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McCarthy DJ, Sheinberg DL, Luther E, McCrea HJ. Myelomeningocele-associated hydrocephalus: nationwide analysis and systematic review. Neurosurg Focus 2020; 47:E5. [PMID: 31574479 DOI: 10.3171/2019.7.focus19469] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 07/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Myelomeningocele (MMC), the most severe form of spina bifida, is characterized by protrusion of the meninges and spinal cord through a defect in the vertebral arches. The management and prevention of MMC-associated hydrocephalus has evolved since its initial introduction with regard to treatment of MMC defect, MMC-associated hydrocephalus treatment modality, and timing of hydrocephalus treatment. METHODS The Nationwide Inpatient Sample (NIS) database from the years 1998-2014 was reviewed and neonates with spina bifida and hydrocephalus status were identified. Timing of hydrocephalus treatment, delayed treatment (DT) versus simultaneous MMC repair with hydrocephalus treatment (ST), and treatment modality (ETV vs ventriculoperitoneal shunt [VPS]) were analyzed. Yearly trends were assessed with univariable logarithmic regression. Multivariable logistic regression identified correlates of inpatient shunt failure. A PRISMA systematic literature review was conducted that analyzed data from studies that investigated 1) MMC closure technique and hydrocephalus rate, 2) hydrocephalus treatment modality, and 3) timing of hydrocephalus treatment. RESULTS A weighted total of 10,627 inpatient MMC repairs were documented in the NIS, 8233 (77.5%) of which had documented hydrocephalus: 5876 (71.4%) were treated with VPS, 331 (4.0%) were treated with ETV, and 2026 (24.6%) remained untreated on initial inpatient stay. Treatment modality rates were stable over time; however, hydrocephalic patients in later years were less likely to receive hydrocephalus treatment during initial inpatient stay (odds ratio [OR] 0.974, p = 0.0331). The inpatient hydrocephalus treatment failure rate was higher for patients who received ETV treatment (17.5% ETV failure rate vs 7.9% VPS failure rate; p = 0.0028). Delayed hydrocephalus treatment was more prevalent in the later time period (77.9% vs 69.5%, p = 0.0287). Predictors of inpatient shunt failure included length of stay, shunt infection, jaundice, and delayed treatment. A longer time between operations increased the likelihood of inpatient shunt failure (OR 1.10, p < 0.0001). However, a meta-analysis of hydrocephalus timing studies revealed no difference between ST and DT with respect to shunt failure or infection rates. CONCLUSIONS From 1998 to 2014, hydrocephalus treatment has become more delayed and the number of hydrocephalic MMC patients not treated on initial inpatient stay has increased. Meta-analysis demonstrated that shunt malfunction and infection rates do not differ between delayed and simultaneous hydrocephalus treatment.
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Alnaami IM, Alayad EG. Review on myelomeningocele management and its current status in Saudi Arabia. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2019; 24:5-10. [PMID: 30842393 PMCID: PMC8015532 DOI: 10.17712/nsj.2019.1.20180169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Major approaches have emerged in the field of myelomeningocele (MMC) management. The prevalence of MMC in Kingdom of Saudi Arabia is 0.44-1.46/1000 births. Nine point seven percent of pregnant Saudi women take folic acid before conception; MMC is estimated to result in 1,417,500 Saudi Riyals (SAR) in lifetime costs per patient. Abortion should be performed cautiously in Muslim countries; another option may be the intrauterine foetal surgical repair of MMC, which has better neuromotor outcomes and reduces the need for ventriculoperitoneal shunt, albeit with a higher risk of obstetric complications. Seven years after intrauterine foetal surgery emerged, there is a need to establish this service in Kingdom of Saudi Arabia. A multidisciplinary approach is required for MMC patients; surgical closure should be carried out within 72 hours after birth to reduce the risk of infection. Advancing MMC care allows patients to survive to adulthood, and action must be taken to improve the quality of MMC care in Kingdom of Saudi Arabia.
