Neurologic Outcome Comparison between Fetal Open-, Endoscopic- and Neonatal-Intervention Techniques in Spina Bifida Aperta

Gestational age at birth varies by surgical technique in prenatal open spina bifida repair: a systematic review and meta-analysis

OBJECTIVE

Prenatal repair of open spina bifida has become well-established. Several surgical approaches have emerged, each focused on optimizing outcomes while minimizing risks. This study aims to compare the gestational age at delivery following the various surgical techniques.

DATA SOURCES

This systematic review and meta-analysis synthesizes data from 37 studies between 2010 and 2023.

STUDY ELIGIBILITY CRITERIA

Eligible studies included pregnant patients diagnosed with open spina bifida who underwent the following intrauterine repair techniques: open repair, mini-hysterotomy, laparotomy-assisted fetoscopic repair, and percutaneous fetoscopic repair.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary outcome investigated was gestational age at delivery, while secondary outcomes were preterm premature rupture of membranes, vaginal birth, and perinatal mortality. The programming language software R (version 4.0.5) was used to execute the analysis.

RESULTS

In this meta-analysis, 2333 prenatal repair of open spina bifida procedures arising from 14 countries were analyzed. Of these, open repair accounted for 65.7%, mini-hysterotomy accounted for 14.4%, laparotomy-assisted fetoscopic repair accounted for 5.36%, and percutaneous fetoscopic repair accounted for 14.6%. The subgroup analyses revealed a nonsignificant mean gestational age at birth: 34+1 weeks for open repair, 34+2 weeks for mini-hysterotomy, 35+3 weeks for laparotomy-assisted repair, and 32+3 weeks for percutaneous fetoscopic repair (P=.26). While the gestational age at birth was not different, there were significant differences (P<.01) in pooled proportions of preterm premature rupture of membranes and preterm birth by surgical approach (overall rates: 75% and 30% respectively). Vaginal birth rates had significant subgroup differences (P<.01), with the laparotomy-assisted fetoscopic group more likely to have vaginal deliveries (0.02, 0.04, 0.49, 0.18 for open, mini, laparotomy, and percutaneous, respectively).

CONCLUSION

The advanced secondary Bayesian analysis of data from this meta-analysis suggests that the mean gestational age at birth may differ among the 4 surgical techniques for prenatal repair of open spina bifida, with a potential advantage for the decrease in preterm births associated with a laparotomy-assisted approach. However, these findings should be interpreted cautiously, and further direct comparison studies are needed to confirm these observations.

Reflections upon the intrauterine repair of myelomeningocele

The intrauterine repair of myelomeningocele presents certain advantages and has gained widespread acceptance. It significantly reduces the incidence of Chiari-2 anomalies and hydrocephalus, and it is thought to enhance the neurologic outcome. Nevertheless, several issues remain unsettled and there are no negligible disadvantages. After working with patients with myelomeningocele for 30 years, I thought about how we currently treat them. There are ethical, organizational, neurological, obstetrical, and postnatal aspects worth discussing.

Myelomeningocele: Long-Term Neurosurgical Management

Open spina bifida, also known as myelomeningocele (MMC), is the most challenging and severe birth defect of the central nervous system compatible with life and it is due to a failure in the dorsal fusion of the nascent neural tube during embryonic development. MMC is often accompanied by a constellation of collateral conditions, including hydrocephalus, Arnold - Chiari II malformation, brainstem disfunction, hydrosyringomyelia, tethered cord syndrome and scoliosis. Beyond early surgical repair of the dorsal defect, MMC requires lifelong cares. Several additional surgical procedures are generally necessary to improve the long-term outcomes of patients affected by MMC and multidisciplinary evaluations are crucial for early identification and management of the various medical condition that can accompany this pathology. In this chapter, the most common pathological entities associated with MMC are illustrated, focusing on clinical manifestations, treatment strategies and follow up recommendations.