Acta Neurochir (2016) 158:12691272

DOI 10.1007/s00701-016-2800-x

REVIEW ARTICLE - NEUROSURGERY TRAINING

Can patients with a CSF shunt SCUBA dive?

Dmitri Shastin 1 & Malik Zaben 1 & Paul Leach 1

Received: 22 December 2015 / Accepted: 4 April 2016 / Published online: 15 April 2016
# Springer-Verlag Wien 2016

Abstract
Background Shunt placement for cerebrospinal fluid (CSF)
diversion is one of the most commonly performed procedures
in neurosurgery. Pleasure or sports diving is a popular sport
enjoyed by millions. At present, no guidelines exist to affirm
the safety of diving in the presence of a CSF shunt.
Methods Literature search and review of medical fitness regulations used by diving organisations.
Results Although the available evidence is anecdotal, no reports of shunt-related complications exist and in vitro studies
show lasting functionality.
Conclusions Patients with CSF shunts should undergo careful
evaluation including assessment of their cognitive and physical needs as well as co-morbidities. Having a CSF shunt in situ
is not in itself a contraindication to SCUBA diving.
Keywords Shunt . Hydrocephalus . Diving . Sports . Safety

Introduction
Shunt placement for cerebrospinal fluid (CSF) diversion is
one of the most commonly performed procedures in neurosurgery. Between 3000 and 3500 shunt operations are undertaken
in the UK each year [14]. The majority of these patients are

* Dmitri Shastin
dmitri.shastin@gmail.com

Department of Neurosciences, University Hospital of Wales, Cardiff

and Vale UHB, Cardiff CF14 4XW, UK

adults, some having little to no functional disability and being

able to perform a full range of activities.
Self-contained underwater breathing apparatus (SCUBA)
diving, defined as pleasure or sports diving without mandatory
decompression to 3550 m [4, 15, 21], is a popular sport
enjoyed by millions of people around the world [6]. The
British Sub-Aqua Club (BSAC) alone has a membership of
35,000 in the UK and abroad [8]. While a number of SCUBA
diving-related neurologic complications are frequently reported [6, 15], no guidelines exist to affirm the safety of diving in
the presence of a CSF shunt.

Diving physics
During immersion, the normal atmospheric pressure applied
to a diver's body is supplemented by the hydrostatic pressure
of water. This pressure will rise in proportion to depth; as such,
the diver will be subjected to higher pressures at greater
depths. However, since the human body consists mainly of
fluids, in accordance to Pascal's principle it will bear equal
pressures throughout, and no significant changes in body volume will result. On the contrary, since gases are compressible,
the space they occupy will vary in accordance to the ambient
pressure. This is relevant to air-filled cavities such as the sinuses or the middle ear, such that a Valsalva manoeuvre is
regularly performed by the diver during descent to prevent
bariatric damage to these organs.
Because shunts are filled with CSF and no air is contained
within the ventricles of the brain or the receiving compartment
(peritoneal cavity, atrium of the heart), hypothetically underwater activities should not impair shunt functionality. For the
reasons mentioned above, the pressure gradient between the
ventricles and the receiving compartment will not change.