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Affiliation(s)
- Ibrahim M Alnaami
- Department of Neurosurgery, Asir Central Hospital, Abha, Kingdom of Saudi Arabia. E-mail:
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Cavalheiro S, da Costa MDS, Moron AF, Leonard J. Comparison of Prenatal and Postnatal Management of Patients with Myelomeningocele. Neurosurg Clin N Am 2017; 28:439-448. [PMID: 28600017 DOI: 10.1016/j.nec.2017.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Myelomeningocele (MMC) is a costly lifetime disease with many comorbidities, including sensory and motor lower limb disability, bladder/bowel dysfunction, scoliosis, club foot, and hydrocephalus. MMC treatment options have changed over time because routine use of fetal ultrasonography and MRI has provided prenatal diagnosis and the potential for fetal surgery. There is still no consensus on how to treat the MMC diagnoses prenatally, mainly related to the infrastructure required to operate on pregnant patients. This article provides an overview of prenatal and postnatal MMC repair and the features in the prenatal diagnosis.
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Affiliation(s)
- Sergio Cavalheiro
- Neurosurgery Department, Federal University of São Paulo-UNIFESP, Rua Pedro de Toledo, 715, 6th Floor, São Paulo, São Paulo 04024-001, Brazil
| | - Marcos Devanir Silva da Costa
- Neurosurgery Department, Federal University of São Paulo-UNIFESP, Rua Pedro de Toledo, 715, 6th Floor, São Paulo, São Paulo 04024-001, Brazil; Department of Pediatric Neurosurgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Antonio Fernandes Moron
- Department of Obstetrics, Federal University of São Paulo-UNIFESP, Rua Pedro de Toledo, 715, 8th Floor, São Paulo, São Paulo 04024-001, Brazil
| | - Jeffrey Leonard
- Neurosurgery Department, Nationwide Children's Hospital, FB, Suite 4 A.2, 700 Children's Drive, Columbus, Ohio 43205, USA.
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Marreiros H, Loff C, Calado E. Who needs surgery for pediatric myelomeningocele? A retrospective study and literature review. J Spinal Cord Med 2015; 38:626-40. [PMID: 25029586 PMCID: PMC4535805 DOI: 10.1179/2045772314y.0000000229] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Children with myelomeningocele (MMC) are usually subjected to multiple surgeries. However, the number and type of surgeries are not the same in every patient with MMC over time. This report summarizes the surgical interventions in a cohort of several ages. MATERIALS AND METHODS Data on all of the patients with MMC, aged from 1 year and 10 months to 21 years and 11 months, were retrospectively reviewed at the Dona Estefânia Hospital in Lisbon, Portugal. Data were collected by chart review and individual interviews. The factors analyzed were demographics, ambulatory status, neurological level of involvement, shunt status, Arnold-Chiari malformation type II, surgical history, and occurrence of fracture. The surgical interventions were categorized as neurosurgical, orthopedic, urinary, ulcer repair and others. RESULTS A total of 84 alive were eligible and enrolled. The average age was 14 years and six months. A total of 59 patients received shunts (all but one ventriculoperitoneal). In the study group, the 84 patients required 663 surgeries. Neurosurgical interventions were the most frequent surgical procedure and predominated during the first 2 years of life. Surgical interventions related to shunts were the most common neurosurgical interventions. Orthopedic surgeries were more frequent in the age group 6-12 years. Urological surgeries were done mainly after 6 years of age. Surgical repair of pressure ulcers was more common after 12 years of age. CONCLUSIONS Our study brings to light the complexity of this condition, with multiple surgeries among patients with MMC.
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Affiliation(s)
- Humberto Marreiros
- Department of Paediatric Neurology, Dona Estefânia Hospital, Lisbon, Portugal,Correspondence to: Humberto Marreiros, Department of Paediatric Neurology, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Rua Jacinta Marto, 1169-045 Lisboa, Portugal.
