The Use of Indomethacin with Complete Amniotic Fluid Replacement and Classic Hysterotomy for the Reduction of Perinatal Complications of Intrauterine Myelomeningocele Repair

OBJECTIVE

This study presented outcomes of classical hysterotomy with modified antiprostaglandin therapy for intrauterine repair of foetal myelomeningocele (fMMC) performed in a single perinatal centre.

STUDY DESIGN

Forty-nine pregnant women diagnosed with fMMC underwent classic hysterotomy with anti-prostaglandin management, complete amniotic fluid replacement and high dose indomethacin application.

RESULTS

The average gestational age (GA) at delivery was 34.4 ± 3.4 weeks, with no births before 30 weeks GA. There were 2 foetal deaths. Complete reversal of hindbrain herniation (HH), assessed in magnetic resonance imaging at 30-31 weeks GA was found in 72% of foetuses (mostly with HH grade I prior to fMMC repair). Our protocol resulted in rare use of magnesium sulphate (6%), low incidence of chorioamniotic membrane separation - chorioamniotic membrane separation (6%), preterm premature rupture of membranes - preterm premature rupture of membranes (pPROM; 15%) and preterm labour - preterm labour (PTL; 17%). The postoperative wound continuity of the uterus was usually stable (in 72% of patients), with low frequency of scar thinning (23%).

CONCLUSION

Our protocol results in rare use of tocolytics, and the low occurrences of CMS, pPROM and PTL in relation to other study cohorts: Management of Myelomeningocele Study, Children's Hospital of Philadelphia, and Vanderbilt University Medical Centre.

A randomized trial of prenatal versus postnatal repair of myelomeningocele

BACKGROUND

Prenatal repair of myelomeningocele, the most common form of spina bifida, may result in better neurologic function than repair deferred until after delivery. We compared outcomes of in utero repair with standard postnatal repair.

METHODS

We randomly assigned eligible women to undergo either prenatal surgery before 26 weeks of gestation or standard postnatal repair. One primary outcome was a composite of fetal or neonatal death or the need for placement of a cerebrospinal fluid shunt by the age of 12 months. Another primary outcome at 30 months was a composite of mental development and motor function.

RESULTS

The trial was stopped for efficacy of prenatal surgery after the recruitment of 183 of a planned 200 patients. This report is based on results in 158 patients whose children were evaluated at 12 months. The first primary outcome occurred in 68% of the infants in the prenatal-surgery group and in 98% of those in the postnatal-surgery group (relative risk, 0.70; 97.7% confidence interval [CI], 0.58 to 0.84; P<0.001). Actual rates of shunt placement were 40% in the prenatal-surgery group and 82% in the postnatal-surgery group (relative risk, 0.48; 97.7% CI, 0.36 to 0.64; P<0.001). Prenatal surgery also resulted in improvement in the composite score for mental development and motor function at 30 months (P=0.007) and in improvement in several secondary outcomes, including hindbrain herniation by 12 months and ambulation by 30 months. However, prenatal surgery was associated with an increased risk of preterm delivery and uterine dehiscence at delivery.

CONCLUSIONS

Prenatal surgery for myelomeningocele reduced the need for shunting and improved motor outcomes at 30 months but was associated with maternal and fetal risks. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00060606.).

Effects of birth advancement in Chiari malformation in a surgical myelomeningocele model in rabbits

BACKGROUND/PURPOSE

In myelomeningocele (MMC), Chiari II malformation progresses during gestation because of the continuous loss of cerebrospinal fluid at the site of the defect. Our purpose was to assess the impact of birth advancement (BA) and prenatal corticosteroid treatment (PCT) on Chiari malformation in a surgical MMC model in rabbits.

METHODS

A surgical MMC-like defect was created in 75 fetal rabbits. Animals were distributed into 4 groups depending on the treatment received: not treated and those undergoing BA + PCT, BA, or PCT. The degree of Chiari malformation in newborn rabbits was defined as the percentage of downward protrusion of the hindbrain between the end of the occipital bone and the beginning of the first vertebral arch.

RESULTS

The degree of hindbrain herniation was 80% (8.15) in the not treated group, 36.8% (10.57) in BA + PCT, 41.8% (8.27) in BA, and 44.4% (8.32) in PCT. The BA + PCT, BA, and PCT groups showed less severe hindbrain herniation than not treated animals (mean decrease, 39.86%; SD, 10.57; P = .000). There were no significant differences between the BA + PCT, BA, and PCT groups (P = .311).

