In-Depth View: How to Perform a Lumboperitoneal CSF Shunt

Abstract

Diversion of lumbar cerebrospinal fluid (CSF) into the peritoneal space was attempted as early as 1898 by Ferguson (1898), who removed the arch of the fifth lumbar vertebra, pulled the cauda equine aside, and drilled a hole through the body of the vertebra. He passed a loop of silver wire bent inferiorly in the thecal sac, toward the peritoneum to act as a conduit for CSF flow. Three such cases did poorly. Subsequently in 1905, Nichol drew the free edge of the omentum into a defect in the spinal dura (Nicholl 1905). At around the same time, Cushing anastamosed the spinal subarachnoid space with the peritoneal or retroperitoneal spaces through a combined laminectomy and laparotomy using a silver cannula (Cushing 1905). Of 12 such patients, he experienced three deaths. Heile experimented with several different anastomotic techniques, including intestinal serosa, silk strands, saphenous vein, a rubber catheter, and a direct anastomosis of the kidney pelvis following nephrectomy (Heile 1914). All these early attempts at CSF diversion, although heroic, were associated with very high mortality and disastrous complications. Indeed Cushing wrote, “among the first of my patients – as will probably have been true of most young men entering this particular field – were infants with what is known as essential hydrocephalus, for which a greater number of treatments have as yet been advocated than successes recorded – if indeed there are any clear-cut successes at all recorded.”