1270

Literature review
In their Internet-based survey of paediatric neurosurgeons in
the US, Blount et al. attempted to catalogue reports of sportassociated shunt malfunction. Of those responding (92 providers), 77 % had never observed a sport-related shunt complication in their practice; an estimated total of 25 to 30 cases
were reported by the remainder. While none of the activities
linked to shunt malfunction were connected to diving, the
authors estimated the overall rate of sport-related complications to be 0.00030.001. Their key word search of the
Westlaw suite of databases failed to find cases of medical
malpractice involving sports injuries and VP shunts in children [2].
Only few case reports exist on diving with a ventriculoperitoneal (VP) shunt. Cheng et al. describe a 15-year-old girl
with spina bifida and paraparesis who succeeded in completing her training and undertook independent open water dives
with no shunt-related complications [6]. Huang et al. mention
a patient enquiring about the safety of diving with a shunt and
reference a diving medicine textbook that acknowledges that
there are individuals with shunts who currently dive. The
group comment that from their experience, application of hyperbaric oxygen therapy in patients with shunts does not lead
to adverse sequelae [13].
To evaluate the effects of a hyperbaric environment, Huang
et al. subjected four Performance Level One Delta Valve
shunts to underwater pressures first beginning with atmospheric, followed by 4 atm abs (equivalent to approximately
a depth of 30 m). During testing, saline was being pumped
through the shunts at the rates of 5, 10, 20, 40, and 50 ml/h. All
shunts functioned without fault within the specified parameters. The authors concluded that there is low suspicion that VP
shunts would malfunction in an underwater hyperbaric environment [13]. Although localised external pressure such as
that seen with wound swelling [1] or scarring [5, 12] may
influence valves with membrane siphon-preventing mechanisms, this is dissimilar to the underwater conditions where,
according to Pascals principle, initial pressure variations (i.e.,
the difference between atmospheric and CSF pressures) will
remain the same after submersion leaving the valve hydrodynamics unaffected.
Underwater diving may occasionally be associated with
hypothermia. Thorough laboratory testing of 26 different
valve models at the Cambridge Shunt Evaluation Laboratory
has concluded that temperatures as low as 30 C do not undermine shunt functionality. [5].

Fitness to dive with regulating authorities

For the purposes of this article, we focussed on the medical
statements required by two major regulators: the United

Acta Neurochir (2016) 158:12691272

Kingdom Sport Diver Medical Committee (UKSDMC),

employed by BSAC [4], and Professional Association of
Diving Instructors (PADI), provider of tthe international standard in diver education [19].
Concerning neurological aspects of health, UKSDMC asks
participants about blackouts/fainting, epilepsy/fits, migraines,
mental/psychological illness, and any other disease of the
brain or nervous system. If any of the above are answered
positively, the participant is referred to one of the affiliated
Medical Referees for further advice/examination to be
assessed for fitness to dive.
More globally, the PADI record states that a person
with epilepsy or a severe medical problem should not
dive. It recommends that individuals with Bother chronic
medical conditions^ should consult their doctor and the
instructor. Specific neurology-related questions to
prompt this consultation include behavioural/mental/psychological problems, epilepsy/seizures, migraines, blackouts/fainting, and head injury with loss of consciousness. A section on neurological abnormalities of the
supplemented guidelines for recreational scuba diver's
physical examination classifies seizures (other than
childhood febrile seizures), history of transient attack
or cerebrovascular accident, and history of serious decompression sickness with residual deficits as severe
risk conditions that discourage diving. Complicated migraines, history of head injury with sequelae, and intracranial tumour or aneurysm are regarded as relative risk
conditions, suggesting that diving may be possible on
an individual basis.

Discussion
Studies of patients undergoing CSF shunt placement in childhood demonstrate that at 2545-year follow-up, 4456 %
maintain social independence and 2633 % work in a competitive labour market [16, 18, 23]. While cognitive and motor
disability remains an issue [23], Paulsen et al. observe that
there seems to be a great deal of independence in daily living
[16]. Many of the primary insertions in these studies were
carried out before or during the introduction of computed
tomography. Since then, significant improvements in diagnostics and shunt technology have been made [16], along with the
introduction of image guidance to facilitate precise shunt
placement. Additionally, neoplasm was shown to be among
the leading indications for CSF diversion in childhood by
some authors [1618]. This, due to advances of modern-day
paediatric neuro-oncology, may also contribute to a better
prognosis in children with shunted hydrocephalus. Taken together, more patients with CSF shunts are likely to be presenting themselves to clinic for which a range of physical activities is possible.

