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Stewart A, Hale AT, Saccomano BW, Barkley AS, Hopson BD, Arynchyna-Smith A, Johnston JM, Rocque BG, Blount JP, Rozzelle CJ. Neurosurgical management of Myelomeningocele in premature infants: a case series. Childs Nerv Syst 2024:10.1007/s00381-024-06524-3. [PMID: 39030337 DOI: 10.1007/s00381-024-06524-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 06/26/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION Myelomeningocele (MMC) is the most common neural tube defect, but rarely seen in premature infants. Most centers advocate for closure of MMC within 24 h of birth. However, this is not always possible in severely premature infants. Given the rarity of this patient population, we aimed to share our institutional experience and outcomes of severely premature infants with MMC. METHODS We performed a retrospective, observational review of premature infants (≤ 32 weeks gestational age) identified through our multidisciplinary spina bifida clinic (1995-2021) and surgical logs. Descriptive statistics were compiled about this sample including timing of MMC closure and incidence of adverse events such as sepsis, CSF diversion, meningitis, and death. RESULTS Eight patients were identified (50% male) with MMC who were born ≤ 32 weeks gestational age. Mean gestational age of the population was 27.3 weeks (SD 3.5). Median time to MMC closure was 1.5 days (IQR = 1-80.8). Five patients were taken for surgery within the recommended 48 h of birth; 2 patients underwent significantly delayed closure (107 and 139 days); and one patient's defect epithelized without surgical intervention. Six of eight patients required permanent cerebrospinal fluid (CSF) diversion (2 patients were treated with ventriculoperitoneal shunting (VPS), three were treated with endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) and 1 patient treated with ETV; mean of 3 years after birth, ranging from 1 day to 16 years). Two patients required more than one permanent CSF diversion procedure. Two patients developed sepsis (defined as meeting at least 2/4 SIRS criteria). In both cases of sepsis, patients developed signs and symptoms more than 72 h after birth. Notably, both instances of sepsis occurred unrelated to operative intervention as they occurred before permanent MMC closure. Two patients had intraventricular hemorrhage (both grade III). No patients developed meningitis (defined as positive CSF cultures) prior to MMC closure. Median follow up duration was 9.7 years. During this time epoch, 3 patients died: Two before 2 years of age of causes unrelated to surgical intervention. One of the two patients with grade III IVH died within 24 h of MMC closure. CONCLUSIONS In our institutional experience with premature infants with MMC, some patients underwent delayed MMC closure. The overall rate of meningitis, sepsis, and mortality for preterm children with MMC was similar to MMC patients born at term.
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Affiliation(s)
- Addison Stewart
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Andrew T Hale
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | | | - Ariana S Barkley
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Betsy D Hopson
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | | | - James M Johnston
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Curtis J Rozzelle
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA.
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Stewart A, Hale AT, Saccomano BW, Barkley AS, Hopson BD, Arynchyna-Smith A, Johnston JM, Rocque BG, Blount JP, Rozzelle CJ. Neurosurgical Management of Myelomeningocele in Premature Infants: A Case Series. RESEARCH SQUARE 2024:rs.3.rs-4158288. [PMID: 38645257 PMCID: PMC11030521 DOI: 10.21203/rs.3.rs-4158288/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Introduction Myelomeningocele (MMC) is the most common neural tube defect, but rarely seen in premature infants. Most centers advocate for closure of MMC within 24 hours of birth. However, this is not always possible in severely premature infants. Given the rarity of this patient population, we aimed to share our institutional experience and outcomes of severely premature infants with MMC. Methods We performed a retrospective, observational review of premature infants (≤ 32 weeks gestational age) identified through our multidisciplinary spina bifida clinic (1995-2021) and surgical logs. Descriptive statistics were compiled about this sample including timing of MMC closure and incidence of adverse events such as sepsis, CSF diversion, meningitis, and death. Results Eight patients were identified (50% male) with MMC who were born ≤ 32 weeks gestational age. Mean gestational age of the population was 27.3 weeks (SD 3.5). Median time to MMC closure was 1.5 days (IQR = 1 -80.8). Five patients were taken for surgery within the recommended 48 hours of birth; 2 patients underwent significantly delayed closure (107 and 139 days); and one patient's defect epithelized without surgical intervention. Six of eight patients required permanent cerebrospinal fluid (CSF) diversion (2 patients were treated with ventriculoperitoneal shunting (VPS), three were treated with endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) and 1 patient treated with ETV; mean of 3 years after birth, ranging from 1 day to 16 years). Two patients required more than one permanent CSF diversion procedure. Two patients developed sepsis (defined as meeting at least 2/4 SIRS criteria), and 2 patients had intraventricular hemorrhage (both grade III). No patients developed meningitis (defined as positive CSF cultures) prior to MMC closure. Median follow up duration was 9.7 years. During this time epoch, 3 patients died: Two before 2 years of age of causes unrelated to surgical intervention. One of the two patients with grade III IVH died within 24 hours of MMC closure. Conclusions In our institutional experience with premature infants with MMC, some patients underwent delayed MMC closure. The overall rate of meningitis, sepsis, and mortality for preterm children with MMC was similar to MMC patients born at term.
