CLINICAL STUDIES

VENTRICULOPERITONEAL SHUNT COMPLICATIONS

IN CALIFORNIA: 1990 TO 2000

Yvonne Wu, M.D., M.P.H.
Departments of Neurology
and Pediatrics,
University of California, San Francisco,
San Francisco, California
Nella L. Green, B.A.
Department of Neurology,
University of California, San Francisco,
San Francisco, California
Margaret R. Wrensch, Ph.D.
Department of Neurological Surgery,
University of California, San Francisco,
San Francisco, California
Shoujun Zhao, M.D.
Department of Neurology,
University of California, San Francisco,
San Francisco, California
Nalin Gupta, M.D., Ph.D.
Departments of Pediatrics
and Neurological Surgery,
University of California, San Francisco,
San Francisco, California
Reprint requests:
Yvonne Wu, M.D., M.P.H.,
Department of Neurology,
University of California, San Francisco,
350 Parnassus Avenue, Suite 609,
San Francisco, CA 94143-0137.
Email: wuy@neuropeds.ucsf.edu
BACKGROUND: Risk factors for ventriculoperitoneal (VP) shunt complications have
not been assessed with population cohort data since the advent of modern surgical
techniques. We examined demographic factors and VP shunt complications in a pop-
ulation-based retrospective cohort study of all nonfederal California hospital admis-
sions between 1990 and 2000.
METHODS: We identified all admissions in a statewide administrative hospital dis-
charge database that indicated a VP shunt insertion. Repeat hospital admissions within
California generating a discharge diagnosis of surgical shunt complication, defined as
a shunt replacement, revision, removal, or exploration, represented the primary out-
come of interest. We performed Kaplan-Meier survival analyses and Cox proportional
hazards modeling to analyze sex, age, ethnicity, socioeconomic status based on payer
status, and type of hydrocephalus in relation to the risk of shunt complications.
RESULTS: The annual population incidence of VP shunt placement was 5.5 per 100,000.
Among 14,455 individuals with 65,040 person-years of follow-up, the cumulative
complication rate at 5 years was 32%. Children demonstrated a higher rate of shunt
complications than did adults at 5 years (48 versus 27%, P ⬍ 0.0001). The following
demographic factors were independently associated with increased risk of shunt com-
plications: male sex (hazard ratio [HR], 1.1; 95% confidence interval [CI], 1.03–1.2),
low socioeconomic status (HR, 1.2; 95% CI, 1.1–1.3), and age younger than 19 years
(HR, 1.6; 95% CI, 1.4–1.7). Compared with communicating hydrocephalus, obstruc-
tive hydrocephalus was also associated with increased risk of shunt complications
(HR, 1.7; 95% CI, 1.5–1.9).
CONCLUSION: VP shunt complications are common, especially in children. Further
study is needed to explain the associations between demographic factors and elevated
shunt complication rates.
KEY WORDS: Epidemiology, Hydrocephalus, Ventriculoperitoneal shunt
Neurosurgery 61:557–563, 2007 DOI: 10.1227/01.NEU.0000280021.61888.C8 www.neurosurgery-online.com

Received, January 30, 2007.

H
Accepted, April 29, 2007. ydrocephalus is a common condition
accounting for 69,000 hospital dis-
charges each year in the United States
(1). Congenital hydrocephalus is the second
most common congenital brain malformation
after spina bifida (22), and there are approxi-
mately 30,000 cerebrospinal fluid (CSF) shunt
procedures performed annually in the United
States (1, 16), amounting to $94 million of med-
ical costs per year (1).
CSF shunt procedures have dramatically
reduced the morbidity and mortality of hydro-
cephalus, but they have potential complica-
tions that may require multiple surgical proce-
dures during a patient’s lifetime. Causes of
shunt malfunction include obstruction, mech-
anical disconnection or breakage, infection,
and overdrainage. In pediatric surgical series,
shunt failures occur in 14% of patients just
within the first month after shunt placement
(13), and 40 to 50% of shunts will fail within
the first year (12, 19). Adults also experience a
relatively high (29%) shunt failure rate within
the first year (7). Long-term studies suggest
that 45 to 59% of all patients, regardless of age,
will require a shunt revision (2, 7). Multiple
shunt failures (11, 19, 21) and infections (10)
are common, and revisions account for 48% of
all shunt-related procedures performed in the
United States (1).