Acta Neurochir (2016) 158:12691272

From reviewing the medical statement forms expected by

regulating authorities it follows that an individual with a CSF
shunt would be referred for a medical opinion or, in cases with
significant functional impairment, discouraged from diving.
Because of the paucity of scientific evidence available, the
decision regarding a patient's fitness to dive will have to be
taken on an individual basis. There are no reports of shunts
malfunctioning in a hyperbaric environment or in relation to
any of the activities involved in diving; as such, those with no
neurological impairment should be considered for clearance.
Motor deficit due to spinal dysraphism or other causes
presents challenges in a large proportion of children with
shunted hydrocephalus (3347 %) [16, 18, 23]. However, this
per se does not preclude an individual from diving. Cheng
et al. describe the use of enabling appliances such as webbed
gloves to increase propulsion ability [6]. Cognitive (47 %) or
behavioural (15 %) disturbances are also frequently encountered [23] and should be accounted for. Depending on individual needs, patients with functional impairment may be considered for clearance, perhaps for a limited period of time with
further reviews. It is important to remember that epilepsy will
be present in 1436 % [16, 18, 23] of this cohort, rendering
their fitness to dive unlikely.
The decision on when to return to diving after a CSF shunt
operation relies on a number of considerations. Wetting the
wound early following surgery does not seem to increase the
incidence of infection [10, 22]; however, the shunt may be
vulnerable to the micro-organisms inhabiting the natural
fresh- and saltwater sources [11]. Consequently, sufficient
time should be allowed for re-epithelialisation of the incisions
and wound contraction to start to occur (seen after 2-3 weeks),
resulting in increased tensile strength of the wounds [20].
Another concern is the possibility of post-operative seizures.
There are no recent studies looking at the time of seizure onset
post-shunt surgery. In the series of Copeland et al. 24 % of
patients without prior history of epilepsy developed seizures;
in 58 %, this happened within 4 weeks of surgery and in the
rest 13 years later [7]. A comparable study by Dan et al.
suggested a peak in new seizures 28 weeks after surgery;
however, seizures continued to manifest even after 3 years
of follow-up [9]. In their large paediatric series, Bourgeois
et al. have shown that following surgery, seizure activity
peaked around day 20 and started to decrease from then on,
reaching pre-operation levels after approximately 1 year [3].
On the basis of the information at hand the authors recommend to avoid diving in the initial 23 months post-shunt
insertion/revision; this period can be extended depending on
individual circumstances.
Prospective data collection would help to shed light on the
safety of CSF shunts with physical activities such as diving.
As part of their database, the Hydrocephalus Association logs
adverse events for shunted patients participating in organised
sports [2] and may provide a basis for future guidelines.

1271

Conclusions
A decision regarding the safety of SCUBA diving is likely to
fall onto the treating neurosurgeon. It is important that those
with CSF shunts in situ who show interest in SCUBA diving
are assessed on an individual basis using a holistic approach
and taking their cognitive and physical needs as well as associated conditions into account. Consideration should also be
given to wound healing and the time lapse after surgery before
diving can be re-commenced. There are precedents in the literature of individuals with CSF shunts undertaking SCUBA
diving. Although the evidence is anecdotal and as such should
be viewed with caution, as of now no shunt-related complications have been reported and in vitro studies of shunts in
underwater hyperbaric environments confirm lasting functionality. The authors conclude that having a CSF shunt in situ
is not in itself a contraindication to SCUBA diving.
Contributors All authors contributed to the conception of this work,
participated in writing the manuscript, and provided approval of the submitted manuscript. All authors agree to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or integrity of
any part of the work are appropriately investigated and resolved.
Ethical standards This article does not contain any studies with human
participants or animals performed by any of the authors.
Conflict of interest The authors declare that they have no conflict of
interest.
Source of support No funding was involved in preparation of this
article.
Disclaimers The views expressed in the article are the authors own.
Not presented at conferences.

References
1.

2.

3.

4.
5.

Aschoff A, Kremer P, Benesch C, Fruh K, Klank A, Kunze S

(1995) Overdrainage and shunt technology. A critical comparison
of programmable, hydrostatic and variable-resistance valves and
flow-reducing devices. Childs Nerv Syst 11:193202
Blount JP, Severson M, Atkins V, Tubbs RS, Smyth MD, Wellons
JC, Grabb PA, Oakes WJ (2004) Sports and pediatric cerebrospinal
fluid shunts: who can play? Neurosurgery 54:11901198
Bourgeois M, Sainte-Rose C, Cinalli G, Maixner W, Malucci C,
Zerah M, Pierre-Kahn A, Renier D, Hoppe-Hirsch E, Aicardi J
(1999) Epilepsy in children with shunted hydrocephalus. J
Neurosurg 90:274281
British Sub-Aqua Club webpage http://www.bsac.com. Accessed
17 Nov 2015
Chari A, Czosnyka M, Richards HK, Pickard JD, Czosnyka ZH
(2014) Hydrocephalus shunt technology: 20 years of experience
from the Cambridge Shunt Evaluation Laboratory. J Neurosurg
120:697707

1272
6.
7.
8.