CONCLUSIONS

Birth advancement and prenatal administration of corticosteroids decrease the severity of the hindbrain herniation component of Chiari II malformation in surgical MMC in fetal rabbits.

The transition from child to adult in neurosurgery

The transition from child to adult is a growing concern in neurosurgery. Data documenting long-term follow-up are necessary to define this population's healthcare needs. In order to evaluate the problems posed by the child-to-adult transition in neurosurgery, we have studied the neurological, functional and social outcome of patients treated in our department for tumor of the central nervous system, hydrocephalus or myelomeningocele, and followed beyond the age of eighteen years. A large number of patients suffered from chronic ailments, either sequelae of their initial disease, or delayed complications of their initial treatment, with significant morbidity. The mortality during adulthood was 4.6% in the tumor group, 1.1% in the hydrocephalus group, and zero in the spina bifida group. The proportion of patients employed in normal jobs was 35.6, 18.7 and 11.5% for tumors, hydrocephalus and myelomeningocele respectively. IQ score and performance at school generally overestimated the capacity for social integration. Based on these data and on the available literature, we tried to identify the problems and devise solutions for the management of the transition from child-to-adulthood transition. Many problems present during childhood persist to adulthood, some of which are made more acute because of a more competitive environment, the lack of structures and inadequate medical follow-up. The transition from child to adult must be managed jointly by pediatric and adult neurosurgeons. More clinical research is required in order to precisely evaluate the problems posed by adult patients treated during childhood for the different neurosurgical diseases. Based on these data, a concerted trans-disciplinary approach is necessary, tailored to the specific needs of patients suffering from different diseases.

[Children with meningomyelocele become adults!]

The survival for children with spina bifida has dramatically increased during the last 30 years. In Sweden today 40-50 adolescents with spina bifida are reaching adulthood each year the next 10 years. Children with spina bifida are from birth to adulthood followed by a multidisciplinary medical and paramedical team within the habilitation organisation. However, from the age of 18 this responsibility is discontinued, often with less readiness in adult medicine to meet the spina bifida adolescents and their special needs. Facing adolescence and adulthood both children and parents need a careful preparation from several points of view for the transition. It is also most important to prepare the adult medical disciplines about the special needs of this group. This process has to start early to reach successful management, including improvement in self-care.

Long-term survival of individuals with myelomeningocele

The objectives of this study were to extend survival analysis into adulthood for patients with myelomeningocele (MM) and to compare survival curves for patients born with varying defect severity before and after 1975. We have reviewed existing data for 904 patients with MM seen in a large multidisciplinary children's clinic over 43 years. Before 1975, a major contributor to decreased survival is death during infancy. The presence of cerebral spinal fluid shunting is a major contributor to increased survival. After 1975, survival to adolescence is similar regardless of shunt status (p = 0.17). For all patients alive at age 16, a significant decrease in survival probability after age 34 years was found for individuals with shunted hydrocephalus compared to those without a shunt (p = 0.03). Although childhood survival for individuals born after 1975 is not related to shunt status, adults with MM and shunted hydrocephalus may be at risk for decreased longevity.

Longevity of patients born with myelomeningocele

There are limited data concerning the life expectancy for individuals born with myelomeningocele (MM), with and without hydrocephalus. To ascertain such data was our first purpose. We have selected all patients with MM in our computer database, The Patient Data Management System (PDMS/fx). Data were transferred to Excel for primary and SPSS/PC for final analysis by Kaplan-Meier life survival curves. Of the 1,054 patients with MM in the Birth Defects Clinic and the University of Washington Medical Center (UWMC) of Seattle, 505 are now over the age of 21 (391) or have died (114). Follow-up information was available since 1994 for 132, 62% of whom we have had contact within the past 2 years. The second purpose was to identify potential health factors associated with long-term outcome of patients with MM. Patient variables chosen as relevant to survival included hydrocephalus, treatment before or after 1975, and health maintenance determined by outcome for those receiving care within the last 5 years or those last seen before. Age at last appointment and reason for visit were determined in order to identify age-specific health care needs of the adult population. Survival and medical needs were obtained from the UWMC's computer database, Mindscape, and by telephone survey for adult patients not seen in the last 2 years. Death is more frequent earlier in life for those MM patients with hydrocephalus. Ordinary degenerative disorders affect MM patients earlier in life than normals. Our data extend life expectancy for patients with MM and hydrocephalus to age 40 years with some reliability for those treated from 1957 to 1974, but only 24 years for those treated with modern techniques after 1974. More data is needed to determine long-term survival.