| | - Clara Loff
- Department of Physical and Rehabilitation Medicine, Dona Estefânia Hospital, Lisbon, Portugal
| | - Eulália Calado
- Department of Paediatric Neurology, Dona Estefânia Hospital, Lisbon, Portugal
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Kshettry VR, Kelly ML, Rosenbaum BP, Seicean A, Hwang L, Weil RJ. Myelomeningocele: surgical trends and predictors of outcome in the United States, 1988-2010. J Neurosurg Pediatr 2014; 13:666-78. [PMID: 24702620 DOI: 10.3171/2014.3.peds13597] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Myelomeningocele repair is an uncommonly performed surgical procedure. The volume of operations has been decreasing in the past 2 decades, probably as the result of public health initiatives for folate supplementation. Because of the rarity of myelomeningocele, data on patient or hospital factors that may be associated with outcome are scarce. To determine these factors, the authors investigated the trends in myelomeningocele surgical repair in the United States over a 23-year period and examined patient and hospital characteristics that were associated with outcome. METHODS The Nationwide Inpatient Sample database for 1988-2010 was queried for hospital admissions for myelomeningocele repair. This database reports patient, hospital, and admission characteristics and surgical trends. The authors used univariate and multivariate logistic regression to assess associations between patient and hospital characteristics and in-hospital deaths, nonroutine discharge, long hospital stay, and shunt placement. RESULTS There were 4034 hospitalizations for surgical repair of myelomeningocele. The annual volume decreased since 1988 but plateaued in the last 4 years of the study. The percentages of myelomeningocele patients with low income (30.8%) and Medicaid insurance (48.2%) were disproportionately lower than those for the overall live-born population (p < 0.0001). More operations per 10,000 live births were performed for Hispanic patients (3.2) than for white (2.0) or black (1.5) patients (p < 0.0001). Overall, 56.6% of patients required shunt placement during the same hospital stay as for surgical repair; 95.0% of patients were routinely discharged; and the in-hospital mortality rate was 1.4%. Nonwhite race was associated with increased in-hospital risk for death (OR 2.8, 95% CI 1.2-6.3) independent of socioeconomic or insurance status. CONCLUSIONS Overall, the annual surgical volume of myelomeningocele repairs decreased after public health initiatives were introduced but has more recently plateaued. The most disproportionately represented populations are Hispanic, low-income, and Medicaid patients. Among nonwhite patients, increased risk for in-hospital death may represent a disparity in care or a difference in disease severity.
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Tamburrini G, Frassanito P, Iakovaki K, Pignotti F, Rendeli C, Murolo D, Di Rocco C. Myelomeningocele: the management of the associated hydrocephalus. Childs Nerv Syst 2013; 29:1569-79. [PMID: 24013327 DOI: 10.1007/s00381-013-2179-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 05/20/2013] [Indexed: 01/28/2023]
Abstract
BACKGROUND The pathogenesis of the hydrocephalus associated with myelomeningocele (MMC) has been the subject of an extensive number of studies. The contemporary reduction of the incidence of the Chiari II malformation and of the associated active hydrocephalus after closure of the spinal defect in utero is in line with previous studies suggesting a prominent role of the posterior cranial fossa abnormalities, where even the increased venous pressure might be at least mostly a consequence of the constriction of the posterior cranial fossa structures. Pure absorptive abnormalities however coexist, the main ones documented to be abnormal cisternal spaces and peculiar cerebrospinal fluid chemical features. MATERIALS AND METHODS We reviewed the pertinent literature concerning the pathogenesis and management of the hydrocephalus associated to MMC. We also reviewed our personal experience in managing the hydrocephalus in such patients through an endoscopic third ventriculostomy. RESULTS AND CONCLUSIONS The literature review demonstrated an overall reduction in more recent series of children with MMC needing to be treated for the associated hydrocephalus postnatally, questioning the role of the prenatal care of the disease in this context. Less severe conditions and a more conservative neurosurgical attitude have certainly contributed to the reduction of the reported active postnatal hydrocephalus rate. Long-term cognitive evaluation of the children with MMC that we managed with an endoscopic third ventriculocisternostomy (ETV) as primary as well as secondary procedure did not demonstrate significant differences in the outcome compared with non-complicated extrathecally shunted children, favouring ETV as a valuable option in this subset of patients.
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Affiliation(s)
- G Tamburrini
- Pediatric Neurosurgery, Department of Head and Neck Surgery, Catholic University Medical School, Largo "A. Gemelli", 8, 00168 Rome, Italy.
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Hervey-Jumper SL, Garton HJL, Wetjen NM, Maher CO. Neurosurgical management of congenital malformations and inherited disease of the spine. Neuroimaging Clin N Am 2011; 21:719-31, ix. [PMID: 21807320 DOI: 10.1016/j.nic.2011.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Congenital malformations encompass a diverse group of disorders present at birth as result of genetic abnormalities, infection, errors of morphogenesis, or abnormalities in the intrauterine environment. Congenital disorders affecting the brain and spinal cord are often diagnosed before delivery with the use of prenatal ultrasonography and maternal serum screening. Over the past several decades there have been major advances in the understanding and management of these conditions. This article focuses on the most common spinal congenital malformations.
