In order to appreciate the impact of shunt-related complications on the individual and society, it is important to recognize that considerable heterogeneity exists in surgical decision-making concerning the management of hydrocephalus [43]. There is no consensus on the optimal methods of CSF diversion, much less the specific devices, procedures, and protocols that should be adopted uniformly to decrease the risk of shunt-related complications. In order to mitigate the burden of complications on individuals and societies, rigor must be applied in identifying modifiable patterns that result in subsequent shunt dysfunction. Indeed, this remains the mission of many organizations and consortia worldwide.

In patients who require insertion of a VP shunt, it is known that various non-modifiable factors may predispose to subsequent complications. For example, premature neonates are more likely develop shunt infections than term equivalents [24]. Furthermore, the underlying etiology of the hydrocephalus has been associated with complications, with obstructive hydrocephalus associated with a disproportionately greater incidence of complications than communicating hydrocephalus [35, 45, 52]. The few studies that have examined novel ways to mitigate shunt complications have largely yielded disappointing results; therefore, there is little evidence on the basis of which surgical decision-making can be standardized. For instance, studies have failed to demonstrate superiority of more complex or expensive shunt device over simpler alternatives [39]. Treatment decisions are often at the discretion of the attending surgeon and tailored towards the specific clinical and radiographic phenotypes of individual patients.

There is some evidence, however, to suggest that procedure-related changes may mitigate certain complications [21]. For example, it has been shown that performing shunt insertions at the beginning of the day, limiting personnel in the operating theater, and administration of periprocedural antibiotics result in considerably lower rates of shunt infections [20]. More recently, intrathecal antibiotics, minimizing exposure of shunt tubing to breached surgical gloves [24], and antibiotic-impregnated shunts [13] have been shown or suggested to decrease complications. It remains imperative for clinicians to be cognizant of heterogeneity in practice and to strive to identify best practices to mitigate shunt-related complications.

Heterogeneity also exists in the underlying pathological conditions leading to shunt-dependent hydrocephalus. They may range from congenital malformations such as aqueductal stenosis and myelomeningocele to acquired conditions such as post-infectious or post-subarachnoid hemorrhage hydrocephalus. Importantly the underlying etiologies of hydrocephalus may be independently associated with poor outcome or poorer health-related quality of life (QOL), and indeed, disentangling the effects of shunt-related complications from other putative factors often proves difficult.

Evaluating the effects of shunt-related complications on an individual’s health is furthermore complicated by the fact that numerous external factors moderate his/her well-being when faced with medical or surgical complications. For example, lower socioeconomic status, worse family functioning, and lower parental education have been shown to correlate with lower quality of life in studies of childhood hydrocephalus [22]. The multifaceted interplay between multiple variables must therefore be considered when evaluating the impact of shunt-related complications.

Concrete data on mortality, disability, and time lost provide less biased estimates of the impact of shunt-related complications on the lives of patients. More robust measures such as QOL indices may, however, provide a more in-depth picture of ways in which shunt complications affect different dimensions of a patient’s well-being. In the subsequent sections, we provide a summary of various indicators used to index the effects of procedure-related complications on a patient’s well-being. Namely, we review data on mortality, disability, and time lost as well as QOL and cognitive function.

Shunt-related complications are also associated with an enormous social burden. The true impact of shunt complications on society is difficult to glean from the literature. Patients with shunted hydrocephalus are less likely to access higher education and often possess poorer social functioning and employment prospects than their peers [38], resulting in an enormous loss of productivity. It is expected that shunt-related complications exacerbate these challenges by extending time lost from work, extended lengths of hospital stay, and health-related economic costs. The effect of complications on families and communities is also substantial. The extent of the social impact of shunt-related complications is also related to the degree in which they result in impairments for the individual. For example, cognitive impairments, childhood onset, and protracted disease course may be associated with a greater cost to society [15].

There are several ways in which the societal impact of hydrocephalus and shunt-related complications may be measured. One salient measure is the cost of intervention for shunting and revisions. Healthcare costs in general comprise a large proportion of any nation’s budget and have repercussions for societies, particularly with socialized healthcare systems [15]. More importantly, disease and disability associated with hydrocephalus and shunt-related complications exact a high societal price, which may be more difficult to quantify. Metrics such as years of potential life lost (YPLL), valued years of potential life lost (VYPLL), years of potential productivity lost (YPPL), and lifetime years of potential life lost (LYPLL) may be used to attempt to quantify this impact [30]. Measures such as quality-adjusted life years (QALY) also take into account the quality of life affected by the disease burden. These are often used in cost-utility analyses to evaluate the impact of a particular intervention on mitigating the cost of a disease on society. Unfortunately, there is a paucity of studies that have examined how shunt-related complications affect these metrics. Given that health economics is a burgeoning field of research, it is expected that greater emphasis will be placed on understanding the impact of shunt-related complications on these measures of society in the future.