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Blount JP, Hopson BD, Johnston JM, Rocque BG, Rozzelle CJ, Oakes JW. What has changed in pediatric neurosurgical care in spina bifida? A 30-year UAB/Children's of Alabama observational overview. Childs Nerv Syst 2023; 39:1791-1804. [PMID: 37233768 DOI: 10.1007/s00381-023-05938-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/23/2023] [Indexed: 05/27/2023]
Abstract
Spina bifida (SB) remains the most serious and most common congenital anomaly of the human nervous system that is compatible with life. The open myelomeningocele on the back is perhaps the most obvious initial problem, but the collective impact of dysraphism upon the entirety of the nervous system and innervated organs is an equal or greater longitudinal threat. As such, patients with myelomeningocele (MMC) are best managed in a multi-disciplinary clinic that brings together experienced medical, nursing, and therapy teams that provide high standards of care while studying outcomes and sharing insights and experiences. Since its inception 30 years ago, the spina bifida program at UAB/Children's of Alabama has remained dedicated to providing exemplary multi-disciplinary care for affected children and their families. During this time, there has been great change in the care landscape, but many of the neurosurgical principles and primary issues have remained the same. In utero myelomeningocele closure (IUMC) has revolutionized initial care and has favorable impact on several important co-morbidities of SB including hydrocephalus, the Chiari II malformation, and the functional level of the neurologic deficit. Hydrocephalus however is not solved by IUMC, and hydrocephalus management remains at the center of neurosurgical care in SB. Ventricular shunts were long the cornerstone of treatment for hydrocephalus, but we came to assess and incorporate endoscopic third ventriculostomy with choroid plexus coagulation (ETV-CPC). Educated and nurtured by an experienced senior mentor, we dedicated ourselves to fundamental concepts but persistently evaluated our care outcomes and evolved our protocols and paradigms for improvement. Active conversations amidst networks of treasured colleagues were central to this development and growth. While hydrocephalus support and treatment of tethered spinal cord remained our principal neurosurgical charges, we evolved to embrace a holistic perspective and approach that is reflected and captured in the Lifetime Care Plan. Our team engaged actively in important workshops and guideline initiatives and was central to the development and support of the National Spina Bifida Patient Registry. We started and developed an adult SB clinic to support our patients who aged out of pediatric care. Lessons there taught us the importance of a model of transition that emphasized personal responsibility and awareness of health and the crucial role of dedicated support over time. Support for sleep, bowel health, and personal intimate cares are important contributors to overall health and care. This paper details our growth, learning, and evolution of care provision over the past 30 years.
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Affiliation(s)
- Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, USA.
- Children's of Alabama, Lowder 400, 1600 Seventh Avenue South, Birmingham, AL, 35233, USA.