Endoscopic coverage of fetal myelomeningocele in utero

OBJECTIVE

Our goal was to evaluate the safety and efficacy of minimally invasive surgery for the coverage of myelomeningocele in utero.

STUDY DESIGN

Women in the mid-second trimester of a pregnancy complicated by fetal myelomeningocele were offered an experimental procedure designed to prevent ongoing exposure of the spinal cord to the intrauterine environment. The procedure consisted of maternal laparotomy while the patient was under both general and epidural anesthesia, with exposure of the gravid uterus. Endoscopic ports were placed for camera and operating instruments. Amniotic fluid was removed and replaced with carbon dioxide. The fetus was then positioned and a maternal split-thickness skin graft was placed over the exposed spinal cord or neural elements. The skin graft and a covering of Surgicel Absorbable Hemostat were attached with fibrin glue prepared from autologous cryoprecipitate.

RESULTS

Four fetuses with open myelomeningocele underwent endoscopic coverage of the spinal lesion between 22 weeks 3 days and 24 weeks 3 days of gestation. One infant, delivered by planned cesarean section at 35 weeks' gestation after demonstration of fetal lung maturity, is almost 3 years old. A second infant was delivered by cesarean section at 28 weeks after preterm labor and is now almost 6 months old. Both survivors manifest only mild motor and somatosensory deficits. One fetus who was delivered 1 week after operation after development of amnionitis died in the delivery room of extreme prematurity. The final fetus died intraoperatively from abruptio placentae.

CONCLUSION

Minimally invasive fetal surgery appears to constitute a feasible approach to nonlethal fetal malformations that result in progressive and disabling organ damage.

Survival at 5 years of a cohort of newborn infants with myelomeningocele

Over a nine-year period, 63 viable newborns with myelomeningocele were consecutively treated, of whom 11 (17%) developed brainstem symptoms assessed to be potentially life-threatening. All 11 underwent brainstem decompression by cervical laminectomy with stent placement between the fourth ventricle and the spinal subarachnoid space, at a median age of 8 months. 86% survived to 60 months of age. Those with brainstem dysfunction had a significantly greater mortality than those without, despite aggressive neurosurgical management by brainstem decompression.

[Aspects of long-term management of children with myelomeningocele. Analysis of the last 10 years from the neuropediatric-neurosurgical viewpoint]

BACKGROUND

Both the use of a selective policy of treatment of newborns with myelomeningocele and the right time of back closure are still controversially discussed. We report our experiences in the long-term care of children with myelomeningocele.

METHODS

103 newborns with myelomeningocele (n = 94) and meningocele (n = 9) born 1980 to 1990 and cared for regularly at the Olgahospital's pediatric clinic were followed up from the neuropediatric-neurosurgical point of view. Postpartum we predominantly practised a selective policy of treatment.

RESULTS

15 of 21 children (71.4%) not operated on died during the first days or months of life, 6 (28.6%) survived. 70 were operated selectively, of which 9 (12.9%) died, 61 (87.1%) survived with mainly good result. There were no differences in the survival rate and frequency/type of postoperative complications with respect to the time of the back closure. 31 children with myelomeningocele (33%) had CNS anomalies other than the Arnold-Chiari-Malformation, mostly being a dys- or aplasia of the corpus callosum and a deformed ventricle system. These were diagnosed almost exclusively by CT or MRT scan.

CONCLUSIONS

We still predominantly practised a selective policy of treatment of newborns with myelomeningocele with mainly good results.

Social circumstances affecting the initial management of children with myelomeningocele in Nigeria

Myelomeningocele is a common congenital abnormality in Nigeria and poses even more problems with rehabilitation than in developed countries. However, some factors peculiar to developing countries, as well societal norms in Nigeria, affect the management decision for these patients. These factors are discussed and their relative contribution to the over-all outcome is assessed.

