title: Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery.
abstract: OBJECTIVE
  As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in CSF shunt surgery concerning the frequency of adverse events in practice, their patterns, and the state of knowledge regarding methods for their reduction. This review may also inform future and ongoing efforts for the advancement of neurosurgical quality.
  
  
  METHODS
  The authors performed a PubMed search using search terms "cerebral shunt," "cerebrospinal fluid shunt," "CSF shunt," "ventriculoperitoneal shunt," "cerebral shunt AND complications," "cerebrospinal fluid shunt AND complications," "CSF shunt AND complications," and "ventriculoperitoneal shunt AND complications." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the adverse events reported.
  
  
  RESULTS
  In this review of the neurosurgery literature, the reported rate of mechanical malfunction ranged from 8% to 64%. The use of programmable valves has increased but remains of unproven benefit even in randomized trials. Infection was the second most common complication, with the rate ranging from 3% to 12% of shunt operations. A meta-analysis that included 17 randomized controlled trials of perioperative antibiotic prophylaxis demonstrated a decrease in shunt infection by half (OR 0.51, 95% CI 0.36-0.73). Similarly, use of detailed protocols including perioperative antibiotics, skin preparation, and limitation of OR personnel and operative time, among other steps, were shown in uncontrolled studies to decrease shunt infection by more than half. Other adverse events included intraabdominal complications, with a reported incidence of 1% to 24%, intracerebral hemorrhage, reported to occur in 4% of cases, and perioperative epilepsy, with a reported association with shunt procedures ranging from 20% to 32%. Potential management strategies are reported but are largely without formal evaluation.
  
  
  CONCLUSIONS
  Surgery for CSF shunt placement or revision is associated with a high complication risk due primarily to mechanical issues and infection. Concerted efforts aimed at large-scale monitoring of neurosurgical complications and consistent quality improvement within these highlighted realms may significantly improve patient outcomes.
authors.affiliation: Department of Health Policy and Management, Harvard School of Public Health, Brigham and Women’s Hospital, Street, Boston, Massachusetts 02115, USA.
authors.forename: Judith M
authors.initials: JM
authors.lastname: Wong
authors.forename: John E
authors.initials: JE
authors.lastname: Ziewacz
authors.forename: Allen L
authors.initials: AL
authors.lastname: Ho
authors.forename: Jaykar R
authors.initials: JR
authors.lastname: Panchmatia
authors.forename: Angela M
authors.initials: AM
authors.lastname: Bader
authors.forename: Hugh J
authors.initials: HJ
authors.lastname: Garton
authors.forename: Edward R
authors.initials: ER
authors.lastname: Laws
authors.forename: Atul A
authors.initials: AA
authors.lastname: Gawande
mesh_terms: D019072:Antibiotic Prophylaxis; D002557:Cerebrospinal Fluid Shunts / Q000009:adverse effects*; D004868:Equipment Failure; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery; D020300:Intracranial Hemorrhages / Q000209:etiology / Q000628:therapy; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D061214:Patient Safety; D019990:Perioperative Care; D011183:Postoperative Complications / Q000209:etiology / Q000628:therapy; D016032:Randomized Controlled Trials as Topic; D013530:Surgical Wound Infection / Q000628:therapy