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WU ET AL.
Studies of CSF shunt complications based on experiences
from a single hospital (2, 6, 9, 11, 13, 14, 17, 19, 21) have shown
that younger age, prematurity, increasing number of previous
revisions, and shorter time to first revision increase the risk of
shunt complications (13, 17, 19). Specific causes of hydro-
cephalus, such as intraventricular hemorrhage and brain
tumor, have also been reported to increase the risk of shunt fail-
ure (7, 11, 19), although not all studies have supported this
association (13, 17).
Few population-based studies of CSF shunts have been
reported in the United States. One study predates the 1980s
(8), whereas the other two are cross-sectional studies that lack
follow-up data (1, 16). Thus, the demographic factors that
influence the risk of shunt complications have yet to be deter-
mined in an unselected population. We analyzed California
hospital discharge data over an 11-year period to examine
ventriculoperitoneal (VP) shunt complication rates and to
determine factors that may be associated with increased risk
of shunt complications.
PATIENTS AND METHODS
The Office of Statewide Health Planning and Development collects
administrative data regarding discharge diagnoses and procedures for
all hospital admissions to nonfederal hospitals in California. Using this
database, we identified all individuals admitted to a California hospi-
tal during the years 1990 to 2000 who received a discharge procedure
code (International Classification of Diseases, 9th Revision-Clinical
Modification [ICD-9-CM], 02.34) indicating insertion of a VP shunt.
Patients who had a revision, replacement, or removal of a CSF shunt
were only included in this study if they also carried a discharge proce-
dure code indicating the placement of a new VP shunt during a previ-
ous hospitalization within the study period. The incidence rate of CSF
shunt insertion was calculated as the total number of new placements
per year, divided by the California population for that given year (4).
Patients whose zip codes indicated residence outside the state of
California were excluded, as were patients with an age of greater than
100 years when their CSF shunts were placed (n ⫽ 9).
Patients who have a social security number are given a unique iden-
tifier in the Office of Statewide Health Planning and Development data-
base and, thus, could be followed over subsequent hospitalizations
within California during the 10-year study period. However, patients
without a unique identifier could not be tracked over time and were,
therefore, excluded from analyses regarding shunt complications.
We analyzed the following individual characteristics in relation to
shunt complication rates: sex, ethnicity, age at the time of the first
shunt placement (⬍1 month [neonate], 1 to 12 months [infant], 1 to 18
years [child], ⬎18 years [adult]), hydrocephalus type (spina bifida,
congenital excluding spina bifida, communicating, obstructive), and
socioeconomic status (SES) based on source of payment (high SES
indicates private insurance or self-pay; low SES indicates Medi-
care/Medicaid or indigent).
Our primary outcome of interest was the time to the first surgical
shunt complication. A surgical shunt complication was defined as the
presence of at least one of the following procedure codes in a subse-
quent hospital discharge record: replacement or revision of ventricular
shunt (ICD-9-CM, 2.42), removal of ventricular shunt (ICD-9-CM,
02.43), exploration of ventricular shunt (ICD-9-CM, 02.41), or distal
shunt revision (ICD-9-CM, 54.95).
558 | VOLUME 61 | NUMBER 3 | SEPTEMBER 2007
In a survival analysis modeling time to first shunt complication, we
considered the period at risk to begin at the time of VP shunt place-
ment. Because the exact date of procedure was not available to us, we
estimated the beginning of the risk period as the 15th of the month
when the VP shunt was placed. The failure event was defined as the
first surgical shunt complication. Patients were censored or removed
from analysis at the time of death during any hospitalization. Patients
who were not identified as deceased in the dataset were assumed to
have been followed until the end of the study period and, thus, were
censored in December of 2000. Because we were unable to account for
patients who left the state of California or to identify those who died
outside of a California hospital, our methods overestimate the true at-
risk period. Thus, our study provides a conservative or lower-bound
estimate of the rate of VP shunt complication.
We constructed Kaplan-Meier curves to model complication-free
shunt survivals and performed log-rank tests to identify factors that are
associated with lower shunt survivals in a univariate analysis. We then
constructed multivariate models using Cox proportional hazard regres-
sion analysis and calculated hazard ratios (HRs) and 95% confidence
intervals (CIs). All individual factors that were significant predictors in
the univariate analysis were included in the multivariate model.
Statistical analyses were performed using the Stata statistical software
package (v. 7; Stata Press, College Station, TX).
RESULTS
The incidence rate of new VP shunt placements was 5.5 per
100,000 per year, based on the 19,284 patients identified during
the study period. Children represented one-third of all patients
who received a VP shunt during the study period (Table 1).
Obstructive hydrocephalus (49%) was the most common
accompanying diagnosis, followed by congenital hydro-
cephalus, including spina bifida (17%) and communicating
hydrocephalus (14%).
The rate of shunt complications could only be determined in
the 75% of patients who had a social security number and who
could, thus, be followed over time. Infants aged younger than
1 year were more likely to lack a social security number and,
thus, to be excluded from follow-up analyses than were
patients aged more than 1 year at the time of initial shunt inser-
tion (67 versus 14%, P ⬍ 0.0001). Hispanics were also more
likely than non-Hispanics to lack a social security number (40
versus 20%, P ⬍ 0.001).
Shunt Complications
The remaining analyses are restricted to the 14,455 patients
(of whom 80% were aged ⬎ 18 yr) with a VP shunt whose
subsequent hospitalizations could be identified. The mean
length of follow-up was 54 months (standard deviation, 38
mo), and children were followed on average longer than
adults (57.4 versus 53.1 mo, P ⬍ 0.001). Three percent of
patients died during the initial hospitalization when the VP
shunt was placed. Another 11% of patients died during a sub-
sequent hospitalization within California. Children were less
likely to die in a hospital during the study period than were
adults (6.2 versus 16.7%, P ⬍ 0.0001). Among those who died
during a subsequent hospitalization, the median time from
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 VENTRICULOPERITONEAL SHUNT COMPLICATIONS IN CALIFORNIA

