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DOI: http://dx.doi.org/10.20534/ESR-16-11.12-44-46
Vakkasov Najmiddin Yuldashevich, free researcher Akhmediyev Makhmud Mansurovich, PhD.
Saidov Sokhib Saidmurodovich, free researcher Republican scientific center of neurosurgery, Uzbekistan, Tashkent E-mail: [email protected]
The analysis of results the ventricular shunting of operations at the children with congenital spinal hernias combined with hydrocephaly
Abstract: Treatment of spinal hernias in a combination to a hydrocephaly presents great difficulties. At patients with the spinal hernias which are combined with a hydrocephaly carrying out a ventrikuloperitoneostomy with the first stage promoted decrease of the sizes of a hernial diverticulum with development of cover tissues for the subsequent plasty of hernia. Keywords: spinal hernia, hydrocephaly, ventricular perithoneostomy operation.
Spinal cord hernias (SCH) which are combined with hydrocephaly meet quite often and fluctuate within 30-80% [1, 9-14]. According to results of the conducted researches in our country and abroad the frequency of a congenital hydrocephaly makes 3-4 cases on 1000 live-born, and SCH makes 1:1000 — the 5000th population [3, 6-9]. Hydrocephaly most SCH frequent satellite which is making heavier the forecast of a disease, and also quite often developing after elimination of hernia [5, 361]. At patients from SCH existence of a hydrocephaly burdens a clinical picture of a disease. Cognitive deficiency arises more often at children with SCH the combined hydrocephaly. Level of mental development is directly bound to the sizes of side ventricles (hydrocephaly degree) and rates of their decrease in the postoperative period [2, 1-6]. It is claimed that it is the serious contingent of patients as they have a very expressed neurologic symptomology, lag in psychomotoric and physical development, and also a combination of spinal hernia and a hydrocephaly to other malformations [7, 36].
Treatment of SH in combination with a hydrocephaly presents great difficulties, and usually it doesn't limited by surgical correction, effective at some the isolated defects. Surgical tactics in such cases means solving not only a question of a plastics of a hernial gate, but also a question of correction of the accompanying hydrocephaly [6, 382]. For purposeful surgical treatment of a hydrocephaly it is necessary to know a form of a hydrocephaly and a stage of its current, and also a combination to other pathology the cerebrospinal fluid (CSF) ofways of a brain [4, 3]. Hydrocephaly meets mainly at open forms of dysraphias (spina bifida opperta), and before introduction the ventricular shunting operations (VSO), it was the leading cause of death and low intellectual development of these children. After VSO the condition of the patient in most cases becomes steadily shunting dependent, at the same time every third patient demands audit of the shunting system. More often dysfunction arises within the first year from the moment of primary operation, at the same patients the high risk of repeated dysfunction within a year after audit becomes perceptible [8, 345]. Use of advanced trial and error methods of parameters of the systems implanted the ventricular shunting at VSO gives a high probability of achievement of adequate control over a hydrocephaly, depressions of frequency of development of postoperative hypo drainage and hyper drainage states.
Research objective: To compare results of the ventricular shunting operations at patients with the congenital spinal hernias
which are combined with a hydrocephaly with use and without use of the cerebrospinal dynamic test.
Research materials. Scientific work is performed in unit of neurosurgery of children's age of Republican scientific center of neurosurgery of MH of RUz. The analysis of 72 children treated in RSCNS with SCH which are combined with a hydrocephaly is carried out. Were examined boys — 41 (56,9%), girls — 31 (43,1%), at the same time the age of children varied from 24 days from the moment of the birth up to 7 years of life. All patient carried out MRI, CT, a neurosonography (NSG), ENMG, a clinical-neurologic research which are made before and in the postoperative period.
