Child's Nerv Syst (1985) 1:77-80
© Springer-Verlag 1985
Originalpapers
CSF shunt complications: an analysis of contributory factors
Robert Griebel, Moe Khan and Leonard Tan
Departments of Clinical Neurosciences and Social and Preventive Medicine, University of Saskatchewan,
Saskatoon, Saskatchewan, Canada
Abstract. The complications arising from 195 shunting
procedures are described and correlated with patient and
operative variables. Neither the patient's age, sex, type of
hydrocephalus, length of surgery, nor the use of prophy-
lactic antibiotics correlated significantly with subsequent
shunt complications. However, the surgeon performing the
procedure and the type of shunt used were highly sig-
nificant correlates.
Key words: Hydrocephalus - Ventriculoperitoneal shunt -
Ventriculoatrial shunt - Complications.
Diversionary shunting of CSF became the established
therapeutic procedure for hydrocephalus in the late 1950s,
following the development of polyethylene shunt tubing
and flow-regulating valves. The initial predilection for
ventriculoatrial shunting systems changed as reports of the
mortality and morbidity associated with intravascular
shunts accumulated [2, 3, 4, 13]. In 1967, Ames [1] and
later H a m m o n [5] advocated shunting CSF to the peri-
toneal cavity. Comparative studies of these two shunt
modalities have consistently demonstrated the lesser
morbidity of ventriculoperitoneal shunting [6-9, 11].
Although the variety and frequency of complications
after placement of CSF shunts have been well documented,
few authors have investigated the variables contributing to
these complications [10, 12].
This paper examines 195 internalized CSF shunting
procedures performed over a 5-year period. The ensuing
complications are identified and a series of factors cor-
related with the complications and functional longevity of
the shunting systems.
Materials and methods
One hundred ninety-five placements or revisions of CSF shunts
were performed in the University Hospital, Saskatoon, between
January, 1976, and June, 1982. These procedures involved 103
patients. For the purposes of this study, however, each shunt
placement or revision was considered and analyzed as a separate
event. Charts were studied retrospectively.
In all patients a presumptive cause of hydrocephalus had
been identified. Cases prior to 1977 were diagnosed by ven-
triculography and, following that year, computed tomography
(CT) with the GE 8800 scanner was used exclusively.
All shunt placements or revisions, with a single exception,
were performed by one of five neurosurgeons. No elective
revisions for shortened catheters were performed, and all revisions
were carried out when there was clinical or radiological evidence
of infection, impaired drainage, or erosion.
Operative time for the procedures was in all instances
recorded on the patients' charts. There were three instances in
which operative times included a consecutive operative procedure,
and these were omitted from the analysis.
Three basic shunt types were used. Three of these were
Torkildson shunts, and although the complications of these
systems are listed, there were too few to subject to separate
statistical analysis. Fourteen ventriculoatrial, and 178 ventriculo-
peritoneal systems were placed. The majority (142) of the ven-
triculoperitoneal shunts were multicomponent systems consisting
of a ventricular and peritoneal catheter and an interposed valve,
reservoir or flushing device. Eight of these systems contained an
in-line antisiphon device as well. Thirty-six of the ventriculoperi-
toneal shunts were the one-piece design (Codman Unishunt).
Standard shunt placement techniques were employed. Prophylactic
intraoperative antibiotics were given at the discretion of the
operating neurosurgeon.
Results
Fifty-seven percent of the shunting systems developed a
complication during the time course of the review, whereas
84 of the 195 (43%) shunts remained free of complication.
The 111 shunts with complications developed a total of
120 complications (outlined in Table 1). Thirty-one per-
cent of all shunts developed an obstructive complication.
Infections complicated 12% of the shunts. Ninety-eight of
the 111 shunts with complications required shunt removal
or revision, whereas the remainder of the complications
were treated non-surgically. The overall revision rate was
thus 50%. Eight of the patients died during the time course
of the study, but only 4 of these deaths were a direct result
of shunt compfications, a shunt complication mortality of
2%.
78

Table 1. Complications (and incidence) in all shunts placed

Shunt complications

Shunt blockage
Total shunts (%)

31
>
LO00-

c~ 0.875-

'.~ 0.750
i
Shunt colonization 8 c 0.625-
Subdural hematoma 3 ._o
Meningitis 3 0.500-
Abdominal ascites 2 o

Shunt disconnection 3 ~ 0.375 "!........