| | - Betsy D Hopson
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, USA
- Children's of Alabama, Lowder 400, 1600 Seventh Avenue South, Birmingham, AL, 35233, USA
| | - James M Johnston
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, USA
- Children's of Alabama, Lowder 400, 1600 Seventh Avenue South, Birmingham, AL, 35233, USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, USA
- Children's of Alabama, Lowder 400, 1600 Seventh Avenue South, Birmingham, AL, 35233, USA
| | - Curtis J Rozzelle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, USA
- Children's of Alabama, Lowder 400, 1600 Seventh Avenue South, Birmingham, AL, 35233, USA
| | - Jerry W Oakes
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, USA
- Children's of Alabama, Lowder 400, 1600 Seventh Avenue South, Birmingham, AL, 35233, USA
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Naicker D, Leola K, Mkhaliphi MM, Mpanza MN, Ouma J, Nakwa FL, Velaphi S, Profyris C. Single surgeon case series of myelomeningocele repairs in a developing world setting: Challenges and lessons. World Neurosurg X 2023; 19:100213. [PMID: 37260695 PMCID: PMC10227453 DOI: 10.1016/j.wnsx.2023.100213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 05/02/2023] [Accepted: 05/08/2023] [Indexed: 06/02/2023] Open
Abstract
Purpose Neural Tube Defects are the second most common group of birth malformations following congenital heart anomalies, with myelomeningoceles being the most severe manifestation (MMC). They require expedited surgical repair, preferably within 72 h of birth. In low- and middle-income countries (LMIC) where resources are limited, timing to MMC repair is not optimal and leads to undesirable outcomes. The purpose of this study was to determine whether a proactive approach in a setting from a LMIC could achieve repair within 72 h. Methods A concerted effort to expedite repair of all neonates referred with a MMC was undertaken from 01 January 2014 to 1 August 2015. A consensus was reached between neonatologists and neurosurgeons that neonates born or admitted with a MMC are referred immediately to surgeons and that repair will be performed within 72 h of birth. Hospital records of neonates who had MMC repaired during this period were reviewed for infant characteristics and hospital outcomes. Results 24 patients with a MMC were operated upon by the senior author (CP) during the study period. Only 13 of these patients were born at the treating institution and 11 were referred from outside hospitals. Most MMCs were in the lumbosacral region and mean MMC surface area was 19.4 cm2. Mean time to repair for the entire series was 13.6 days. Patients born at the treating institution has a mean time to repair of 10.5 days and patients referred from outside had a mean time to repair of 17.3 days. Series wide, only 21% of neonates were operated upon in less than 72 h. Conclusion Despite a pro-active commitment to repairing MMCs within 72 h for the duration of this series, satisfactory time to repair was not achieved. Late referral, referral from outside hospitals and operating theatre availability were the predominant factors leading to delay in MMC repair. Nevertheless, time to repair in our series was significantly shorter than that reported in MMC repair series based in similar environments. This suggests that even if the gold-standard of a 72-h window cannot be achieved, neonates benefit from much quicker repair when a concerted effort to minimise repair time is employed. This study also highlights the urgent need to address health care constraints in LMIC to improve outcomes for this vulnerable group.
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Affiliation(s)
- Denver Naicker
- Department of Neurosurgery, Chris Hani Baragwanath Academic Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Keletso Leola
- Department of Neurosurgery, Helen Joseph Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mlamuli Mzamo Mkhaliphi
- Department of Neurosurgery, Helen Joseph Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Morena Nthuse Mpanza
- Department of Neurosurgery, Helen Joseph Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - John Ouma
- Department of Neurosurgery, Chris Hani Baragwanath Academic Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Firdose Lambey Nakwa
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithembiso Velaphi
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Christos Profyris
- Department of Neurosurgery, Helen Joseph Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Lo WB, Herbert K, Rodrigues D, Afshari FT. The 'transverse guard' wound dressing technique to reduce faecal contamination after spinal surgery in neonates and infants. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:S12-S15. [PMID: 32579458 DOI: 10.12968/bjon.2020.29.12.s12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Wound care following lower spinal surgery in infants, especially open lumbosacral myelomeningocele (MMC) repair is challenging for a number of reasons: the babies' small size, uneven contour of the natal cleft, proximity of the wound to the perianal area, continuous soiling by loose/poorly-formed stool, and fragile skin. Faecal contamination of the wound can lead to infection, ascending meningitis and further morbidity. A single adhesive dressing does not reliably obliterate the space in the natal cleft and, therefore, does not prevent faecal material tracking rostrally underneath the dressing. This increases the risk of contamination and necessitates frequent wound dressing changes. The authors describe the use of the 'transverse guard', a simple technique routinely used in their unit that help overcome these problems. They also report on the wound infection rates of neonates undergoing open MMC repair who had the new dressings versus those who had conventional dressings.
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Affiliation(s)
- William B Lo
- Consultant Neurosurgeon, Department of Neurosurgery, Birmingham Women and Children's Hospital NHS Foundation Trust
| | - Katie Herbert
- Clinical Nurse Specialist, Department of Neurosurgery, Birmingham Women and Children's Hospital NHS Foundation Trust
| | - Desiderio Rodrigues
- Consultant Neurosurgeon, Department of Neurosurgery, Birmingham Women and Children's Hospital NHS Foundation Trust
| | - Fardad T Afshari
- Neurosurgery Specialty Registrar, Department of Neurosurgery, Birmingham Women and Children's Hospital NHS Foundation Trust
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