The combination of all-brain and focal syndrome complex was characteristic of children with SCH which are combined with hydrocephaly, at the same time character of a neurologic deficit differed in variety. The clinic from a spinal disraphy was generally characterized by motive, sensitive and pelvic disorders. From a brain the following changes were marked: the positive symptom of the setting sun — at 46 (63,8%), the meeting squint — at 13 (18%), the dispersing squint — at 3 (4,2%), looking paresis — at 2 (2,8%) and a deficit in the form of lowering pharyngeal reflex and a choke when swallowing — at 2 (2,8%) patients. From an eye bottom the angiopathy of a retina is revealed — at 60 (83,3%), an initial atrophy of a disk of an optic nerve — at 2 (2,8%) patients, stagnation of DNO — at 10 (13,9%) patients.
Two-stage operation is made: ventricular shunting operation (VSO) — a ventricular perithoneostomy (VPS) and a herniotomy. For the purpose ofselection ofparameters ofthe shunting systems we used the computer program "Liquorodynamic Test" (Akhmediyev M. M., I. A. Yugay, Makhmudov Sh. D., No. DGU 01982, 2010 of) which is developed in RSC of NS. The program works at a basis of an algorithm of exceeding of average arithmetical between indices of change of CSF pressure during fractional deduction of a CSF. The program has the convenient interface and a possibility of database maintenance. Process of the analysis of got data, a finite output and selection of the shunting system is carried out automatically. All patients were distributed on 2 groups: First (main) group: children to whom VPS using the CSF dynamic test — 36 (50%) is carried out by the patient. The second (control) group was made by patients to whom valvate systems without carrying out this method — 36 (50%) patients are installed.
Results of a research. The task in which we shall determine what transaction, and when to make, whether it is a herniotomy
The analysis of results the ventricular shunting of operations at the children with congenital spinal hernias combined...
or VPS was set. At the same time a number of factors including a gen- protrusion, progression of a hypertension-hydrocephalic syndrome, eral somatic condition of the patient was considered: form, sizes of high-quality and quantitative composition of CSF and elements of a circle of the head and hernia, condition of integuments of hernial blood. The type and a staging of transaction are shown in table 1.
Table 1. - Type and staging of the performed operations in case of spinal hernias combined with hydrocephaly
Type of operational intervention Primary group N=36 Control group N=36
A6c. %±m A6c. %±m
Ventricular perithoneostomy 1-step 33 91,7±4,6 28 77,8 ±6,9
Ventricular perithoneostomy 2nd step 3 8,3±4,6 8 22,2± 6,9
In total the shunting transactions 36 100 36 100
Herniotomy 35 97,2±2,7 34 94,4 ±3,8
Totally 36 100 36 100
From table 1 it is seen that at all 72 patients VSO is made. In a primary group of VPS is made: the first stage — at 33 (91,7%) patients, the second stage, after a herniotomy — at 3 (8,3%) patients. In the VPS control group is made: the first stage — at 28 (77,8%) patients, the second stage — at 8 (22,2%) patients.
After carrying out the first stage VPS happened both regress the hydrocephalic symptomology, and removal of threat of a gap of hernial protrusion to its reduction, and also improvement in psychomotor development was noted that is important for further adaptation to life of such patients. (Fig 1.)
before & after operation Figure 1. A status of a hernial bag before and after shunting operation
In figure 1 the hernial bag before the shunting operation where clearly is visible that hernial protrusion decreased in the amount is provided.
At 2 (2,8%) patients combined with Chiari's syndrome, regress stem symptoms after shunting operations were marked. It is defined that at patients with SCH which is combined with hydrocephaly it is necessary to carry out at the first stage surgical treatment in the form of VPS whereas the moderated and not progressing ventriculomegaly and absence of signs of increase in intra cranial pressure give the chance to delay ventricularshunting operation or even to postpone it. Arguments in favor of shunting are normaliza-
tion of intracranial pressure, removal of threat of a gap, improving of psychomotor and intellectual development of the child, lowering of frequency of the inflammatory phenomena, smaller frequency of CSF from hernia. Tactics choice in favor of carrying out the first stage of a herniotomy are existence of deformation of ventricular system and a ventricular dilatation, but at the same time absence of signs of increase in ICP and the progressing hydrocephaly.
Determination of parameters of the installed shunting systems was result of application of the CSF dynamic Test program. Distribution of patients on the level of correction of pressure are shown by the valvate shunting systems in table 2.