~-~."......... ~,~,~n~""; ~.... I .... Congenital
Skin erosion 2 L ....
Dandy-Walker
Tumor I
j
I Communicating
Intracerebral hematoma 1 0.250
l
Intraperitoneal abscess 1 Spina bifida
Symptomatic overdrainage 1 0.~25
Abdominal cyst 1
Liver laceration 0.5
10 20 3'0 4'0 5'0 6'0 7'0 8'0 9'0 160
Total 56.5 Months
Fig. 1. Survival analysis of CSF shunts according to type of
hydrocephalus (P < 0.18)
Table 2. Complication rate per age group
followed by the congenital and secondary non-com-
Age group 0-3 3 months 1-3 3-18 18+
months -1 year years years municating groups.
years
A shunt survival analysis (Fig. 1) of each of these
Total 35 33 24 45 58 categories illustrates that the underlying cause of hydro-
procedures cephalus was not a factor influencing the longevity of the
Complications 51 55 50 62 60 shunt system (P < 0.18).
(%)

Previously revised systems versus complications

Table 3. Hydrocephalic types and incidence of each (%)
Communicating hydrocephalus
Congenital aqueductal or foraminal stenosis
Secondary obstructive hydrocephalus
Hydrocephalus with spinal dysraphism
"Normal pressure" hydrocephalus
Eighty-nine of the 195 shunts were placed primarily,
37 whereas the remaining 106 were either shunt revisions or
21 replacements. The virgin systems had a complication rate
21
16 of 50.6% compared to a 62.3% complication rate for the
5 replaced or revised group (P <0.1). However, only 40.4%
of the virgin shunts required a subsequent revision, com-
100
pared to 58.5% of the once-revised group. This difference
is statistically significant (P < 0.012).

Age~sex of patient versus complications

The age range at time of surgery varied from 2 days to
76 years. Thirty-five percent of the procedures were car-
ried out on children less than a year of age and 70% on
individuals less than 18 years old. The patients were sub-
divided into five age groupings (0-3 months, 3 months-1
year, 1-3 years, 3-18 years, 18 + years). Table 2 illustrates
the total procedures performed in each age grouping, as
well as the subsequent complication rates of those shunt
placements. The difference in complication rates between
the various age groupings is not significant (P < 0.78).
The sex ratio of males to females was 53:50. The
systems inserted in males had a complication rate of 58%
and those in females 54.5%.
Surgical time versus complications
The mean operative time of all shunt placements was
62 rain. There was no significant difference in operative
time between those shunts which subsequently developed
complications and those which did not. Similarly, when
only infective complications were examined, operative
time did not appear to be an influencing variable (Ta-
ble 4).
Table 4. Surgical time in groups with complications versus groups
without complications
Mean length of
operation

Uncomplicated shunts 64 rain

Type of hydrocephalus versus complications P<0.5
Complicated shunts 61 min
The hydrocephalic patients were separated into five Infected shunts 55 min
P<0.5
categories, as outlined in Table 3. Patients with com- Non-infected shunts 60 min
municating hydrocephalus formed the largest grouping,
 79
Prophylactic antibiotic use versus complications 1.000

Prophylactic antibiotics were used either prior to or during

surgery in 148 (76%) of the procedures. No antibiotics
D~
c
0.875

•~ 0.750
1
~. I Codman Unishunt

were given in 47 cases. The overall complication rate in m

= 0.625 ii
those cases in which antibiotics were given was 54.9% .£
ii
Ii
compared with 57.8% in the untreated group (P<0.7). 0.500 IL,--,
o
Infective complications alone were found in 9.7% of the & i ~""11,.i %
0.375
treated group and 17.8% of the uncovered group. Al- [,. . . . ~ tm. . . . Multicomponent VP
though the infection rate was almost double in the group 0.250
1--- 1
E
not given antibiotics, P < 0.14. I ........... "''''']
d 0.125
h . . . . . . . "I VA

