Postnatal Management of Myelomeningocele: Outcome with a Multidisciplinary Team Experience

Tethered cord prevalence among patients with prenatal or postnatal myelomeningocele repair

BACKGROUND

Myelomeningocele (MMC) is a severe form of spina bifida characterized by spinal cord extrusion into a cerebrospinal fluid (CSF) filled sac which may lead to lifelong disability. Repair of these lesions have classically occurred shortly after birth, but more recently, prenatal myelomeningocele repair techniques have been elucidated. This study aimed to investigate the outcome of surgery, particularly with subsequent spinal cord tethering, in patients with prenatal myelomeningocele closure and those with postnatal repair surgery.

MATERIALS AND METHODS

In this retrospective study which assessed patients from April 2002 to April 2020, the data of 18 total patients with MMC were reviewed. Nine patients from each group were included, closed prenatally or postnatally, respectively. Demographic information including age and sex, birth week, infant comorbidities, presence of dermoid or lipoma, cutaneous stigmata, total number and timing of detethering procedures, presence of Chiari malformation, and need for VPS was obtained.

RESULTS

Eighteen patients including nine infants closed prenatally and nine infants with myelomeningoceles closed postnatally were reviewed. The mean age was 4 ± 3 years and 6.22 ± 2.4 in prenatal and postnatal retrospectively. There was a significant relationship between the number of detethering procedures (p-value = 0.03) and the need for a ventriculoperitoneal shunt (VPS) (p-value = 0.01) between the groups, with the prenatal closure group having lower rates of each. There was no significant difference between the groups in regard to the mean age at the detethering procedure (p = 0.4), sex (p = 0.09), birth week (p = 0.8), comorbidities (p = 0.8), presence of intraspinal dermoid or lipoma (p = 0.09), presence of cutaneous stigma (p = 0.08), Chiari (p = 0.6), fatty filum (p = 0.08), syrinx (p = 0.4), bone anomaly (p = 0.4), and spina bifida neurological scale (p = 0.66).

CONCLUSION

There was a significant relationship between the two groups in terms of the number of detethering procedures, and the need for VPS. Our data represents a possible difference in the need for detethering surgeries and ventriculoperitoneal shunt placements between patients with prenatal and postnatal myelomeningocele closures.

Overcoming Airway Hurdles: A Case Report of Anesthetic Challenges in Meningomyelocele Complications

This case report delves into the anesthesia management in a 23-year-old male with complications of meningomyelocele, a catastrophic congenital neural tube defect. The patient, paraplegic since birth with severe scoliosis, presented with a femoral fracture, prompting the need for careful consideration of anesthesia strategies. The challenges included counseling the family on the risks and benefits of surgery under general anesthesia, selecting an appropriate anesthetic plan for an anticipated difficult airway, and addressing ventilation strategies for restrictive lung disease. To tackle the anticipated difficult airway, an awake pediatric fiberoptic bronchoscopy was performed in the recovery room, facilitating a conscious sedation approach. In the operating room, monitored anesthesia care with dexmedetomidine infusion was employed, complemented by careful positioning and padding in the lateral position. The awake fiberoptic checkscopy proved crucial in avoiding unnecessary general anesthesia. A patient-centered approach contributed to the successful execution of a complex anesthesia plan, ensuring optimal care for this unique patient population.

Potential higher risk of tethered spinal cord in children after prenatal surgery for myelomeningocele: A systematic review and meta-analysis

INTRODUCTION

We performed a systematic review and meta-analysis on the incidence of secondary tethered spinal cord (TSC) between prenatal and postnatal closure in patients with MMC. The objectives was to understand the incidence of secondary TSC after prenatal surgery for MMC compared to postnatal surgery for MMC.

MATERIAL AND METHODS

On May 4, 2023, a systematic search was conducted in Medline, Embase, and the Cochrane Library to gather relevant data. Primary studies focusing on repair type, lesion level, and TSC were included, while non-English or non-Dutch reports, case reports, conference abstracts, editorials, letters, comments, and animal studies were excluded. Two reviewers assessed the included studies for bias risk, following PRISMA guidelines. TSC frequency in MMC closure types was determined, and the relationship between TSC occurrence and closure technique was analyzed using relative risk and Fisher's exact test. Subgroup analysis revealed relative risk differences based on study designs and follow-up periods. A total of ten studies, involving 2,724 patients, were assessed. Among them, 2,293 patients underwent postnatal closure, while 431 received prenatal closure for the MMC defect. In the prenatal closure group, TSC occurred in 21.6% (n = 93), compared to 18.8% (n = 432) in the postnatal closure group. The relative risk (RR) of TSC in patients with prenatal MMC closure versus postnatal MMC closure was 1.145 (95%CI 0.939 to 1.398). Fisher's exact test indicated a statistically non-significant association (p = 0.106) between TSC and closure technique. When considering only RCT and controlled cohort studies, the overall RR for TSC was 1.308 (95%CI 1.007 to 1.698) with a non-significant association (p = .053). For studies focusing on children up until early puberty (maximum 12 years follow-up), the RR for tethering was 1.104 (95%CI 0.876 to 1.391), with a non-significant association (p = 0.409).