9.
10.

11.

12.

13.

14.

Acta Neurochir (2016) 158:12691272

Cheng JF, Diamond M (2005) SCUBA diving for individuals with
disabilities. Am J Phys Med Rehabil 84:369375
Copeland GP, Foy PM, Shaw MD (1982) The incidence of epilepsy
after ventricular shunting operations. Surg Neurol 17:279281
Cumming B, Peddie C, Watson J. A review of the nature of diving
in the United Kingdom and of diving fatalities in the period 1st
Jan 1998 to 31st Dec 2009. British Sub-Aqua Club http://www.
bsac.com/core/core_picker/download.asp?id=20349. Accessed 17
November 2015
Dan NG, Wade MJ (1986) The incidence of epilepsy after ventricular shunting procedures. J Neurosurg 65:1921
Dayton P, Feilmeier M, Sedberry S (2013) Does postoperative
showering or bathing of a surgical site increase the incidence of
infection? A systematic review of the literature. J Foot Ankle
Surg 52:612614
Diaz JH, Lopez FA (2015) Skin, soft tissue and systemic bacterial
infections following aquatic injuries and exposures. Am J Med Sci
349:269275
Drake JM, da Silva MC, Rutka JT (1993) Functional obstruction of
an antisiphon device by raised tissue capsule pressure.
Neurosurgery 32:137139
Huang ET, Hardy KR, Stubbs JM, Lowe RA, Thom SR (2000)
Ventriculo-peritoneal shunt performance under hyperbaric conditions. Undersea Hyper Med 27:191194
Jenkinson MD, Gamble C, Hartley J, Hickey H, Hughes D,
Blundell M, Griffiths MJ, Solomon T, Mallucci CL (2014) The
British antibiotic and silver-impregnated catheters for

ventriculoperitoneal shunts multi-centre randomised controlled trial

(the BASICS trial): study protocol. Trials 15:4
15. Newton HB (2001) Neurological complications of scuba diving.
Am Fam Physician 63:22112218
16. Paulsen AH, Lundar T, Lindegaard KF (2015) Pediatric hydrocephalus: 40-year outcomes in 128 hydrocephalic patients treated with
shunts during childhood. Assessment of surgical outcome, work
participation, and health-related quality of life. J Neurosurg
Pediatr 16:633641
17. Paulsen AH, Lundar T, Lindegaard KF (2010) Twenty-year outcome in young adults with childhood hydrocephalus: assessment
of surgical outcome, work participation, and health-related quality
of life. J Neurosurg Pediatr 6:527535
18. Preuss M, Kutscher A, Wachowiak R, Merkenschlager A, Bernhard
MK, Reiss-Zimmermann M, Meixensberger J, Nestler U (2015)
Adult long-term outcome of patients after congenital hydrocephalus
shunt therapy. Childs Nerv Syst 31:4956
19. Professional Association of Diving Instructors webpage http://
www.padi.com. Accessed 17 Nov 2015
20. Singer AJ, Clark RA (1999) Cutaneous wound healing. N Engl J
Med 341:738746
21. The Sub-Aqua Association webpage http://www.saa.org.uk.
Accessed 17 Nov 2015
22. Toon CD, Sinha S, Davidson BR, Gurusamy KS (2015) Early versus delayed post-operative bathing or showering to prevent wound
complications. Cochrane Database Syst Rev 7:CD010075
23. Vinchon M, Baroncini M, Delestret I (2012) Adult outcome of
pediatric hydrocephalus. Childs Nerv Syst 28:847854