失调节能力

192023/1/13NomuraS.Effectofcellphonemagneticfieldsonadjustablecerebrospinalfluidshuntvalves.SurgicalNeurology,63(2005),467-468.可以改变不同阀门压力的最小磁通密度UtsukiS.AlterationofthePressureSettingofaCodman-HakimProgrammablevalvebyaTelevision.Neurol.Med.Chir.(Tokyo)46,405-407,2006..«

…weshouldrecognizethattherearemanysourcesofweakmagneticfieldsthatmayinfluenceaprogrammablevalveineverydaylife

».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

Dailylifemagneticfields(1)日常生活中的磁场（1）202023/1/13ZuzakT.J.Magnetictoys:forbiddenforpediatricpatientswithcertainprogrammablevalves.?Child’sNervousSyst.25:161-164(2009).AndersonR.Adjustmentandmalfunctionofaprogrammablevalveafterexposuretotoymagnets.J.Neurosurg.:Pediatrics101:222-225.«

BothCodmanandStrataprogrammablevalvesrevealedalterationsofpressuresettingsafterexposuretocommerciallyavailabletoymagnets.

»Surgeonsshouldwarnthefamiliesofpatientswithprogrammablevalvestoavoidtoymagnets.»«

ItwasshownthatthemagneticpropertiesofmagnetictoysareofsufficientstrengthtoalterprogrammableStrataandCodmanvalves.

»Dailylifemagneticfields(2)日常生活中的磁场（2）212023/1/13headphones 14.0mTearphones(Walkman) 23.0mTcordlesstelephone 34.0mTcellulartelephone 17.5mTtoymagnet 67à82mTDeSchneideretal.J.Neurosurgery96:331-334,2002Potentialsourcesofdysadjustment–dailylife222023/1/13IndicationofLPshuntingCommunicatinghydrocephalus交通性脑积水idiopathicNormalPressureHydrocephalus(iNPH)自发性正常颅压脑积水SecondaryNormalPressureHydrocephalus继发性正常颅压脑积水

Contraindication:obstructivehydrocephalus禁忌症：梗阻性脑积水Exclusion!:Intracranialsolidoccupyinglesion(+)Queckenstedttestpositive

Itisimportanttodiagnoseinaccordancewiththeguidelines232023/1/13idiopathicNormalPressureHydrocephalus(iNPH)Age:≧

60y.o.(JapaneseiNPHGL)ref)≧40y.o.(RelkinNet.al.Neurosurgery2005,iNPHguidelineUS&Euro)Symptom(Triad)≧

1：gaitdisturbance,urinaryincontinence,dementiaRadiologicalfindings:Ventricledilatation(Evansindex>0.3),CSFpressure<200mmH2ODiagnosis:CSFdrainagetest(US&Euro),CSFtaptest(≧30ml)(J)->Improvement=ProbableiNPHTreatment:Shuntsurgery(V-Pshunt,L-Pshunt) ->Improvement=DefiniteiNPHImprovementsymptom:Gait>UI>Dements242023/1/13SINPHONI

(ThestudyofiNPHonneurologicalimprovement)iNPHspecificradiologicalfeature: Ventriculomegaly Tighthigh-convexityandmedialsubarachnoidspace ExpandedsylvianfissureHashimotoMet.al.CerebrospinalFluidRes.20107:18.DiagnosisofidiopathicnormalpressurehydrocephalusissupportedbyMRI-basedscheme:aprospectivecohortstudy.DifferentwithbrainatrophyDESH(DisproportionatelyEnlargedSubarachnoid-spaceHydrocephalus)Shunteffectiverate≧80%252023/1/13ClassificationofNormalPressureHydrocephalus(NPH)NPHIdiopathicNPHDESHNon-DESHSecondaryNPHAcquiredetiologiesCongenital/DevelopmentaletiologiesDESH(DisproportionatelyEnlargedSubarachnoid-spaceHydrocephalus)≧

60y.o.(JapaneseiNPHGL)80%20%262023/1/13EtiologyofiNPHProbableiNPHisestimated:aminimumprevalenceofiNPHinourpopulationof21.9/100,000.PrevalenceofprobableidiopathicnormalpressurehydrocephalusinaNorwegianpopulation.BreanA,EidePK.ActaNeurolScand2008:118:48–53272023/1/13MRIfeatureofiNPH282023/1/13WhyLPshunt?beforeiNPHguideline(20thcentury)OncerelinquishsurgeryforiNPHsecondary

hydrocephalus(relativelyyoung)hydrocephalusinchildren

mostlyadapttheVPshunt.2004iNPHguidelinestheproportionofelderlypatientsLPshuntispreferredthanVPshuntAvoidintraparenchymalhematomawithventricularcatheterplacement.<SINPHONI>iNPHpatients:Age74.5+5.1Y.O.292023/1/13

Videoseminar

ThedetailedprocedureoflumboperitonealshuntIntroductionofSurgicalmaterials&Design手术耗材和设计介绍Preoperativepreparation:术前准备shuntvalveadjusting阀门调节Operationroomarrangement手术室安排Positioning摆体位Surgicalprocedure(video)手术过程（视频）302023/1/13Lumbo-peritonealCatheter

腰大池-腹腔导管

TheSophysaLumbo-PeritonealCatheterSet

索菲萨LP分流导管套装-Lumbarcatheter（腰椎管）,0.76mmID,1.6mmOD,length60cm,multi-perforatedproximaltip,radiopaque,depthmarkingsat11,16,21,26cmfromtheproximaltip.

-Intermediarycatheter（中间管）,1.1mmID,2.5mmOD,length10cm,withintegratedproximalasymmetricstep-downconnectorforattachmenttolumbarcatheter,radiopaquestripe.（在腰椎管和阀门中间过度连接）

-Peritonealcatheter（腹腔管）,1.1mmID,2.5mmOD,length70cm,multiperforatedopenend,radiopaquestripe.

-Tuohyneedle14Gauge,length9cm.

-FemaleLuer-Lockconnector（Luer接头）.312023/1/13Adjustmentforvalvepressure[Polaris]PositionOperatingPressure(mmH2O)

SPVSPV-140SPV-300SPV-4001301050802704010015031108015023041501102203305200140300400SPVA:Polaris®AdjustableValve,30-200,AntechamberPreoperativepreparation322023/1/13<A-Pview>DesignofLPshuntPolaris®

valvePeritonealcatheterLumbarcatheterIntermediarycatheter*Design:Shuntvalvewouldplaceaboveiliaccrestforpumping.332023/1/13DesignofLPshuntPolaris®

valvePeritonealcatheterLumbarcatheterIntermediarycatheter<Lateralview>342023/1/13OperatingroomarrangementAnesthesiologistSurgeonSurgeonBipolar&monopolarcoagulatorsuctionApparatus&nurseArmstandApparatus&nurse352023/1/13Positioning&skinincision

LateralpositionArmstandFixation@ Sternum&Pubis<