TABLE 1. Characteristics of 19,284 patients who received a ven- TABLE 2. Surgical shunt complication rates among 14,455 chil-
triculoperineal shunt in California between 1990 and 2000 dren and adults who received a ventriculoperineal shunt in
California between 1990 and 2000a
%
All patients (%) Children (%) Adults (%)
Male 52.4
n ⴝ 14,455 n ⴝ 2905 n ⴝ 11,550
Age at shunt placement
Any shunt complication 29.0 46.4 24.6
Neonate (<1 mo) 7.9
Shunt replacement 21.6 36.4 17.9
Infant (1 mo-1 y) 12.2
Shunt removal 11.0 20.8 8.6
Child (1–18 y) 13.8 Distal shunt complication 5.2 7.9 5.9
Adult (>19 y) 66.2 Shunt exploration 0.7 1.1 0.5
Ethnicity
a
Note that all types of shunt complications were statistically more common in
Caucasian 60.1 children than in adults (P ⬍ 0.0001).
Hispanic 18.7
African-American 7.2
Asian 5.9 adults (26 versus 12% in the first month, 39 versus 21% at
Native American 0.4 1 year, 48 versus 27% at 5 years, and 55 versus 29% at 10 years,
Unknown 7.8 P ⬍ 0.0001, log-rank test). Compared with adults, neonates
(univariate HR, 2.5; 95% CI, 2.2–2.9) had the worst outcome
Low socioeconomic status 50.2
(Fig. 1A). Infants (HR, 2.0; 95% CI, 1.8–2.2) and older children
Hydrocephalus type (HR, 2.0; 95% CI, 1.9–2.2) also exhibited an increased risk of
Obstructive only 48.5 complications when compared with adults.
Communicating only 14.3 Patients with obstructive hydrocephalus (Fig. 1B) exhibited a
Communicating and obstructive 11.5 higher shunt complication rate than patients with communicat-
ing hydrocephalus (HR, 1.9; 95% CI, 1.7–2.1). The shunt failure
Congenital, not spina bifida 11.5
rates did not differ significantly between patients with spina
Spina bifida 5.7
bifida and those with other types of congenital hydrocephalus
None of the above 8.5 (P ⫽ 0.45). Male sex (HR, 1.14; 95% CI, 1.1–1.2) and lower SES
(HR, 1.5; 95% CI, 1.4–1.6) were also associated with a higher
rate of shunt complications.
shunt placement to in-hospital death was 8 months (inter- Caucasians and Asians (Fig. 1C) exhibited similar survival
quartile range, 2–30 mo). curves that were not statistically different (P ⫽ 0.38), and sur-
Among patients with a VP shunt who could be followed vival curves for African-Americans and Hispanics also were
over time, 35% experienced at least one surgical shunt compli- not statistically different (P ⫽ 0.71). In univariate analysis,
cation during the study period, and 11% had multiple (two or African-Americans and Hispanics together experienced an
more) shunt complications. Patients with multiple complica- increased risk of VP shunt complications when compared with
tions had a mean of three complications each (standard devia- Caucasians and Asians (HR, 1.3; 95% CI, 1.2–1.4). The 54 Native
tion, 1.8), and 16 patients underwent 10 to 23 hospitalizations Americans identified in our cohort had the highest complica-
for shunt complications during the follow-up period. tion rate compared with Caucasians (HR, 1.7; 95% CI, 1.2–2.6).
Shunt replacement or removal occurred in 95% of patients
with a shunt complication, whereas distal shunt complica- Multivariate Analysis
tions and shunt explorations were less common (Table 2). All
We included the following variables in a Cox proportional
forms of shunt complications were significantly more frequent
hazards model: sex, ethnicity, age group, type of hydro-
in children.
cephalus, and SES. The type of hydrocephalus was the
strongest independent risk factor for VP shunt complications
Time to First Shunt Complication (Table 3). Compared with patients with communicating hydro-
The shunt survival analysis included 11,550 adults and 2905 cephalus only, those with congenital hydrocephalus (HR, 3.1;
children who received a VP shunt, with 51,150 and 13,889 per- 95% CI, 2.6–3.6) or obstructive hydrocephalus (HR, 1.7; 95% CI,
son-years of follow-up, respectively. Children consisted of 1.5–1.9) were at increased risk of shunt complications, as were
patients aged 1 to 18 years (56%), infants aged 1 to 12 months patients with both communicating and obstructive hydro-
(32%), and neonates aged less than 1 month (12%). cephalus (HR, 2.4; 95% CI, 2.1–2.7). Male sex (HR, 1.1; 95% CI,
Overall, the cumulative VP shunt complication rate was 15% 1.03–1.2) and low SES (HR, 1.2; 95% CI, 1.1–1.3) were also asso-
in the first month, 25% at 1 year, 32% at 5 years, and 34% at 10 ciated with increased risk of shunt complications, whereas eth-
years. Children had higher rates of shunt complications than nicity no longer demonstrated a significant effect on outcome