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Yilmaz A, Müslüman AM, Dalgic N, Cavuşoğlu H, Kanat A, Colak I, Aydın Y. Shunt insertion in newborns with myeloschisis/myelomenigocele and hydrocephalus. J Clin Neurosci 2010; 17:1493-6. [PMID: 20869250 DOI: 10.1016/j.jocn.2010.03.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 01/20/2010] [Accepted: 03/09/2010] [Indexed: 11/16/2022]
Affiliation(s)
- Adem Yilmaz
- Neurosurgery Clinic, Şişli Etfal Education and Research Hospital, Şişli, İstanbul 34077, Turkey
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Margaron FC, Poenaru D, Bransford R, Albright AL. Timing of ventriculoperitoneal shunt insertion following spina bifida closure in Kenya. Childs Nerv Syst 2010; 26:1523-8. [PMID: 20422197 DOI: 10.1007/s00381-010-1156-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 04/08/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE In Western medical centers, emphasis has been placed on simultaneous myelomeningocele closure and ventriculoperitoneal shunting for children with spina bifida (SB) and co-morbid hydrocephalus (HC). This is not practical in developing countries where patients present in a delayed fashion, many with open, dirty myelomeningoceles. The purpose of this study was to evaluate whether timing of shunting in relation to myelomeningocele closure affected shunt-related complications such as SB wound infection, shunt infection, and shunt malfunction. METHODS A retrospective analysis was undertaken of all SB patients undergoing ventriculoperitoneal shunting within 11 days following myelomeningocele closure at Kijabe Hospital between 1997 and August 2007. Data were collected from hospital records and analyzed in SPSS. RESULTS Over the study period there were 276 patients included. Eighteen patients were shunted prior to SB closure and 13 patients had simultaneous shunting and SB closure. Patients shunted prior to, simultaneously, or within the first 4 days after SB closure had a fivefold higher shunt infection rate (23%) than those shunted 5-10 days following SB closure (4.7%) (p < 0.0001). Shunt malfunctions were also significantly higher in the group shunted prior to back closure (33.3%) vs. those shunted simultaneously (15.4%) or within the first 10 days following SB closure (13.9%) (p = 0.0001). No difference was seen in these groups with regard to wound infections. No difference in shunt-related complications was observed between those shunted 5 to 10 days following back closure. CONCLUSIONS This study indicates that in developing countries, patients with SB who present in a delayed fashion but require shunting and have sterile CSF, should have their shunts inserted 5-10 days after SB closure.
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Radmanesh F, Nejat F, El Khashab M, Ghodsi SM, Ardebili HE. Shunt complications in children with myelomeningocele: effect of timing of shunt placement. Clinical article. J Neurosurg Pediatr 2009; 3:516-20. [PMID: 19485738 DOI: 10.3171/2009.2.peds08476] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT There has been controversy over whether CSF shunt insertion simultaneously with repair of myelomeningocele (MMC) might increase shunt-related complications. The purpose of this study was to evaluate shunt complication rates in patients who underwent concurrent MMC surgery and shunt placement and compare them to the rates in patients treated with shunt placement in a separate procedure. METHODS The authors retrospectively reviewed the outcome of shunt placement in 127 patients with MMC who were followed up for >or=1 year after shunt surgery. In 65 patients shunt surgery was performed in a second operation after MMC repair and in 46 the 2 procedures were performed concurrently. In 7 patients shunt placement was the initial surgery, and in 9 it was the only procedure performed. The patients were evaluated for shunt complications. RESULTS There was no statistically significant between-groups difference in age at which patients underwent shunt placement. The overall rates of shunt infection and shunt malfunction were 16.5 and 39.4%, respectively. There was a high rate of shunt infection and mortality in those patients treated with CSF shunting only. There was no statistically significant difference between complication rates in patients in whom the 2 procedures were performed concurrently and those who underwent separate operations. CONCLUSIONS The order in which myelomeningocele repair and shunt placement were carried out did not have a significant effect on the rate of shunt complications. Thus, when indicated these procedures can be performed concurrently with a level of risk comparable to that associated with delayed shunt placement.