Long-term outcome and complications of children born with meningomyelocele

The long-term functional outcome of 101 children born with meningomyelocele between 1971 and 1981 was assessed, by a combination of retrospective chart review and follow-up assessments. The children had been managed at birth using a process of nonstandardized selection. Eighty-three of the 101 patients survived after a minimum follow-up of 8.6 years, for a mortality rate of 18%. Forty-four of 83 children (53%) were community ambulators, and this correlated well with the presence of intact quadriceps function. Forty-eight children (58%) attended normal school and were grade-appropriate. Sixty-two of 83 patients (75%) were socially continent of urine, and 71/83 (86%) were socially continent of stool. Hydrocephalus was present in 93 of the 101 children in the study, and 85 children were shunted. Half of the shunted children required a shunt revision in the first year of life, and thereafter the rate of revision decreased, so that after 2 years the risk of revision was approximately 10% per year.

Prenatal diagnosis of fetal cephalocele: a sonographic spectrum

We present the findings in a series of 15 fetuses diagnosed as having a cephalocele. Eleven cephaloceles were located in the occipital region and two each at the vertex and the frontonasal region. Eleven fetuses were diagnosed before 24 week's gestation. Nine families opted for an interruption. Of the two fetuses that went to term, one had a benign meningocele and is growing normally at 18 months, the other died in the neonatal period of associated cardiac anomalies. Of the four fetuses diagnosed after 24 weeks, one is normal (after surgery) at 9 months, two are severely handicapped, and one died in the immediate postpartum period.

Spina bifida cystica in northern Nigeria

At the Ahmadu Bello University Hospitals in northern Nigeria 152 boys and 160 girls with spina bifida cystica were registered from 1971 to 1985. Only 21% of the patients were registered at the hospital within 24 h of birth; 90% had been delivered at home and without antenatal care. The malformation occurred in the lumbar or lumbosacral region in 75% of cases. Meningomyeloceles comprised 81%. Surgical closure was performed by general surgeons in 112 (36%) of the patients mainly for nursing care and social reasons. Of the children, 56 died in the hospital, 33 moved and 166 were lost to follow-up at 1 month. Only 8 were seen up to 1 year but 4 have lived beyond 4 years. This series serves as a baseline for comparison with future experience in this part of the world.

[Analysis of mortality in myelomeningocele]

Authors present a study of 84 patients with myelomeningocele between years 1971 to 1985. They analyze morbimortality related to level and condition of the lesion, Lorber's selection criteria and treatment received. They find better survival in females and in patients in whom surgical closure of the lesion was carried out without variations if one Lorber's criteria is present. The moment of operation did not change survival and was not related with development of hydrocephaly.

Sudden death in hydrocephalic spina bifida aperta patients

Twelve patients of 146 hydrocephalic spina bifida aperta patients, treated with a ventricular drainage system, died suddenly. In 7 of them the cause of death was most probably related to the use of a ventriculovascular shunt, causing pulmonary embolism. Thromboembolic complications were not seen in the 26 hydrocephalic spina bifida patients treated with a ventriculoperitoneal shunt. In 4 other patients shunt malfunction was considered as the cause of sudden death. The case reports of these 11 patients are presented. Pathophysiological mechanisms are discussed and measures for prevention of these two potentially lethal complications are described.

Prognosis for babies with meningomyelocele and high lumbar paraplegia at birth

The life expectation of babies with paralytic lumbar meningomyelocele not offered immediate surgery at birth appears to be influenced by the extent to which parents are involved in the child's early care. 8 of the 27 children offered family-centred care in one hospital in 1971-80 and not offered immediate surgery survived to school entry and none of these children has since died. All are chairbound and incontinent, but none is intellectually retarded and many are no more handicapped than the children offered immediate surgical treatment at birth. The choice before the family at birth does not have to be presented as an urgent and immediate choice between life and death.

