Time to shunt failure in children with myelomeningocele: an analysis of the National Spina Bifida Patient Registry

Brandon G. RocqueDivision of Pediatrics, Department of Neurosurgery, University of Alabama at Birmingham, Alabama;

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Betsy HopsonDivision of Pediatrics, Department of Neurosurgery, University of Alabama at Birmingham, Alabama;

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Isaac ShamblinDivision of Pediatrics, Department of Neurosurgery, University of Alabama at Birmingham, Alabama;

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Tiebin LiuBirth Defects Monitoring and Research Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia;

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Elisabeth WardCarter Consulting, Inc., consultant to Centers for Disease Control and Prevention, Atlanta, Georgia;

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Robin BowmanDivision of Pediatric Neurosurgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois;
Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois;

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Andrew B. FoyDepartment of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin;

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Mark DiasDepartment of Neurosurgery, Penn State Hershey Children’s Hospital, Hershey, Pennsylvania;
Penn State College of Medicine, Hershey, Pennsylvania;

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Gregory G. HeuerDivision of Neurosurgery, Children’s Hospital of Philadelphia, Pennsylvania; and

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Kathryn SmithDepartment of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California

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Jeffrey P. BlountDivision of Pediatrics, Department of Neurosurgery, University of Alabama at Birmingham, Alabama;

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OBJECTIVE

Hydrocephalus is common among children with myelomeningocele and is most frequently treated with a ventriculoperitoneal shunt (VPS). Although much is known about factors related to first shunt failure, relatively less data are available about shunt failures after the first one. The purpose of this study was to use a large data set to explore time from initial VPS placement to first shunt failure in children with myelomeningocele and to explore factors related to multiple shunt failures.

METHODS

Data were obtained from the National Spina Bifida Patient Registry. Children with myelomeningocele who were enrolled within the first 5 years of life and had all lifetime shunt operations recorded in the registry were included. Kaplan-Meier survival curves were constructed to evaluate time from initial shunt placement to first shunt failure. The total number of children who experienced at least 2 shunt failures was calculated. A proportional means model was performed to calculate adjusted hazard ratios (HRs) for shunt failure on the basis of sex, race/ethnicity, lesion level, and insurance status.

RESULTS

In total, 1691 children met the inclusion criteria. The median length of follow-up was 5.0 years. Fifty-five percent of patients (938 of 1691) experienced at least 1 shunt failure. The estimated median time from initial shunt placement to first failure was 2.34 years (95% confidence interval [CI] 1.91–3.08 years). Twenty-six percent of patients had at least 2 shunt failures, and 14% of patients had at least 3. Male children had higher likelihood of shunt revision (HR 1.25, 95% CI 1.09–1.44). Children of minority race/ethnicity had a lower likelihood of all shunt revisions (non-Hispanic Black children HR 0.74, 95% CI 0.55–0.98; Hispanic children HR 0.74, 95% CI 0.62–0.88; children of other ethnicities HR 0.80, 95% CI 0.62–1.03).

CONCLUSIONS

Among the children with myelomeningocele, the estimated median time to shunt failure was 2.34 years. Forty-five percent of children never had shunt failure. The observed higher likelihood of shunt revisions among males and lower likelihood among children of minority race/ethnicity illustrate a possible disparity in hydrocephalus care that warrants additional study. Overall, these results provide important information that can be used to counsel parents of children with myelomeningocele about the expected course of shunted hydrocephalus.

ABBREVIATIONS

CDC = Centers for Disease Control and Prevention; CI = confidence interval; FLOL = functional level of lesion; HR = hazard ratio; NSBPR = National Spina Bifida Patient Registry; VPS = ventriculoperitoneal shunt.
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Illustration from Wang et al. (pp 538–546). © Ju-lei Wang, published with permission.

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