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  • First-choice Lumboperitoneal Shunting for Idiopathic Intracranial Hypertension (IIH): Are We Making the Correct Choice? An Analysis of Cost and Complications Using the Nationwide Inpatient Sample

    Final Number:

    David E. Connor DO; Ashish Sonig MD MCh neurosurgery; Anil Nanda MD FACS

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: Complications following lumboperitoneal (LP) shunting have been reported in from 18 to 85% of cases. The need for multiple revision surgeries, incidence of iatrogenic Chiari malformation and frequent wound issues have prompted many to abandon this procedure or the treatment of IIH altogether. A direct comparison of the healthcare costs between first-choice LP versus ventriculoperitoneal (VP) shunting is presented.

    Methods: The Nationwide Inpatient Sample database was queried for all patients with the diagnosis of benign intracranial hypertension (ICD-9-CM 348.2) from 2005-2009. This data was stratified by operative intervention with demographic and cost of hospitalization data generated for each.

    Results: A weighted sample of 4480 patients were identified as having the diagnosis of IIH, with 2505 (55.9%) undergoing first-time VP shunting and 1754 (31.2%) undergoing initial LP shunting. Revision surgery occurred in 3.8% of admissions (n=98) for VP shunts and in 6.6% of admissions (n=123) for LP shunts (p<0.0001). Initial VP shunts were identified to occur at teaching institutions in 84.6% of cases, versus only 77.6% for LP shunts (p<0.0001). The incidence of shunt revision did not differ significantly based upon teaching status (p=0.3339). Hospital length of stay (LOS) differed significantly between primary VP (3 days) and primary LP shunt (4 days) procedures (p < 0.001). Mean total cost for revision or removal of a single LP shunt was $45,911.00, with a cumulative cost over the entire study period of $5,424,999, or $1,084,999 per year. VP shunt malfunction showed a mean total cost of $41,478.50 with a cumulative cost of $3,726,440 or $745,288 per year.

    Conclusions: The presented results appear to call into question the selection of LP shunting as primary treatment for IIH, as this procedure is associated with significantly greater likelihood of need for revision and greater overall cost to the healthcare system.

    Patient Care: -This investigation highlights the increased incidence of hardware complications following lumboperitoneal shunting in this particularly difficult to treat population, as well as the overall cost to the healthcare system. -The conclusions drawn here could be applied by neurosurgeons making the choice of initial treatment strategy for Idiopathic Intracranial Hypertension.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the healthcare cost implications involved in the most commonly selected surgical treatment options for Idiopathic Intracranial Hypertension. 2) Compare the incidence and cumulative impact of revision surgery for lumboperitoneal versus ventriculoperitoneal shunting procedures. 3) Discuss justifications for appropriate treatment decisions with patients based upon known risk factors and overall healthcare cost output.

    References: 1. Sinclair AJ, Kuruvath S, Sen D, et al. Is cerebrospinal fluid shunting in idiopathic intracranial hypertension worthwhile? A 10-year review. Cephalalgia 2011;31:1627–33. 2. Karabatsou K, Quigley G, Buxton N, et al. Lumboperitoneal shunts: are the complications acceptable? Acta Neurochir 2004;146:1193–7. 3.Tarnaris A, Toma AK, Watkins LD, et al. Is there a difference in outcomes of patients with idiopathic intracranial hypertension with the choice of cerebrospinal fluid diversion site: a single centre experience. Clin Neurol Neurosurg 2011;113:477–9. 4.El-Saadany WF, Farhoud A, Zidan I. Lumboperitoneal shunt for idiopathic intracranial hypertension: patients’ selection and outcome. Neurosurg Rev 2012;35:239–243; discussion 243–244.

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