Table 2. - Distribution of patients on the level of correction of pressure by valvate shunting systems
Pressure Groups Total, n=72
Main, n=36 Controlling, n=36
Abs. %±m Abs. %±m Abs. %±m
High 2 5,5±3,8 1 2,8 ±2,7 3 4,1±2,3
Average 9 25 ±7,2 18 50 ±8,3 27 37,5±5,7
Low 24 66,7±7,8 17 47,2± 8,3 41 56,9±5,8
Too low 1 2,8 ±2,7 - - 1 1,4±1,4
Totally 36 100 36 100 72 100
From table 2 it is seen that at patients of the main group according to the CSF dynamic test the percent of installation of the shunting systems of extreme indices increased: at 2 (5,5%) patients — high pressure, at 24 (66,7%) patients — low pressure, and at one patient is very low pressure.
Implantation of constant valvate systems using the CSF dynamic test allowed to improve results of surgical treatment of SCH which are combined with hydrocephaly. The positive effect of the carried-out VSO was estimated on regress of a hydrocephalic syndrome and improving of the neurologic status. (Table 3).
Table 3. - The comparative characteristic of results of VSO using the cerebrospinal fluid dynamic test
Sign 1 group with application of the program cerebrospinal fluid dynamic test 2 group without application of the program the cerebrospinal fluid dynamic test T differences
Improvement Without changes Improvement Without changes
Аbs % Аbs % Аbs % Аbs %
Hydrocephalic syndrome 33 91,7±4,6 3 8,3±4,6 30 83,3±6,2 6 16,7±6,2 P<
Oculomotoric violations 19 52,8±8,3 2 5,5±3,8 18 50,0±8,3 4 11,1±5,2 P<
Reduction tension of a big fontanel 32 88,9±5,2 4 11,1±5,2 28 77,8±6,9 8 22,2±6,9 P<
Reduction tension of a hernial bag 30 83,3±6,2 3 8,3±4,6 20 55,5±8,3 8 22,2±6,9 P<
Proceeding, from data of table 3 it is possible to draw a conclusion that application of the CSF dynamic test has considerably improved results ofVSO in comparison with control group ofpatients which had a similar pathology.
Proceeding from it, it is possible to draw a conclusion that the program cerebrospinal fluid dynamic test when carrying
From table 4 it follows that adequate selection led the parameter of the shunt to reduction hypo — and hyper drainage complications in the main group of patients. The complications connected with inadequate selection of the shunting systems in control group were observed 2,5 times more than in the main group.
Thus, the computer program «Hyper drainage dynamic Test» has improved results of surgical treatment of patients with the spinal hernias which are combined with hydrocephaly.
Conclusions: 1. Application of the Hyper drainage dynamic Test program has given the chance rather precisely to determine the parameter of the implanted shunting systems for adequate cor-
out VSO improves dynamics of such indicators as regress of a hydrocephalic syndrome, regress of oculomotoric violations, reduction of tension of a big fontanel and reduction of a hernial bag in 1,1; 1,05; 1,14 and 1,5 times (p < 0,05) respectively. The analysis of the complications observed by us in two groups of patients after the shunting operations (table 4) is presented in the table below.
rection of the hydrocephaly making difficult the flow of SCH at children.
2. Application of the Hyper drainage dynamic Test program has raised the favorable result of treatment of hydrocephaly at patients with SCH, has improved a condition of patients on such indicators as regress of a hydrocephalic syndrome, regress of oculomotoric violations, reduction of tension of a big fontanel and reduction of a hernial bag in 1,1; 1,05; 1,14 and 1,5 times (p < 0,05) respectively. Decrease in probability of development hypo — or hyper drainage complications after VSO by 2,5 times is noted.
Table 4. - The comparative characteristic of hypo- or hyper drainage complications after VSO in 2 groups depending on application of CSFDT
Disfunction 1 group with application of the CSFDT 2 program group without application of the CSFDT program
Аbs % Аbs %
Hypodrainage 2 5,5% 4 11,1%
Hyperdrainage - - 1 2,8%
Total 2 5,5% 5 13,9%
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