CONCLUSION AND DISCUSSION

This review found no significant increase in relative risk of TSC between prenatal and postnatal closure in MMC patients, but a trend of increased TSC in the prenatal group. More long-term data on TSC after fetal closure is needed for better counseling and outcomes in MMC.

Antenatal counselling for prospective parents whose fetus has a neurological anomaly: part 2, risks of adverse outcome in common anomalies

After diagnosis of a fetal neurological anomaly, prospective parents want to know the best and worst-case scenarios and an estimation of the risk to their infant of having an atypical developmental outcome. The literature on developmental outcomes for fetal neurological anomalies is poor: studies are characterized by retrospective design, small sample size, often no standardized assessment of development, and differing definitions of anomalies. This review provides an aide-memoir on the risks of adverse neurodevelopmental outcome for ventriculomegaly, cortical anomalies, microcephaly, macrocephaly, agenesis of the corpus callosum, posterior fossa anomalies, and myelomeningocele, to assist healthcare professionals in counselling. The data in this review should be used alongside recommendations on counselling and service design described in part 1 to provide antenatal counselling.

CSF shunting in myelomeningocele-related hydrocephalus and the role of prenatal imaging

OBJECTIVE

Hydrocephalus is commonly associated with myelomeningocele (MMC). Indication and timing of cerebrospinal fluid (CSF) shunting are still a topic of discussion. The aim of this study was to investigate whether the analysis of prenatal cerebral imaging studies could provide information that is predictive of the necessity of CSF shunting in the postnatal period.

MATERIAL AND METHODS

Among 73 infants operated on because of MMC between January 2003 and June 2020, 50 had undergone prenatal and postnatal MRI studies and were considered for analysis. For each patient, frontal horn width, atrial ventricle diameter, third ventricle diameter, and subarachnoid spaces (sinocortical width, craniocortical width, and the interhemispheric width) have been measured on prenatal, postnatal, and a follow-up MRI study. The need of CSF shunting device placement in relation to prenatal and early postnatal MRI data was investigated.

RESULTS

Of the 50 infants, 31 (62%) developed a progressive hydrocephalus. Of these, 30 needed a CSF shunt and the majority of them (n=29) was operated on within 28 days after birth. One patient needed CSF shunt implantation at 45 days after birth and one child developed a late progressive hydrocephalus, successfully treated by ETV alone, at 14.2 months of age. All patients with an atrial ventricle diameter greater than 1.9 cm and a 3rd ventricle diameter larger than 0.3 cm on antenatal third trimester imaging have undergone CSF shunting within 1 month after birth. Conversely, all the children that did not undergo a CSF shunt placement showed an atrial cerebral ventricle diameter inferior to 1.2 cm and a 3rd ventricle width < 0.3 cm on antenatal imaging. Frontal horn width and subarachnoid CSF spaces' evolution did not seem to play a role.

CONCLUSION

The prenatal MRI assessment of the associated prenatal ventriculomegaly in MMC provides parameters that have a predictive value heralding the probability of a CSF diversion procedure after birth. In the same way, the analysis of intrauterine MRI studies may identify those subjects that are less at risk of developing a progressive hydrocephalus after birth, therefore encouraging a more cautious attitude towards the early implantation of CSF shunting devices in the current clinical practice.

Orthopedic management of myelomeningocele with a multidisciplinary approach: a systematic review of the literature

Background

Myelomeningocele (MMC) is the most common and severe form of spina bifida and imposes a significant burden on patients and the healthcare system. Recently, the multidisciplinary management of MMC has become popular. Herein, we aimed to review the orthopedic management, outcomes, and complications of the of patients with MMC eyeing a multidisciplinary approach.

Methods

We searched PubMed and EMBASE to find relevant studies published before August 2020. All studies that included clinical management of MMC patients and published earlier than 2000 were considered for review on the condition that they reported at least one orthopedic intervention and the rate of complications. We excluded review articles, case reports, case series, letters, commentaries, editorials, and conference abstracts. The primary and secondary goals of our review were to report the outcomes and complication rates of multidisciplinary management for MMC patients.

Results

Twenty-six studies included data for the management of 229,791 patients with MMC and were selected. Sixteen studies reported multidisciplinary management in addition to orthopedic management. From those, 11 (42.31%) included urologic management, 13 (50%) neurosurgical management, 11 (42.31%) neurologic management, and 5 (19.23%) gastrointestinal management. All studies included postnatal operations and related management. No randomized clinical trial was found in our search.