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WU ET AL.

A B

FIGURE 1. A, Kaplan-Meier curves showing the proportion of patients with C

a VP shunt who remain free of shunt complications over time, stratified by age.
Neonates demonstrate a significantly higher rate of shunt complications than
all other age groups (P ⬍ 0.01, log-rank test). Infants and children exhibit no
difference in their rates of shunt complications (P ⫽ 0.73). Adults experience
a significantly lower risk of shunt complications than children of all ages (P
⬍ 0.001, log-rank test). B, Kaplan-Meier curves showing proportion of
patients with a VP shunt who remain free of shunt complications, stratified by
diagnosis (communicating [Comm], obstructive [Obstr], both communicat-
ing and obstructive, spina bifida, and other congenital hydrocephalus).
Patients with spina bifida or other types of congenital hydrocephalus demon-
strate an equally high rate of shunt complications. Other types of hydro-
cephalus differ significantly from each other (P ⬍ 0.0001, log-rank test), with
communicating hydrocephalus demonstrating the lowest rates of complica-
tions. C, Kaplan-Meier curves showing proportion of patients with a VP
shunt who remain free of shunt complications, stratified by ethnicity.
Caucasians and Asians demonstrated the lowest complication rates, and Native Americans (Nat Amer) exhibited the highest rates.

