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1 Date: 3/17/2017 Lecture title: Rate of shunt revision as a function of age in patients with shunted hydrocephalus due to myelomeningocele Anastasia Arynchyna, MPH, CCRP Clinical Research Manager, Department of Neurosurgery University of Alabama at Birmingham, Children s of Alabama Does not intend to discuss commercial products or services. Does not intend to discuss non-fda approved uses of products/providers of services.

2 Rate of shunt revision as a function of age in patients with shunted hydrocephalus due to myelomeningocele Esther B. Dupepe, MD, MSPH Betsy Hopson, MSHA James M. Johnston, MD Curtis J. Rozzelle, MD W. Jerry Oakes, MD Jeffrey P. Blount, MD Brandon G. Rocque, MD, MS* Presenting: Anastasia Arynchyna, MPH, CCRP Department of Neurosurgery University of Alabama at Birmingham Children s of Alabama Birmingham, AL, USA

3 Background Myelomeningocele (MMC) is the most common form of neural tube defect Hydrocephalus present in 60-90% of children with myelomeningocele Complications from CSF shunts contribute greatly to morbidity and mortality in MMC population Bowman et al. Childs Nerv Syst 25: , 2009.

4 Background Young age at first shunt placement is associated with: Increased risk of revision Increased risk of multiple revisions Higher risk of revision within 6 months of initial shunt insertion Suggests a relationship between age and risk of revision Tuli S et al. J Neurosurg 92:31 38, 2000

5 Purpose Evaluate the burden of shunt revision for a specific patient age

6 Methods Multidisciplinary spina bifida clinic Adult: University of Alabama at Birmingham Pediatric: Children s of Alabama Annual visit for all individuals with spinal dysraphism 99% are enrolled in the CDC National Spina Bifida Patients Registry (NSBPR) Discrete data elements entered into the NSBPR Electronic Medical Record All surgeries in past year entered into NSBPR EMR Chart review Verification with family

7 Methods Inclusion: all patients with MMC and shunted hydrocephalus Exclusion: Closed spinal dysraphism (lipomyelomeningocele, split cord malformation, dermal sinus tract, etc.) Hydrocephalus treated without shunt (ETV, ETV/CPC) Included if shunted after failed ETV Events with no date available

8 Methods Identify each individual incidence of surgical treatment of hydrocephalus Identify age at the time of each surgery Identify how many patients lived through each year of life Calculate revision rate for each year of life # of shunt revisions in each year of life # of patients who have reached that year of life

9 Results 655 patients October 2009 to May patients with myelomeningocele 417 with shunted hydrocephalus 39 shunt revisions without date available (excluded)

10 Results Table 1. Demographics n=519 (all myelos) Age, years Sex (%) Mean (SD) (11.7) Median (Range) (0-63) Male 244 (47) Female 275 (53) Race (%) Caucasian 397 (76.5)* African-American 92 (17.7) Asian 12 (2.3) American Indian or Alaska native 2 (0.4) Multi-racial 12 (2.3) Other/unknown 4 (0.8) Level of Lesion Left (%) Right (%) Sacral (foot plantar flexion present) 98 (18.9) 101 (19.5) Low-lumbar (foot dorsiflexion present) 78 (15.0) 71 (13.7) Mid-lumbar (knee extension present) 138 (26.8) 149 (28.7) High-lumbar (hip flexion present) 43 (8.3) 41 (7.9) Thoracic (flaccid lower extremities) 153(29.5) 149 (28.7) Missing data 8 (1.5) 8 (1.5) Payor Type (%) Medicaid 323 (62.2) Private 147 (28.3) Medicare 41 (7.9) Missing data 8 (1.5)

11 Results 94 Revisions # of shunt revisions in each year of life # of patients who have reached that year of life

12 Results 417 patients # of shunt revisions in each year of life # of patients who have reached that year of life

13 Results 0.23 y=-0.04ln(age)+0.17, R 2 =0.52

14 Results First year of life 94 shunt revisions 417 patients at risk 0.23 revisions per patient Fewer revisions per year with increasing age Increasing revisions per year in teen years Continued risk for revisions into middle age

15 Discussion Young age, at time of placement, is a risk factor for shunt revision Riva-Cambrin et al. JNS:Peds 17(4)382

16 Discussion Young age, at time of placement, is a risk factor for shunt revision Increase in shunt revision frequency in early teen years

17 Discussion Young age, at time of placement, is a risk factor for shunt revision Increase in shunt revision frequency in early teen years Adults continue to experience shunt malfunction

18 Limitations Single institution Retrospective data Single hydrocephalus etiology: myelomeningocele Assumption: All patients received shunt within the first few months of life

19 Conclusions Risk of shunt failure is highest in the first year of life Risk declines with increasing age except in early teen years Risk of shunt failure persists into adulthood Thank You