Constipation is associated with spina bifida occulta in children

Sacral Spina Bifida Occulta: A Frequency Analysis of Secular Change

Substantial relaxation of natural selection beginning around 1900 changed the mutation/selec­tion balance of modern genetic material, producing an increase in variable anatomical structures. While multiple structures have been affected, the temporal increase in variations of the sacrum, specifically, ‘Sa­cral Spina Bifida Occulta,’ have been reliably demonstrated on a localised scale. Calculation of largescale frequency has been hindered by the localised nature of these publications, the morphological variability of this variation, and potential pathological associations, which have produced divergent classifications, and conflicting reported rates of occurrence. A systematic review of the reported literature was conducted to provide an objective analysis of Sacral Spina Bifida Occulta frequency from 2500 BCE to the present. This review was designed to compensate for observed inconsistencies in reporting and to ascertain, for the first time, the temporal trajectory of this secular trend. A systematic review of Sacral Spina Bifida Occulta lit­erature was conducted through the strict use of clinical meta-analysis criteria. Publications were retrieved from four databases: PubMed, Embase, the Adelaide University Library database, and Google Scholar. Data were separated into three historical groups, (1 = <1900, 2 = 1900 to 1980 and 3 = >1980), and frequency outcomes compared, to determine temporal rates of occurrence. A total of 39/409 publications were included in the final analysis, representing data for 16,167 sacra, spanning a period of 4,500 years. Statistically significant results were obtained, with total open S1 frequen­cy increasing from 2.34%, (79 to 1900CE), to 4.80%, (1900 to 1980CE) and to 5.43% (>1980CE). These increases were significant at p<0.0001, with Chi-squared analysis. A clear secular increase in the global frequency of Sacral Spina Bifida Occulta has been demonstrated from 1900 to the present. This research provides a novel and adaptable framework for the future assessment of variation distribution, with impor­tant implications for the fields of biological anthropology and bioarchaeology.

Spina Bifida Occulta Is a Risk Factor for Spinal Cord Injury Without Fracture or Dislocation for Children Performing a Backbend During Dance

OBJECTIVE

This study aimed to explore the clinical features and outcomes of children with spinal cord injury (SCI) without fracture or dislocation.

METHODS

The clinical data of children with SCI without fracture or dislocation in this retrospective study were collected in Chongqing, China (January 2010 to December 2021). We collected patient demographics at admission including age, gender, cause, level, and severity of the injury in admission and complications. Reports from radiologic imaging were reviewed to identify spina bifida occulta (SBO). Neurological function was evaluated using the American Spinal Injury Association (ASIA) Impairment Scale (AIS) for an SCI.

RESULTS

A total of 74 children with SCI (male, 27%; female, 73%; male-to-female ratio, 1:2.7; average age, 5.7 years) were included. The main cause of injury was backbend during the dance (34 patients, 45.9%, including 2 patients who hugged back falling backward), followed by traffic accidents (17 patients, 23%). Children with backbend-related SCI were older than other children (6.9 vs. 4.9 years old, P < 0.001). When reviewing all radiological images, it was found that 20 (27%) patients with SCI had SBO. The proportion of SCI with SBO caused by backbend was considerably higher than those caused by non-backbend (41.2 vs. 15%, P = 0.012). The AIS were 22 (29.7%), 4 (5.4%), 8 (10.8%), 31 (41.9%), and 9 (12.2%) in A, B, C, D, and E, respectively. The prognosis was poorer in the backbend during dancing than other causes of injury (p = 0.003).

CONCLUSION

This study showed that backbend during the dance was the main cause of children's SCI without fracture or dislocation in Chongqing, China. The prognosis was poorer in those children than in other causes of injury. Meanwhile, we have established an association between SBO and SCI for children performing a backbend during the dance.

Evolving Evidence Supporting Use of Rectal Irrigation in the Management of Bowel Dysfunction: An Integrative Literature Review

Disorders of bowel function are prevalent, particularly among patients with spinal cord injuries and other neurological disorders. An individual's bowel control significantly impacts quality of life, as predictable bowel function is necessary to actively and independently participate in everyday activities. For many patients with bowel dysfunction, initial lifestyle adjustments and other conservative therapeutic interventions (eg, digital stimulation, oral laxatives, suppositories) are insufficient to reestablish regular bowel function. In addition to these options, rectal irrigation (RI) is a safe and effective method of standard bowel care that has been used for several decades in adults and children suffering from bowel dysfunction associated with neurogenic or functional bowel etiologies. Rectal irrigation is an appropriate option when conservative bowel treatments are inadequate. Unlike surgical options, RI can be initiated or discontinued at any time. This report summarizes the clinical, humanistic, and economic evidence supporting the use of RI in clinical practice, noting features (eg, practical considerations, patient education) that can improve patients' success with RI treatment.