after adjustment for other factors such as SES. Compared with
adults, children of all age groups also demonstrated an
increased risk of shunt complications, after adjustment for
potential confounders (neonate: HR, 1.4; 95% CI, 1.1–1.7; infant:
HR, 1.3; 95% CI, 1.2–1.5; and child: HR, 1.7; 95% CI, 1.5–1.8).
Of the patients who had a first shunt complication, 31% went
on to experience at least one more complication during the
study period. A shorter time to first shunt complication (⬍6
mo) was associated with a greater probability of having a sub-
sequent shunt complication in children (odds ratio, 1.3; 95% CI,
1.02–1.7) but not in adults (odds ratio, 0.85; 95% CI, 0.71–1.03).
DISCUSSION
In this first longitudinal study of VP shunts within a United
States population since the 1970s, we found that the overall
rate of surgical shunt complications was 35% during a mean
follow-up period of 4.5 years. Children, and especially neo-
nates, experienced the highest complication rates. Almost half
of the children required a repeat surgical procedure by 5 years
of follow-up. Although African-Americans and Hispanics
demonstrated a significantly higher rate of VP shunt complica-
tions than Caucasians and Asians in univariate analyses, eth-
nic differences were no longer apparent after adjusting for SES
in the multivariate analysis. Male sex and type of hydro-
cephalus also independently increased the risk of surgical
shunt complications.
This study is subject to a number of important limitations.
Only patients with a social security number were able to be fol-
lowed over time, leading to potential selection bias and an
underrepresentation of infants and Hispanics. We lacked data
regarding mortality outside of California hospitals during the
study period, as well as information regarding which patients
might have left the state, again leading to potential bias if
patients remaining in California differed systematically from
those who were unknowingly lost to follow-up. Furthermore,
our shunt complication and mortality rates represent lower-
bound estimates of the true population rates, given our lack of
knowledge of how many patients left the state. We relied on
hospital discharge codes that may not have been recorded reli-
ably. For instance, the accuracy with which communicating
and obstructive hydrocephalus was coded is unknown. These
study limitations are offset by a number of advantages, includ-
ing the large, ethnically diverse population base, a relatively