Influence of prognosis on decisions regarding the care of newborns with myelodysplasia

Treatment of newborns with myelodysplasia (meningomyelocele and related disorders) continues to be a controversial subject. We have used a consistent plan of care and have employed the same prognostic criteria over the period from 1965 to 1982 to address the needs of 212 affected newborns. A good prognosis and early surgical care were given to 42 per cent of 53 newborns during the period 1965 to 1970, to 58 per cent of 65 newborns from 1971 to 1976, and to 71 per cent of 94 newborns from 1977 to 1982. Of the newborns with an initially poor prognosis, 19 per cent of 31 received early surgery between 1965 and 1970, as compared with 33 per cent of 27 between 1971 and 1976 and 52 per cent of 27 between 1977 and 1982. Life-table analyses of survival in the three periods revealed significant improvement over time in the survival of newborns receiving early surgical care, regardless of the initial prognosis (log-rank statistic = 8.240, P = 0.016) and in comparison to recipients of supportive care alone (log-rank statistic = 5.975, P = 0.05). We conclude that early surgery permits the survival of an increasing percentage of patients with myelodysplasia.

Selective surgical management of neural tube malformations

The physical characteristics of 49 children with spina bifida cystica, survivors of a group subjected to selection for early surgery are compared with 39 children alive from an earlier unselected series, born in the 1960s, and reviewed retrospectively. Sixteen children were also studied in whom the initial decision not to operate had been followed by survival and subsequent treatment. Children selected for initial surgery have a significantly lower mortality than those not selected and their mobility at 5 to 7 years of age is better, although only marginally so compared with the unselected group. Selection does not decrease the need for shunt treatment of the associated hydrocephalus. None of those not initially selected for surgery have normal faecal or urinary continence, whereas 35% of the selected in group have normal continence and urinary tracts. Children treated immediately have significantly higher degrees of intelligence than both the unselectively treated and those whose treatment was delayed but a fifth of the latter group were intellectually normal. There were only small differences in intelligence between children given delayed treatment and those unselectively treated, suggesting that postponing surgery does not necessarily have a deleterious effect on ability.

Survival of infants with spina bifida--Atlanta, 1972-1979

We studied the survival of a population-based cohort of 154 infants with spina bifida who were born during the eight-year period from 1972 through 1979 to residents of Atlanta. Our objectives were to describe the cohort's survival experience and to explore relationships between clinical characteristics and survival. Overall, 57% of the cohort survived one year or more. This figure is misleading, however, because it conceals important differences in survival among subgroups of affected infants. From univariate analyses, we observed significant differences in survival among infants categorized by year of birth, birth weight, the open-closed status of the defect, the highest level of the defect on the spine, the presence of multiple major birth defects, and the presence of hydrocephalus at birth. More infants born in the late 1970s survived their first year of life than infants born in the early 1970s; infants with open defects had lower survival than those with closed defects; and infants whose defects were low on the spine had better survival than those whose defects were higher. When comparing the survival experience of this cohort with that of other groups from other areas or from more recent years, health workers must consider referral biases and differences in the distribution of clinical characteristics.

[Experiences with selection criteria in myelomeningocele surgery]

Between 1972 und 1983 85 children with myelomeningocele were treated according to the criteria for selective treatment as given by Lorber. The results of children with early or delayed operation and of those who had only supportive care are presented. Survival time and causes of death in the group of children not operated on are in particular given, the sequelae of selective treatment are discussed.

A review of the management policy for new-born spina bifida children at Our Lady's Hospital for Sick Children, Crumlin, 1973-1983

The management policy at Our Lady's Hospital for Sick Children, Crumlin, for newborn spina bifida infants consists of immediate operation for those considered likely to benefit and full nursery care for those who do not have early surgery. In the eleven years since this policy was first implemented, there have been 493 infants admitted with open myelomeningocele, of whom 260 (52.7%) were managed non-operatively. The mortality for all infants so managed was 78% at one year. 171 (66%) of this group died without further intervention. 89 (34%) survived long enough for some form of treatment to be instituted. 41 of these children are still alive and it is felt that their handicaps have not been increased by their early management. It is argued that an approach to management which considers the needs and interests of the individual infant is more acceptable than one that seeks to enforce total care, regardless of circumstances, or the impersonal assignment, by criteria, into "treatment" and "non-treatment" groups.

Early management and decision making for the treatment of myelomeningocele

A program for early selection and treatment of the infant with myelomeningocele was developed at the University of Oklahoma Health Sciences Center in 1977. Over a 5-year period, 69 babies were evaluated, 36 babies were recommended for early vigorous treatment. Of the 33 babies for whom only supportive care was recommended, five were initially treated at the parents' request, two underwent delayed vigorous treatment, one was subsequently treated by "crisis management," one moved and did not return for follow-up, and 24 received only supportive care. All 24 babies died between 1 to 189 days of age (mean 37 days). The involvement of several physicians and paramedical support personnel is considered essential for this approach of early selection and treatment. Continued support and regular follow-up is necessary for any baby who receives only supportive care. Parents retain legal custody. Although ethical concerns make any approach difficult, the method presented is considered to be the best alternative available at this time.

