Myelomeningocele

[How I do it: myelomeningocele in bolivia]

INTRODUCTION

Neural Tube Defects (NTD) are the second congenital malformation, second only to cardiac malformations. Myelomeningocele (MMCL) is the most frequent NTD and the more complex. In Bolivia, like in many countries in South America, the low socio economical level of the population increases its incidences and complicates its management.

MATERIALS AND METHODS

Retrospective study of 70 cases of MMC at Hospital Universitario Japonés (HUJ), Santa Cruz de la Sierra, between 2008-2011. Sixty had surgery.

RESULTS

Prenatal care in 27 women (38.6%), positive diagnosis for spinal disraphism in 2 (7.4%). The child arrived after 24 hours of birth (65.5%). Lumbosacral lesion (64.3%). Of those 67.2% were open, with 32.9% evidencing partial motor lesion in contrast with 47.1% who were paraplegic bellow the level of the lesion. Three children were not operated because they had complex and severe malformations associated to the MMCL. The most common surgical complications were; wound dehiscence or infection (16.6%), CSF fistula (10%) CNS infection (11.7%). Mortality and specifically postoperative mortality were 7.1% y 3.3%, respectively. Hydrocephalus wass evident in 80% of the patients who were operated, they received a VP shunt medium pressure. Nine patients who had long term follow up presented with tethered cord.

CONCLUSIONS

A characteristic, delayed referral. No gender predominance. Majority of cases were lumbar or lumbar sacral. Mortality similar to what is reported in the literature. Few patients came for follow up. MMCL is a pathology that requires concentrated attention by the national authorities. A multi center and multi national study will improve our management of these patients.

Intelligence quotient in children with meningomyeloceles: a case-control study

OBJECT

Meningomyelocele (MMC) is a common central nervous system birth defect. As one of many problems facing patients with MMC, learning disabilities are often overlooked. The aim of this study was to evaluate IQs in a group of children with MMCs and determine if a correlation exists between intelligence level and the presence of an MMC and/or its complications.

METHODS

A case-control study was conducted at the Children's Hospital Medical Center in Tehran, Iran, from December 2004 through December 2005. The patient group included 50 children with MMC from 5 to 12 years of age who were referred to the authors' institution for treatment of complications or for follow up after surgery for MMC closure. The patient group was individually matched for age and sex with a control group of 50 children referred to the hospital for other reasons and who did not have MMC or other neurological abnormalities. The IQs in all children in this study were evaluated using the Ravens Progressive Matrices test. The children in both groups were similar in the socioeconomic status of the family (p = 0.347) and educational status of the father (p = 0.117) and mother (p = 0.439). Patient age at the time of surgery for MMC closure varied from 1 day to 96 months (mean 4.1 months). Only 20% of the patients with MMC could walk with a normal gait. Forty-six percent of the patients had undergone placement of a ventriculoperitoneal shunt, and half of these patients experienced shunt-related complications; 72% of the children in the patient group were completely incontinent for both urine and feces. The IQ results obtained in the patient group ranged from 73 to 134 with a mean (+/- standard deviation) of 96.62 +/- 13.01. In the control group the IQ range was 70 to 128, and the mean was 104.82 +/- 12.30. Compared with the control group there was a statistically significant correlation between having an MMC and having a lower IQ (p < 0.001, paired t-test).

CONCLUSIONS

Although the average IQ in the patient group was significantly lower than that in the control group, it is important to note that all children in the patient group had an average or above-average IQ. In contrast with the results reported in other studies, earlier repair of the MMC, the presence of a shunt or shunt-related complications, walking difficulty, and the spinal level of the lesion did not correlate significantly with IQs. Therefore, the lower IQ and reduced cognitive levels noted in these patients result from the disease process itself and not from the associated complications.

Longterm oculomotor and visual function in spina bifida cystica: a population-based study

PURPOSE

To document and describe the development from birth of visual and oculomotor functions in a group of children with spina bifida cystica (myelomeningocele and myeloschisis [MMC]). The emphasis in this study is on findings at 12-14 year follow-up.

METHODS

Twenty children aged 12-14 years with myelomeningocele and Chiari-related malformations were examined by an orthoptist and a paediatric ophthalmologist. A further child who did not wish to participate actively in the study is also reported. Visual acuity for near and distance, refractometer readings in cycloplegia, the presence of ocular motility disorders and nystagmus were recorded. Accommodation, convergence, colour vision and stereo acuity were assessed and the fundus and media were examined.

RESULTS

Six children (29%) in the study group had subnormal vision, although no child was visually impaired. Eleven (52%) showed manifest strabismus and 17 (81%) had a significant refractive error. Near visual acuity was normal in nearly all the children, but accommodation was defective in 10. Nine children had nystagmus and two had optic atrophy. No visual field defects were found.

CONCLUSIONS

The high incidence of ocular disturbances in children with spina bifida highlights the importance of regular ophthalmological investigation and follow-up.

Children With Chronic Continence Problems

For families who are raising children with myelomeningocele, bowel and bladder incontinence presents unique challenges for everyday life. The Parenting and Childhood Chronicity model is used to describe the work of raising a child with a chronic condition in 6 areas, including medical care, adapted parenting, dealing with the systems, caring for siblings, maintaining relationships, and personal coping (keeping yourself going). This article provides an overview of the physiologic and developmental challenges inherent in this neural tube defect and illustrates the work that is involved in the child's care and the challenges of maintaining a balance in family life. Clinical implications are discussed, including the setting of appropriate expectations, providing parents with accurate information, ensuring that a focus on continence is not at the expense of other important aspects of the child's functioning, and supporting parents in their interaction with the school system. The medical team, consisting of nursing, urology, nephrology, and psychology working together, can be a strong support for families.

A comparison of visual function scores in hydrocephalic infants with and without lumbosacral myelomeningocoele

PURPOSE

The cerebrum is frequently malformed in children with myelomeningocoele. This anomaly renders them potentially susceptible to cerebral visual impairment. In these patients, hydrocephalus is an important and frequent complicating lesion which compromises intellectual function and may also cause cerebral visual impairment. In this study, we determined whether hydrocephalic patients with lumbar myelomeningocoele (HLM) are at a greater risk of visual impairment than hydrocephalic patients without this lesion (H).

METHODS

In this prospective study, we assessed five parameters of visual function in 20 hydrocephalic children with lumbar myelomeningocoele and compared the total visual function scores (TVFS) obtained with those from hydrocephalic children without overt spinal dysraphism, but similar in age, sex and ventricular size. The parameters, which were assessed with the aid of a quantitative grading scale, were pupillary size and reaction, optic atrophy, visual fixation and tracking.

RESULTS

The age and sex distributions of the patients in the two groups were similar. The anterior and posterior dimensions of the lateral ventricles were also similar. The mean (SD) of the TVFS were 24.25 (3.63) and 24.20 (3.47) respectively for the two groups (P = 0.90).

CONCLUSIONS

The results suggest that, in hydrocephalic infants with lumbar myelomeningocoele, visual function is not further diminished by the associated dysraphism and that ventricular dilatation is the major determinant of visual impairment.