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 VENTRICULOPERITONEAL SHUNT COMPLICATIONS IN CALIFORNIA

by children (3, 5). In one large European multicenter study,

TABLE 3. Multivariate hazard ratios of individual characteristics 80% of shunt infections occurred in infants aged younger
associated with increased risk of developing a ventriculoper- than 6 months (7). In our study, the in-hospital mortality rate
ineal shunt complicationa of pediatric patients with VP shunts was 6.2% after a mean
HR 95% CI P value follow-up period of 4.8 years. This rate is an underestimate of
total mortality because we did not have access to outpatient
Male 1.1 1.03–1.2 0.003
death records. A recent report of children who received a
Age group CSF shunt at a single institution suggests that overall mortal-
Adult Reference Reference ity rate is 8.9% at 5 years (20).
Neonate 1.4 1.1–1.7 0.002 Male patients are disproportionately represented among
Infant 1.3 1.2–1.5 ⬍0.001 those who receive a CSF shunt (6, 7, 15). The male-to-female
Child 1.7 1.5–1.8 ⬍0.001
ratio of patients receiving CSF shunts is 1.17 to 1 (1). We found
that the risk of shunt complications was also elevated in male
Ethnicity
patients by approximately 10%. Obstructive hydrocephalus
Caucasian Reference Reference was also associated with an increased risk of shunt complica-
African-American 1.0 0.9–1.2 0.48 tions in our cohort when compared with communicating
Hispanic 1.0 0.9–1.1 0.98 hydrocephalus and congenital hydrocephalus. Others have
Asian 1.0 0.8–1.1 0.49 also reported an increase in shunt failure rates among patients
with obstructive hydrocephalus caused by a tumor (19),
Native American 1.5 0.98–2.2 0.06
although not all studies have found that the type of hydro-
Low socioeconomic status 1.1–1.3 ⬍0.001
cephalus affects the risk of shunt complications (6, 13, 17).
Type of hydrocephalus Differences in underlying cause or mechanical factors may be
Communicating Reference Reference responsible for the higher shunt complication rates in patients
Obstructive 1.7 1.5–1.9 ⬍0.001 with obstructive hydrocephalus, although future studies are
Communicating 2.4 2.1–2.7 ⬍0.001 needed to confirm this hypothesis.
and obstructive To our knowledge, this is the first study that addresses the
risk of VP shunt complications in relation to ethnicity and SES.
Congenital (including 3.1 2.6–3.6 ⬍0.001
African-Americans, Hispanics, and Native Americans fared
spina bifida)
worse, as illustrated by the Kaplan-Meier graphs, whereas
a
HR, hazard ratio; CI, confidence interval. Caucasians and Asians demonstrated a significantly lower rate
of shunt complications on univariate analyses. However, these
differences were no longer significant after adjusting for the
recent cohort, and our ability to follow a large number of effect of SES. Lower SES was independently associated with a
patients over a significant period of time, whereas previous 20% increased hazards ratio for VP shunt complications. To
population-based studies have been primarily cross-sectional in determine whether this is the result of disparities in hospital
design (1, 16). characteristics and surgeon volume (18) or to other factors is
The incidence rate of first-time VP shunt placements in our beyond the scope of this study.
population was 5.5 per 100,000. This approximates the aver- VP shunt procedures represent a significant health care
age age- and sex-adjusted incidence of initial CSF shunts dur- expenditure, costing, by one estimate, approximately one bil-
ing the early 1970s in Minnesota (4.6 per 100,000) (9). During lion US dollars during the year 2000 (16). Approximately half of
the study period, the mean number of new VP shunts placed the cost associated with VP shunt procedures are spent on
in California was 1300 per year. Because the population of shunt revisions (1). The fact that 32% of our population with VP
California is approximately one-tenth that of the United shunts experienced a surgical complication reminds us that the
States, our study would suggest that approximately 13,000 current treatment for hydrocephalus is unsatisfactory for a
new VP shunts are placed each year in patients in the United large proportion of patients. More studies are needed to eluci-
States. This number falls directly between the two previous date the risk factors that contribute to shunt complications, so
population estimates of new VP shunts inserted annually in that preventative strategies can be devised to improve the long-
patients in the United States (8300 and 17,000) (1, 16). term outcome of patients with hydrocephalus.
Children are known to experience a high rate of shunt
complications. The children in our study had a 39% shunt
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Acknowledgments
We thank Heather J. Fullerton for her assistance with the data analysis and for
critically reviewing this article. Yvonne Wu, M.D., Ph.D., is supported by
NS35902. Nalin Gupta, M.D., Ph.D., is supported by K08 NS055061 to 01.
Margaret R. Wrensch, Ph.D., is supported by R01CA52689 and P50CA097257.
COMMENTS
T his carefully constructed population-based study provides us with
contemporary data that will be a useful resource for future epi-
demiological investigations of ventriculoperitoneal shunting for the
treatment of hydrocephalus. Although none of the findings are sur-
prising, they do at least support the results of a wide range of previ-
ous studies. It is a bit disappointing that we have not made greater
562 | VOLUME 61 | NUMBER 3 | SEPTEMBER 2007
inroads into the epidemiological problems associated with shunts
over the past 25 years.
Paul H. Chapman
Boston, Massachusetts
