Lumbar Catheter Misplacement into the Spinal Subdural Epiarachnoid Space Causing Lumboperitoneal Shunt Malfunction: Report of Two Cases

Abstract

Lumboperitoneal (LP) shunting is a standard treatment for idiopathic normal pressure hydrocephalus (iNPH), with equivalent efficacy to ventriculoperitoneal (VP) shunting, and it is associated with a favorable outcome in approximately 75% of patients with iNPH. Despite the advantages, LP shunting can result in problems associated with the lumbar catheter, the obstruction of which has not been well described. This report presents two cases of LP shunt malfunction caused by lumbar catheter misplacement into the spinal subdural epiarachnoid space (SSES), and by subsequent obstruction. A 67-year-old man and a 69-year-old woman with iNPH underwent LP shunt placement without intraoperative fluoroscopy. Shortly after the surgery, they experienced a temporary improvement of their symptoms which was, however, followed by recurrence within a few months. This was suggestive of shunt malfunction. Although shunt pumping tests were normal, shuntography and subsequent computed tomography (CT) revealed lumbar catheter misplacement into the SSES. Shunt revisions, in which only the lumbar catheters were exchanged, were performed with intraoperative fluoroscopy and shuntography. Their symptoms have improved again following the revisions. In the present cases, lumbar catheter misplacement into the SSES caused LP shunt malfunction, and shuntography and CT were useful to detect the abnormality. Moreover, unrecognized lumbar catheter misplacement into the SSES might potentially have occurred in some patients considered as “non-responders” to LP shunting; hence, shuntography may be useful in those patients.