Bowel Management and Quality of Life in Children With Spina Bifida in South Korea

Bowel management is a concern in patients with spina bifida. We evaluated the status of bowel management in children with spina bifida (SB) and the effects on quality of life (QoL) of children and their caregivers. Data were collected from 173 children with SB between January and June 2011, whose bowel management status and QoL were assessed using a self-administered questionnaire. Of the 173 children, 38 (22.0%) reported normal defecation, 73 (42.2%) reported constipation only, and 62 (35.8%) reported fecal incontinence with/without constipation. For defecation, 59 children (34.1%) used digital stimulation or manual extraction, 28 (16.2%) used suppositories or enemas, 35 (20.3%) used laxatives, 4 (2.3%) used an antegrade continence enema, and 3 (1.7%) used transanal irrigation. There were significant differences in QoL, depending on defecation symptoms. Children with fecal incontinence and their caregivers had difficulties in travel and socialization (p < .0001), caregivers' emotions (p < .0001), family relationships (p < .0001), and finances (p < .0001). Constipation and fecal incontinence affect QoL of children with SB and their caregivers. Therefore, more attention should be paid to bowel problems and help should be provided to children and their caregivers to improve QoL.

Sensory neuron differentiation potential of in utero mesenchymal stem cell transplantation in rat fetuses with spina bifida aperta

BACKGROUND

In previous studies, we found that the deficiency of sensory and motor neurons was a primary defect associated with the spinal malformation. Upon prenatal treatment of spina bifida through in utero stem cell transplantation in a retinoic acid-induced spina bifida rat model, we found that the mesenchymal stem cell (MSCs) survived, migrated, and differentiated into cells of a neural lineage. In the present study, we investigated whether the transplanted MSCs had the potential to differentiate into sensory neurons or to protect sensory neurons in the defective spinal cord.

METHODS

Pregnant rats treated with retinoic acid on embryonic day (E) 10, underwent fetal surgery for MSC transplantation on E16. The fetuses were harvested on E20. Immunofluorescence was used to detect the expression of Brn3a protein in the transplanted MSCs and dorsal root ganglion (DRG) neurons in the defective spinal cords. The expression of the transcription factors Brn3a and Runx1 in spinal cords was analyzed using real-time polymerase chain reaction.

RESULTS

Some of the transplanted MSCs expressed sensory neuron cell specific phenotypes. The expression of Brn3a and Runx1 was upregulated in the defective spinal cords when compared to controls. The percentage of Brn3a-positive neurons in DRG was also increased after transplantation.

CONCLUSION

Our results indicate that the transplantation of MSCs into the spinal cord could promote the transplanted MSCs and the surrounding cells to differentiate toward a sensory neuron cell fate and to play an important role in protecting sensory neurons in DRG. This approach might be of value in the treatment of sensory neuron deficiency in spina bifida aperta.

Decreased enteric fatty acid amide hydrolase activity is associated with colonic inertia in slow transit constipation

BACKGROUND

Constipation is one of the most common chronic digestive complaints. Gastrointestinal transit studies have divided it into three patterns: normal transit, slow transit constipation (STC), and outlet obstruction. It has been demonstrated that STC patients respond poorly to standard therapies, and the etiology of STC remains poorly understood. Animal studies have also shown that fatty acid amide hydrolase (FAAH) controls intestinal motility through its putative receptors or non-receptor-mediated pathways. However, the role of FAAH in STC has not been elaborated.

METHODS

A case series was carried out on thirty-two STC patients fulfilling the Rome II criteria and on 24 controls. All of the subjects underwent a laparotomy in Shengjing Hospital. Colonic specimens were obtained and used for FAAH expression analysis, enzyme activity assay, and cannabinoid detection.

RESULTS

FAAH immunoreactivity occurred in the enteric neurons and in the surface epithelial and glands. The expression level and enzyme activity of FAAH in the STC group were both significantly lower than those in the control group (P < 0.05). The amounts of anandamide, 2-arachidonylglycerol, and palmitoylethanolamide, which are negatively correlated with enzyme activity, were significantly higher in the constipation group than that in the control group. In the STC group, cannabinoid receptor type 1 immunoreactivity occurred predominantly in the submucosal and myenteric fibers that were obviously strong and wave-like in their appearance. Enteric ganglions decreased or disappeared.

CONCLUSIONS

The tone of the enteric cannabinoids system is disturbed in STC, and the decreased enteric FAAH activity contributes to colonic inertia in STC.