Measuring the benefits of screening for open neural tube defects

Evaluation of the costs and benefits of public sector programmes is necessary to plan the optimum uses for society's resources. Here the benefits of screening for open neural tube defects are examined, and the most appropriate methodological approach to their valuation is discussed in the context of the possible provision by the National Health Service of a routine prenatal screening programme. It is argued that, in measuring the benefits of screening, previous evaluations have adopted an approach that is rather unsatisfactory from the standpoint of economic methodology. An attempt is therefore made here to show the effect that adopting a more appropriate approach would have on the estimated value of the benefit of routine screening. The effect is found to be a substantial increase in its estimated value.

Survival of infants with open spina bifida in relation to maternal serum alpha-fetoprotein level. Third report of the UK collaborative study on alpha-fetoprotein in relation to neural-tube defects

Thirteen centres collaborated to determine the relation between maternal serum alpha-fetoprotein (AFP) levels and the survival and handicap of infants with open spina bifida. Data were collected on 97 pregnancies tested for maternal serum AFP at 10-24 weeks gestation which resulted in the birth of an infant with open spina bifida. Pregnancies with relatively high AFP levels were associated with decreased infant survival though the extent of handicap at 6 months was not significantly related to AFP level. The survival rate at 6 months was 13% (3/23) among infants born to women with AFP values in the highest of three groups, 32% (13/41) among women with values in the middle group and 45% (15/33) in the lowest AFP group (X2l for trend 6.48, P less than 0.01). Antenatal screening of maternal serum AFP at 16-18 weeks gestation with a cut-off level of 2.5 times the normal median would have detected about 68% of those who survived for at least 6 months compared with 79% of all open spina bifida pregnancies tested.

Results of selective treatment of spina bifida cystica

The results of selective treatment in 120 infants with open spina bifida, admitted between May 1971 and December 1976, were prospectively studied. Seventy-one infants had adverse criteria at birth and were not treated. They all died, more than 90% of them within 6 months of birth. Seven had meningocele. All were treated and survived without handicap. Forty-two infants with myelomeningocele were actively treated. Thirty-six survive at follow-up after 3 to 9 years. The quality of survival is much better than when selection was not used but 8 children have moderate or severe handicaps. The parents were fully informed and consulted at every decision-making step; they fully supported the principle of selection and the action taken on behalf of their own child.

Survival and handicap of infants with spina bifida

A follow-up study was carried out on 213 infants born with spina bifida cystica (including encephalocele and occipital meningocele) from 1965 to 1972 to women resident in Oxfordshire and the western part of Berkshire. The 5-year survival rate was 36% (39/107) for those with open lesions, 60% (30/50) for those with closed ones, and 18% (10/56) for those with lesions which could not be classified (not known) but which were probably nearly all open. The extent of handicap among these survivors was assessed by means of criteria described by Lorber; among those with open lesions (including 'not known') 84% (41/49) were severely handicapped, 10% (4/49) were moderately handicapped, and only 6% (3/49) had no handicap; among those with closed lesions, 37% (11/30) were severely handicapped, 33% (10/30) were moderately handicapped, and the remaining 30% (9/30) were not handicapped. Closed head lesions (encephalocele or occipital meningocele) were more often associated with severe handicap (6/8; 75%) than were closed spinal lesions (5/22; 23%). The children with open lesions who survived for at least 5 years spent, on average, at least 6 months in hospital during the first 5 years of their life and had, on average, at least 6 major surgical operations. In comparison, those with closed lesions spent one-third less time in hospital, and had fewer than half as many operations. During the period of the study a selective treatment policy was adopted typical of that commonly practised now, and all the infants were born before antenatal screening had been introduced. Our results therefore may be helpful in assessing the benefits to be expected from antenatal screening for open spina bifida.