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Affiliation(s)
- Farid Radmanesh
- Department of Neurosurgery, Children's Hospital Medical Center, and Department of Biostatistics, Tehran University of Medical Sciences, Tehran, Iran
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Fichter MA, Dornseifer U, Henke J, Schneider KTM, Kovacs L, Biemer E, Bruner J, Adzick NS, Harrison MR, Papadopulos NA. Fetal spina bifida repair--current trends and prospects of intrauterine neurosurgery. Fetal Diagn Ther 2008; 23:271-86. [PMID: 18417993 DOI: 10.1159/000123614] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2005] [Accepted: 01/24/2007] [Indexed: 12/14/2022]
Abstract
Myelomeningocele is a common dysraphic defect leading to severe impairment throughout the patient's lifetime. Although surgical closure of this anomaly is usually performed in the early postnatal period, an estimated 330 cases of intrauterine repair have been performed in a few specialized centers worldwide. It was hoped prenatal intervention would improve the prognosis of affected patients, and preliminary findings suggest a reduced incidence of shunt-dependent hydrocephalus, as well as an improvement in hindbrain herniation. However, the expectations for improved neurological outcome have not been fulfilled and not all patients benefit from fetal surgery in the same way. Therefore, a multicenter randomized controlled trial was initiated in the USA to compare intrauterine with conventional postnatal care, in order to establish the procedure-related benefits and risks. The primary study endpoints include the need for shunt at 1 year of age, and fetal and infant mortality. No data from the trial will be published before the final analysis has been completed in 2008, and until then, the number of centers offering intrauterine MMC repair in the USA is limited to 3 in order to prevent the uncontrolled proliferation of new centers offering this procedure. In future, refined, risk-reduced surgical techniques and new treatment options for preterm labor and preterm rupture of the membranes are likely to reduce associated maternal and fetal risks and improve outcome, but further research will be needed.
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Affiliation(s)
- M A Fichter
- Department of Plastic and Reconstructive Surgery, Technical University of Munich, Munich, Germany
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Gamache FW. Treatment of hydrocephalus in patients with meningomyelocele or encephalocele: a recent series. Childs Nerv Syst 1995; 11:487-8. [PMID: 7585688 DOI: 10.1007/bf00334972] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Meningomyelocele/encephalocele with associated ventriculomegaly can be treated as a single-stage procedure (i.e., both lesions treated simultaneous) or as two-stage procedures (i.e., each lesion treated at a separate time). A delay in closure of the meningomyelocele/encephalocele is associated with a higher incidence of ventriculitis/ventricular shunt infection-particularly when closure is performed more than 36 h after birth. In these situations, closure followed by surveillance cultures, appropriate antibiotics, ventricular drainage, and then delayed ventricular shunting seems more reasonable.
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Affiliation(s)
- F W Gamache
- New York Hospital-Cornell Medical Center, New York 10021, USA
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Chadduck WM, Reding DL. Experience with simultaneous ventriculo-peritoneal shunt placement and myelomeningocele repair. J Pediatr Surg 1988; 23:913-6. [PMID: 3236159 DOI: 10.1016/s0022-3468(88)80383-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A program evaluating simultaneous shunt placement and neural tube repair is described and compared with a concomitant series of patients whose surgeons preferred delayed shunting. Twenty-two patients had simultaneous closure of neural tube defects and placement of ventriculoperitoneal shunts; one was shunted 1 day prior to closure of a leaking myelomeningocele. Eleven other patients had closure of myelomeningoceles followed by shunting 6 to 14 days later. Four patients have not required shunting. Three patients needed complex flap rotations and silastic dural closures, but the complexity of the myelomeningocele closure was not a criterion for excluding simultaneous shunting. The only criteria were preference of the attending surgeon, and ventricular size. All but one in the simultaneous shunting (SS) group had moderate to marked hydrocephalus at birth; one initially selected not to have a shunt, but within 24 hours had marked increase in ventricular size by ultrasonography performed when the child was anesthetized for the myelomeningocele closure. In the SS group, surgical innovations included (1) use of the semilateral position for exposure of both operative sites for shunting and the myelomeningocele closure, (2) posteriorly-placed subcutaneous peritoneal catheter, and (3) a combined surgical approach using two surgeons and separate instrumentation. There was no operative mortality in either group; there were no infections within 30 days in either group. There was one infection at 5 months in the SS group, and one at 2 months in the delayed shunting (DS) group; the long-term infection rate was 5%, comparable to any published series.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- W M Chadduck
- Spina Bifida Program, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock 72202
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