Review article: faecal incontinence in children: epidemiology, pathophysiology, clinical evaluation and management

BACKGROUND

Faecal incontinence (FI) in children is a significant gastrointestinal problem, with great personal and social impacts. It is characterised by recurrent loss of faecal matter into the underwear. Both functional and organic causes contribute to its aetiology with the former predominating.

AIM

To review the epidemiology, pathophysiology, clinical evaluation and management of functional faecal incontinence in children.

METHODS

A PubMed search was conducted using search terms f(a)ecal incontinence, and encopresis. Articles on epidemiology, pathophysiology, clinical evaluation, investigation and management of functional FI in children were retrieved and assessed.

RESULTS

Community prevalence of this distressing problem ranges from 0.8% to 7.8% globally. Male: female ratio varies from 3:1 to 6:1. The diagnosis of FI is often based on established clinical criteria. The majority (82%) have constipation associated functional FI. Biopsychosocial factors play a crucial role in the pathogenesis. Limited physiological testing of anorectal function is recommended in the diagnostic procedures, particularly in children with atypical symptoms and possible organic disorders. Management of FI needs a multidisciplinary approach which includes establishment of an effective doctor-patient partnership, understanding the underlying mechanisms, pharmacotherapy and behavioural treatment. Approximately 15% of children with functional nonretentive faecal incontinence (FNRFI) had the same symptoms at the age of 18 years.

CONCLUSION

Significant therapeutic advances have been made for retentive faecal incontinence, but treatment options for functional nonretentive faecal incontinence are limited. Limited long-term outcome data show that the majority outgrow faecal incontinence. A substantial proportion of children progress to adulthood with faecal incontinence.

Therapeutic potential of in utero mesenchymal stem cell (MSCs) transplantation in rat foetuses with spina bifida aperta

Neural tube defects (NTDs) are complex congenital malformations resulting from incomplete neurulation in embryo. Despite surgical repair of the defect, most of the patients who survive with NTDs have a multiple system handicap due to neuron deficiency of the defective spinal cord. In this study, we successfully devised a prenatal surgical approach and transplanted mesenchymal stem cells (MSCs) to foetal rat spinal column to treat retinoic acid induced NTDs in rat. Transplanted MSCs survived, grew and expressed markers of neurons, glia and myoblasts in the defective spinal cord. MSCs expressed and perhaps induced the surrounding spinal tissue to express neurotrophic factors. In addition, MSC reduced spinal tissue apoptosis in NTD. Our results suggested that prenatal MSC transplantation could treat spinal neuron deficiency in NTDs by the regeneration of neurons and reduced spinal neuron death in the defective spinal cord.

Transcutaneous interferential electrical stimulation for management of neurogenic bowel dysfunction in children with myelomeningocele

PURPOSE

We describe the efficacy of transcutaneous interferential (IF) electrical stimulation on constipation symptoms in children with myelomeningocele (MMC).

METHODS

MMC children (30, comprising of 17 girls and 13 boys), mean age 6.7 ± 2.9, with moderate to severe intractable constipation were enrolled in this study. They were divided into treatment (IF stimulation, 15 children) and control (sham stimulation, 15 children) groups. All children underwent anorectal manometry before and 6 months after IF therapy considering the rectoanal inhibitory reflex and sphincter pressure. Parents were instructed to complete a bowel habit diary by providing data on the number of defecations per week, form of stool and episodes of pain during defecation. According to parents' report a total neurogenic bowel dysfunction score questionnaire was filled before and 6 months after treatment. A 15-course abdominal area IF electrical stimulation was performed for 20 min and three times per week, with low-frequency current in a duration of 250 μs every 6 s. Children were followed up for a minimum period of 6 months.

RESULTS

In the treatment group, sphincter pressure and rectoanal inhibitory reflex significantly improved compared with sham stimulation and pretreatment measures (P < .05). In 73% of patients, the characteristics of constipation decreased immediately after IF therapy, while in 53% patients, they persisted for 6 months. Frequency of defecation increased statistically significant from 2.5 ± 1.1 per week before treatment to 4.7 ± 2.3 per week after treatment (P < .001).

CONCLUSIONS

This pilot study showed that IF therapy is safe, noninvasive, and effective modality to improve constipation symptoms and anorectal manometry parameters in children with history of myelomeningocele.

Distribution of affected muscles and degree of neurogenic lesion in patients with spina bifida

INTRODUCTION

Patients with spina bifida in the lumbosacral region usually have various degrees of motor and sensory dysfunctions of the lower extremities and anal sphincter. The aim of our study was to evaluate the distribution and differences in frequencies of affected muscles, number of affected muscles and degree of neurogenic lesion between patients with spina bifida occulta (SBO) and spina bifida aperta (SBA).