T his is a population-based survey performed over a 10-year period
in California examining the outcomes of 14,455 shunt placements.
Via uni- and multivariate analysis, the authors found that younger
age, male sex, low socioeconomic status, and obstructive hydro-
cephalus were independent risk factors for shunt complications. As
the authors discuss, there are a number of inaccuracies related to
inaccurate coding, missing patients (patients not entered because of
lack of social security number), patients lost to follow-up or moving
out of state, patients dying, etc. in large data sets such as this. These
inaccuracies are somewhat compensated for by large numbers; thus,
the estimates for the patients identified are reasonably accurate and
are likely lower estimates of complications. Suffice it to say that
shunt complications remain 32% overall and 48% in children and
have likely not changed much over the previous several decades.
Studies such as this remind us that the success of treatment of hydro-
cephalus with shunts is not satisfactory and is worthy of every effort
to improve things.
James M. Drake
Toronto, Canada
T
his is a review of adult and pediatric shunts performed in California
over a 10-year period, with data on reoperation for shunt complica-
tions obtained from a state registry. The results are not surprising and
basically confirm earlier and smaller single institution studies. Children
had a higher rate of shunt problems than adults, and lower socioeco-
nomic status was an independent risk factor for shunt complications.
The study probably underestimates the true incidence of problems
because patients who died or moved out of state were lost to follow-up
and infants were underreported because they often lacked social secu-
rity numbers. The analysis of obstructive versus communicating hydro-
cephalus is probably erroneous because there was no way to really
distinguish these from each other in a study of this type.
Despite the hope that endoscopic third ventriculostomy would elim-
inate the need for shunts and shunt complications, shunts with all of
their attendant problems remain. The fact that patients of lower socioe-
conomic status had more problems is unexplained. I suspect this is
because this group of patients had more complex forms of hydro-
cephalus, such as postinfectious, posttraumatic, and posthemorrhagic
types, which tend to lead to multicompartmental ventricles, infections,
and other risk factors.
Leslie N. Sutton
Philadelphia, Pennsylvania
T
his study examines a number of factors related to the incidence of
ventriculoperitoneal shunt complications in the state of California
from 1990 to 2000, thereby providing a large cohort to analyze. As the
authors note, there were a number of limitations to the data available,
including the fact that 25% of the patients had no social security num-
ber and could not be followed. The accuracy of coding is also subject to
question. Coding for sex was highly accurate and the reliability of males
being at higher risk for shunt complications leaves little doubt, as does
younger age. The validity of coding for types of hydrocephalus is very
suspect and differentiation of complication rates for communicating
hydrocephalus, obstructive hydrocephalus, and communicating and
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 VENTRICULOPERITONEAL SHUNT COMPLICATIONS IN CALIFORNIA
obstructive hydrocephalus leaves much room for question. How is it
possible to accurately separate communicating and obstructive hydro-
cephalus from hydrocephalus that is only communicating versus hydro-
cephalus that is only obstructive? This is pure fiction. As a side note, all
hydrocephalus are obstructive with the exception of that related to cere-
brospinal fluid overproduction associated with a choroid plexus papil-
loma. A neonate born with hydrocephalus will be correctly coded as
having congenital hydrocephalus. On subsequent admissions, this dis-
tinction is often lost. Even in our office records, I note discrepencies for
older children as to whether the hydrocephalus is properly coded as
congenital versus acquired.
The incidence of hydrocephalus associated with an open neural tube
defect (spina bifida/myelomeningocele) has dropped markedly. A
study covering the time interval from 2000 to 2010 will have but a frac-
tion of the 5.7% incidence noted in the present study.
Fifty-four of the 14,455 patients in the study group were classified as
Native American. What are the criteria to be classified as Native
19th century English whaling gear, illustrated by William Scoresby, Jr. From: Matthews, LH: The Whale. New York, Simon & Schuster,
1968.
NEUROSURGERY
American? To be considered as such, does one have to be 100% Native
American or will 51% suffice? Presumably, the selection was made by
the individual checking off a box on a questionaire. Were genealogy
studies performed for confirmation? It would take but few complica-
tions to skew the outcomes. To draw conclusions based on 54 Native
Americans seems suspect.
This study does put into broad overview the complication rates asso-
ciated with ventriculoperitoneal shunts. As long as hydrocephalus is
treated with mechanical devices, there will be complications. To say
that the current treatment of hydrocephalus is unsatisfactory for a large
proportion of patients is a bit harsh. One has only to remember the
prognosis for patients with hydrocephalus before shunts became avail-
able. The complication rate has slowly diminished, but do we need to
do better? Yes, much better.
J. Gordon McComb
Los Angeles, California
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