Conclusion

Orthopedic approaches play a key role in MMC management by alleviating spinal deformities, particularly scoliosis, and hip, foot, and ankle complications. However, the most appropriate management, whether surgical or non-surgical, may vary for different patients, given disease severity and the age of patients.

Graphical abstract

Intrauterine fetoscopic closure of myelomeningocele: Clinical case and literature review

OBJECTIVE

Spina bifida (SB) is a congenital birth defect defined as a failure of the neural tube formation during the embryonic development phase. Fetoscopic repair of SB is a novel treatment technique that allows to close spinal defect early and prevent potential neurological and psychomotor complications.

CASE REPORT

We present a case report of a 32-year-old-multigravida whose fetus was diagnosed with lumbosacral myelomeningocele at 23rd week. Fetoscopic closure of MMC was performed at 26 weeks. At 32 weeks, due to premature amniorrhexis and placental abruption, an emergency C-section was performed. Newborn's psychomotor development was within normal limits.

CONCLUSION

Although intrauterine treatment has an increased risk of premature labor, placental abruption, prenatal closure is associated with improved postnatal psychomotor development. Prenatal surgery decreases the risk of Arnold-Chiari II malformation development and walking disability. Fetoscopic closure of SB is becoming a choice for treatment with beneficial outcomes for mother and fetus.

Myelomeningocele in Slovenia: results of a 10-year follow-up

BACKGROUND

Myelomeningocele (MMC) is a congenital malformation that results from a failure in the process of neurulation. A multidisciplinary follow-up is required to manage and treat all associated sequelae. The aim of the study was to present the epidemiological data and the results of the multidisciplinary follow-up of children born in Slovenia with myelomeningocele (MMC) between 2007 and 2017.

METHODS

We presented a retrospective analysis of all children born in Slovenia with between 2007 and 2017. The multidisciplinary follow-up included neurosurgical, urological, neurological, endocrinological and orthopedic expertise.

RESULTS

Twenty children were treated in Slovenia for MMC from 2007 to 2017 (mean follow-up of 7.7 years). 9 MMC were thoracic, 2 higher lumbar, 5 lower lumbar and 4 sacral. Thirteen children needed a CSF shunt, 1 was treated with endoscopic ventriculostomy (ETV). Four children needed a craniocervical decompression and 2 needed a detethering procedure. 14 children had a neurogenic bladder and 17 referred bowel continence. Orthopedic correction of the lower limbs was required in 9 cases. 4 children had seizures, 10 had endocrinological deficits. Among 16 children attending school, 11 were inserted in special educational classes.

CONCLUSIONS

The prevalence of MMC in Slovenia between 2007 and 2017 was 1/10000 births. Our follow-up results are comparable with those of previous, larger studies and confirm the efficacy of treating hydrocephalus with ETV in selected cases and with CSF shunt only in cases of clearly increased intracranial pressure. By adopting this strategy, we reduced the CSF shunt rate to 65%.

Meningomyelocele with unusual feet deformity combination: A report of a rare case

A 19-month-old male infant had presented to a paediatric orthopaedic clinic at the age of 6 months with meningomyelocele and bilateral feet deformity. The patient was admitted to the neonatal intensive care unit because of multiple congenital anomalies. These anomalies included meningomyelocele, right clubfoot, left vertical talus, imperforated anus, and an indirect hernia. Radiographs confirmed the diagnosis of right clubfoot and left-sided vertical talus. The course of management was delayed because of late diagnosis. At the age of 9 months, the patient underwent serial casting using the Ponseti and reverse Ponseti techniques for right clubfoot and left-sided vertical talus, respectively. The casting was performed weekly for 12 weeks. The right foot gained normal position before the left, but we decided to keep it in the cast until surgical correction was performed for both feet. The patient underwent right Achilles tendon tenotomy and casting and left Achilles tendon tenotomy, manipulation, and talonavicular reduction and k-wire fixation with casting. The casts remained for 3 and 6 weeks (clubfoot and vertical talus, respectively). The ultimate goal of the treatment was to produce braceable, plantigrade feet with the use of a well-padded knee ankle-foot orthosis to improve the quality of life.

The role of sacral laminoplasty in the management of spina bifida and sacral cystic lesions: case series

OBJECTIVE

Although laminae are not viewed as essential structures for spinal integrity, in the sacrum the anatomical weakness and gravity makes it a vulnerable area for CSF accumulation and expansion. The congenital or postoperative defects of sacral laminae, such as in patients with spina bifida, make this area more susceptible to forming progressive dural ectasia, pseudomeningocele, or expansile arachnoid cyst (Tarlov cyst). In addition, adhesions between the dura and surrounding soft tissue after laminectomy can cause some local symptoms, which are difficult to relieve. The authors propose that sacral laminoplasty with titanium mesh can provide a rigid support and barrier to resolve these sacral lesions and local symptoms.