A retrospective analysis of conservative versus active management in severe open myelomeningocele

88 patients with thoraco-lumbar myelomeningocele not operated upon in the 1976-1977 period were compared with 76 patients with the same condition operated upon in the 1964-1971 period. There was no significant difference in sex and hydrocephalus at birth in the two groups. Mortality was less in the surgically treated group only after the age of three months. Ventriculitis appeared to be related to the incidence of hydrocephalus in the surgically treated group. There was a reduced risk of developing progressive hydrocephalus after birth in the untreated group, and the neurological status of the survivors at one year was the same in both groups. Interpreting the results as indicating that early surgery increased the incidence of progressive hydrocephalus and ventriculitis, and might increase survival of more disabled infants, then non-surgical treatment is justified since survivors are no worse as a result of this non-active approach.

Results of treatment in myelomeningocele

A follow-up study was made in 48 surviving children with myelomeningocele, the material being derived from a time when all infants were operated upon in the newborn period without primary selection. The follow-up revealed several children with severe physical handicap, whereas relatively few were both physically and intellectually handicapped. The results were compared with two earlier published studies of which one from Sheffield comprised cases where selection had not been applied and the other from Edinburgh in which certain criteria had been set up as contra-indications to early closure of the lesion. The effect of a hypothetical selection applied to the Swedish material is discussed. It is recommended that a uniform system of assessment in grading of handicap is applied to facilitate a comparison between different follow-up investigations.

Survival of infants with unoperated myeloceles

Of the infants with spina bifida referred to a neonatal surgical unit over three years and denied early closure of the myelocele, a significant proportion survived long enough for procedures to drain hydrocephalus to be needed. The key decision in the management of this condition is not whether myeloceles should be closed but whether hydrocephalus should be treated.

Ethical problems in the management of myelomeningocele and hydrocephalus. The Milroy Lecture 1975

Within the last generation the application of major advances in drug therapy, intensive care, transfusion techniques, surgery, anaesthesia, and radiotherapy, together with a vast expansion of knowledge due to increased investigative facilities, have led to an unprecedented, dramatic and beneficial increase in the number of persons who would previously have died, or lived with severe handicaps, but can now be cured. Techniques have also been developed to prolong the lives of many people who are now able to enjoy several extra years of productive and meaningful existence, and to alleviate and improve the quality of life of many seriously handicapped persons, enabling them to become integrated as useful and contented members of the community. Choosing from numerous examples of paediatric experience, it is notable that many more extremely premature infants now survive without physical or intellectual damage; infection can almost always be cured, including neonatal and all other forms of pyogenic meningitis and the now rare cases of tuberculous meningitis and miliary tuberculosis. The few remaining new cases of Rh-haemolytic disease are also readily cured. There are outstanding successes in the treatment of childhood malignancy. Paediatric surgery has made great strides. The prognosis of congenital heart disease, of obstructions of the alimentary canal and many other conditions has improved beyond recognition. Unfortunately, the indiscriminate use of advanced techniques of all types has also kept alive those who would have died but now live with distressing physical or mental handicaps or both, often for many years, without hope of ever having an independent existence compatible with human dignity. There are many examples, including those who have sustained major brain or spinal cord injuries.

Late follow-up in spina bifida cystica

The further progress of the survivors in 1969, of a group of 150 babies born with spina bifida cystica in the period 1960-66 is described. Children with a meningocele continued to do well. Those with a myelomeningocele are divided into 2 groups. There were 4 late deaths and a considerable degree of handicap in the group of 23 in whom the spinal cord was exposed on the surface as a plaque at birth. There were 2 late deaths and a much lower incidence of handicap in the group of 25 in whom only ectopic nervous tissue was found in the sac at birth. The incidence and treatment of hydrocephalus is described. Changes in the attitude to the treatment of a neonate with a myelomeningocele are discussed.

Follow-up comparison of hydrocephalus with and without myelomeningocele

A series of 454 hydrocephalic patients with and without myelomeningocele and with and without treatment is reviewed. The survival rates for hydrocephalus alone and for hydrocephalus with myelodysplasia are comparable. The authors reach the conclusion that treatment of the hycrocephalic process and its complications is the most critical therapeutic consideration. Mental retardation is the major unalterable cause for failure to develop independence; some lesser emotional causes can be modified by encouragement. Repeated reassessment of the patient's condition and adjustment are important. Before treatment is started parents or guardians should be fully informed of the child's future potential for independent life and mental development.