MATERIAL AND METHODS

In 100 patients with SB, 6 muscles in the lower limbs were separately analysed. Due to the number of affected muscles, we evaluated 5 groups of patients: with 1 affected muscle, 2 affected muscles, 3 affected muscles, 4 affected muscles and 5 affected muscles. Three degrees of neurogenic lesions were assessed: mild, moderate and severe.

RESULTS

The tibialis anterior muscle was most frequently affected in SB patients. The outer anal sphincter was frequently affected in the group of SBA patients. Single muscle affection is frequent in the group of patients with SBO, while in the group of patients with SBA, 4 muscles were significantly frequently affected. The great majority of patients (45.46%) with affected outer anal sphincter (OAS) in the group of SBO were without affection of other muscles, while for the SBA group it was for every third patient. Mild neurogenic lesion was significantly frequent in SBO patients, while severe form was significantly frequent in SBA patients.

CONCLUSIONS

Patients with SBO usually present with mild to moderate clinical presentation, while multiple root involvement and severe degree of neurogenic lesion is associated more frequently with SBA.

MR imaging features of common variant spinal anatomy

The spine is one of the most commonly imaged body parts for all age groups, with indications ranging from congenital abnormalities at birth to degenerative pathology toward the end of life. Because of the importance of softtissue contrast when imaging the spine, MR imaging has become the most important modality in its evaluation. One of the key challenges in the clinical analysis of spinal MR imaging lies in the wide range of so-called normal variability. The goal of this article is not to provide the reader with an exhaustive atlas detailing the appearance of every known variant. Instead, the authors review the MR appearance of the most important variants and provide a logical and, they hope, memorable framework for assimilating this information into practice. To understand why these variations occur, the authors examine the aberrant pathways of embryology, growth, and development that lead to their formation.

Magnetic resonance imaging of the lumbosacral spine in children with chronic constipation or non-retentive fecal incontinence: a prospective study

OBJECTIVE

To determine the prevalence of lumbosacral spine (LSS) abnormalities in children with defecation disorders, intractable constipation, or non-retentive fecal incontinence (NRFI) and evaluate whether LSS abnormalities on magnetic resonance imaging (MRI) are clinically detected by neurologic examination.

STUDY DESIGN

MRI of the LSS and complete neurologic examination by a pediatric neurologist blinded to the MRI results were performed in patients with intractable defecation disorders.

RESULTS

Patients with intractable constipation (n = 130; 76 males; median age, 11 years; range, 6-18 years), and patients with NRFI (n = 28; 18 males; median age, 10 years; range, 7-15 years) participated. One occult spina bifida (OSB) and 3 terminal filum lipomas were found in patients with a normal neurologic examination. One patient had a terminal filum lipoma and neurologic complaints. Gluteal cleft deviation was found in 3 of 4 patients with LSS abnormalities. Neurosurgical treatment was not required in any patient during the 12-week follow-up.

CONCLUSIONS

MRI showed LSS abnormalities in 3% of patients with defecation disorders and normal neurologic examination, all of whom reported symptom relief at the 12-week follow-up without neurosurgical intervention. Thus, whether or not LSS abnormalities play a role in defecation disorders remains unclear.

Review of the efficacy and safety of transanal irrigation for neurogenic bowel dysfunction

STUDY DESIGN

Neurogenic bowel dysfunction (NBD) is a common occurrence after spinal cord injury (SCI) and in patients with spina bifida or multiple sclerosis. The impact of NBD on well-being is considerable, affecting both physical and psychological aspects of quality of life. Transanal irrigation (TAI) of the colon promotes the evacuation of faeces by introducing water into the colon and rectum through a catheter inserted into the anus. Regular and controlled evacuation in this manner aims at preventing both constipation and faecal soiling.

OBJECTIVES

The aim of this study was to review current evidence for the efficacy and safety of TAI in patients with NBD.

MATERIALS AND METHODS

A literature search was conducted in PubMed. All identified papers were assessed for relevance based on the title and abstract; this yielded 23 studies that were considered to be of direct relevance to the topic of the review.

RESULTS

A multicentre, randomized, controlled trial has supported observational reports in demonstrating that TAI offers significant benefits over conservative bowel management in patients with SCI, in terms of managing constipation and faecal incontinence, reducing NBD symptoms and improving quality of life. Among other populations with NBD, TAI shows the greatest promise in children with spina bifida; however, further investigation is required. The overall safety profile of TAI is good, with few, and rare, adverse effects.

CONCLUSIONS

Building on the positive data reported for patients with SCI, continued evaluation in the clinical trial setting is required to further define the utility of TAI in other populations with NBD.