Operating surgeon versus complications 10 20 3'0 4'0 50 60 7'0 80 9'0 160

Months
Fig. 2. Survival analysis ofCSFshunts according to type ofshunt
The percentage of overall shunt placements and revisions (e < 0.00)
performed by each of five neurosurgeons is shown in Ta-
ble 5, along with the complication rates of the shunts
placed by each individual. In order to eliminate the bias of As the majority of the ventriculoatrial shunts had been
the different shunt types used by different surgeons, the inserted early in the study and the majority of the
complication rates of a specific shunt type, i.e., the multi- Unishunt systems in the last 2 years of the study, a life
component V-P shunt, was calculated. The difference in survival analysis of the different shunt types was computed
shunt-specific complication rates remains significant. (Fig. 2). A clear discrimination between the various shunt
types is shown. In spite of the shorter follow-up period for
the Unishunts, the accumulated survival of 80% of these
Shunt type versus complications systems at 6 months compares with a 50% survival of the
multicomponent V-P shunts, and only 25% of the V-A
The complication rates of each of the various shunt types shunts during this same period (P < 0.000).
were examined (Table 6). Various subgroupings of compli-
cations were compared. Of these, only skin erosion oc-
curred more frequently in the Unishunt group. This com- Discussion
plication occurred in the low-birth-weight infants who
were almost invariably shunted with the Unishunt. The interplay of multiple factors determines the functional
lifespan of a CSF shunt. These might reasonably be
categorized as host variables, operative variables, and
Table 5. Complication rates of different surgeons variables involving the shunt system itself.
In our study we found the host variables to be most
Surgeon Percentage of Complication Shunt-specific elusive. Neither the patient's age, sex, or underlying condi-
total shunts rate (%) complication tion appeared to influence the shunt complication rate or
placed rate (%) survival. On the other hand, Raimondi et al. [10] have
A 31 35 48 reported that both overall complication and infection rates
B 42 68 66 were higher prior to 3 months of age. Steinbok [12] found
C 5 78 83 an increased incidence of all complications in patients
D 14 82 77 with spina bifida but did not calculate the significance of
E 8 20 21
this finding.
P<0.000 P<0.003
Previous authors [12] have found that patients having a
shunt revision are more likely to develop complications
than those undergoing an initial shunt placement. We
Table 6. Complication rates by shunt type found this relationship to be tenuous. The difference in the
Shunt type complication rates between the two groups was not sig-
Overall Obstructive Infective Skin
compli- compli- compli- erosion nificantly different, but the subsequent revision rate be-
cations cations cations tween the two groups did show a signitqcant discrepancy.
(%) (70) (%) (70) One may infer that the complications in the virgin group
were more amenable to non-surgical treatment.
Unishunt 22 8 6 6
Multicomponent VP 60 37 10 3 It has been a long-standing maxim of shunt surgery
Ventriculoatrial 93 57 29 0 that "meticulous asepsis and scrupulous technique help
P<0.000 P<0.001 P<0.07 P<0.5 assure the best results in each case" [13]. The marked dif-
ference between the complication rates of the various
80
surgeons in our series testifies to the importance of this
operative variable. Other intraoperative factors, such as
the length of the surgical procedure and the use of intra-
operative antibiotics, did not show a statistically significant
influence. Venes [14], however, has demonstrated the
efficacy ofintraoperative antibiotic usage combined with a
strict operative aseptic technique.
The basic shunt design itself was shown to be an
important variable in shunt survival. Although the superi-
ority ofventriculoperitoneal systems over ventriculovenous
systems has been previously demonstrated, the definite
improvement in complication rates and shunt survival
offered by the one-piece ventriculoperitoneal system has
been only more recently established [10]. This report lends
support to use of a Unishunt system for a broad range of
hydrocephalic conditions.
Acknowledgements. We thank Mrs. Mavis Hopewell and Mr.
Robert van den Beuken for their assistance in preparation of the
manuscript.
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