METHODS

From January 2016 to December 2017, patients with progressive CSF-containing lesions in the sacral area and defective sacral laminae were included in the study. After repair of the lesion, the authors performed sacral laminoplasty with titanium mesh in each patient. Subsequently, the soft tissue and skin were closed primarily.

RESULTS

A total of 6 patients were included. Four patients with repaired myelomeningocele had progressive dural ectasia. One patient with lipomyelomeningocele previously underwent detethering surgery and developed postoperative pseudomeningocele. One patient had a symptomatic Tarlov cyst. Four of these 6 cases presented with low-back pain and local tenderness. During follow-up, ranging from 13 to 37 months, all 6 patients experienced no recurrence of dural ectasia or pseudomeningocele and were free from local symptoms.

CONCLUSIONS

Sacral laminoplasty with titanium mesh is a safe and effective procedure for treating progressive sacral dural ectasia and refractory pseudomeningocele, preventing CSF leakage as well as relieving local symptoms that may occur years after previous surgery for spina bifida.

Low level myelomeningoceles: do they need prenatal surgery?

BACKGROUND

Postnatal closure of a myelomeningocele remains the standard of care in many countries. The prenatal closure has given hope for decreasing the damage to the neural placode and has challenged classic management. However, this technique presents potential sources of complications. Patients with MMC with an anatomical level of L4 and below have a better functional prognosis than higher level malformations. Are they still candidates for prenatal surgery?

OBJECTIVE

To evaluate outcome of MMC with an anatomical level of L4 and below and discuss, with support of the literature, the indications to perform prenatal closure in this particular group of patients.

MATERIALS AND METHODS

Twenty-nine children were included in this observational study. The level of the vertebral malformation was sacral in 12 cases (41.4%) or lumbar (level ≤ L4) in 17 cases (58.6%). All the patients was operated postnatally for closure of the MMC with microsurgical technique as soon as possible after clinical evaluation (range 0-97 days).

RESULTS

Only 11 out of 29 patients (37.9%) needed of a CSF diversion. A Chiari II malformation was present before MMC closure in 17 patients (58.6%) and only in 5 (17%) after. Twenty-six patients (89.7%) were able to walk. Seven (23%) and 16 (55%) of our patients have a normal bladder and bowel control, respectively. All school-aged children attend school.

CONCLUSIONS

The functional outcome for low-level MMC is good when managed with modern microneurosurgical techniques with a low risk for the patient and the mother. Therefore, we do not suggest prenatal surgery for subgroup of infant with MM.

Clinical evaluation and surveillance imaging of children with myelomeningocele and shunted hydrocephalus: a follow-up study

OBJECTIVEThe majority of children with myelomeningocele undergo implantation of CSF shunts. The efficacy of adding surveillance imaging to clinical evaluation during routine follow-up as a means to minimize the hazard associated with future shunt failure has not been thoroughly studied.METHODSA total of 300 spina bifida clinic visits during the calendar years between 2012 and 2016 were selected for this study (defined as the index clinic visit). Each index visit was preceded by a 6-month period during which no shunt evaluation of any kind was performed. At the index clinic visit, all patients were evaluated by a neurosurgeon. Seventy-four patients underwent previously scheduled surveillance CT or shunt series scans in addition to clinical evaluation (surveillance imaging group), and 226 patients did not undergo surveillance imaging (clinical evaluation group). Subsequent unexpected events, defined as emergency department visits, caregiver-requested clinic visits, and shunt revision surgeries were reviewed. The timing and likelihood of an unexpected event in each of the 2 groups were compared using Cox proportional hazard survival analysis. The rate of shunt revision surgery in the follow-up period as well as the associated outcomes and rate of complications were analyzed.RESULTSThe clinical characteristics of the 2 groups were similar. In the clinical evaluation group, 4 of 226 (1.8%) patients underwent shunt revision based on clinical findings during the index visit, compared to 8 of 74 (10.8%) patients in the surveillance imaging group who underwent shunt revision based on clinical and imaging findings at that visit (p < 0.05). In the subsequent follow-up period, there were 74 unexpected events resulting in 10 shunt revisions in the clinical evaluation group, for an event rate of 33% and operation rate of 13.5%. In the surveillance imaging group there were 23 unexpected events resulting in 2 shunt revisions, for an event rate of 34.8% and an operation rate of 8.7%; neither difference was statistically significant. The complication rate for shunt revision surgery was also not different between the groups.CONCLUSIONSObtaining predecided, routine surveillance imaging in children with myelomeningocele and shunted hydrocephalus resulted in more shunt revisions in asymptomatic patients. For patients who had negative results on surveillance imaging, the rate of shunt revision in the follow-up period was not significantly decreased compared to patients who underwent clinical examination only at the index visit.