Ventriculoperitoneal Shunt Malfunction, a Rare Cause of Paraplegia after Kyphosis Correction

Ventriculoperitoneal shunt (VPS) malfunction after kyphosis surgery in 12-year boy caused a sudden hydrocephalus which increased cerebrospinal fluid pressure within the spinal cord and decreased cord perfusion. Spinal cord at apex of deformity was vulnerable to ischemia which caused paraplegia. The ischemic event was reversible after re-insertion of the VPS. Study Design. Case report and literature review. Objective. The aim of this study was to report a rare case of hydrocephalus due to ventriculoperitoneal shunt (VPS) malfunction following kyphosis correction that resulted in paraplegia in the postoperative period. The available English literature to explain the possible cause of paraplegia is reviewed. Summary of Background Data. Twelve-year male child presented with a severe dorsal kyphoscoliosis deformity with spastic paraparesis since 4 months. The lower extremities had grade-2 power and spasticity. The sensation was reduced below D9. The deep tendon reflexes were exaggerated with ankle clonus. Bowel-bladder had urgency and frequency. The radiographs and CT showed D6-7 hemi-vertebra with complex kyphoscoliosis deformity. magnetic resonance imaging showed a stretching cord at D6-7 due to 92° angular kyphosis. The somatosensory evoked potential showed posterior column involvement. The VPS was placed for hydrocephalus at 4 months of age. The shunt remained functioned throughout childhood. Methods. He underwent posterior vertebral column resection and kyphosis correction surgery. Postoperative CNS function was normal. Neurology was status quo. After 20 hours, the boy appeared irritable, confused with a headache and repetitive vomiting (Glasgow coma scale: 7-8/15). Computed tomography brain showed dilated both ventricles with left shunt in situ. Immediate re-shunting was done from right side. The CNS status improved dramatically and regained consciousness. Neurology deteriorated to grade-0 with increased spasticity and further decreased sensation below D9. The spinal causes (hematoma, implant malposition, syrinx) were ruled out. Results. Delayed neurological recovery was seen at 6th week after shunt surgery. The Rapid motor march was observed and became independent ambulatory at 12th week. At 6 months, he improved up-to grade4 power with grade 2 spasticity which maintained at 2 years. Conclusion. VPS blockage caused a sudden hydrocephalus which increased CSF pressure within the spinal cord and decreased cord perfusion. Spinal cord at apex of deformity was vulnerable to ischemia which caused paraplegia. Level of Evidence: 5