Experience with various reconstructive techniques for meningomyelocele defect closure in India

The Importance of Neurosurgical Intervention and Surgical Timing for Management of Pediatric Patients with Myelomeningoceles in Bangladesh

OBJECTIVE

Reports on the management and survival of children with myelomeningocele defects in Bangladesh are limited. This study describes the characteristics and outcomes of these children, focusing on the timing of surgical repair and factors affecting survival.

METHODS

We enrolled patients with myelomeningoceles in a case-control study on arsenic exposure and spina bifida in Bangladesh. Cases were subsequently followed at regular intervals to assess survival. Demographic, clinical, and surgical characteristics were reviewed. Univariate tests identified factors affecting survival.

RESULTS

Between 2016 and 2022, we enrolled 272 patients with myelomeningocele. Postnatal surgical repair was performed in 63% of cases. However, surgery within 5 days after birth was infrequent (<10%) due to delayed presentation, and there was a high rate (29%) of preoperative deaths. Surgical repair significantly improved patient survival (P < 0.0001). Older age at time of surgery was also associated with improved survival rates, which most likely represents that those who survived to older ages prior to surgery accommodated better with their lesions. Patients who presented with ruptured lesions had lower survival rates.

CONCLUSIONS

Timely neurosurgical repair of myelomeningoceles in Bangladesh is hindered by late patient presentation, resulting in a high preoperative patient death rate. Neurosurgical intervention remains a significant predictor of survival. Increased access to neurosurgical care and education of families and non-neurosurgical providers on the need for timely surgical intervention are important for improving the survival of infants with myelomeningoceles.

Myelomeningocele Defects Reconstruction With Various Types of keystone Flaps: An Algorithmic Approach Based on Defect Shape

The keystone flap has become an established option that has been utilized recently to close significant myelomeningocele defects. Although the keystone flaps can be adapted to repair myelomeningocele defects of different sizes, the shape of the defect is also an essential factor to consider. In this study, the authors proposed an algorithmic approach for reconstructing significant meningomyelocele defects utilizing different types of keystone flaps based on the shape of the resulting defect. From September 2016 to March 2022, the authors retrospectively reviewed the medical records of 28 patients with meningomyelocele who underwent repair with the keystone flaps. The mean age was 28 days (3 days to 4.5 months). Twenty-one meningomyelocele defects were in the lumbosacral (75%) and 7 in the thoracolumbar regions (25%). The defect sizes ranged from 3.5×5 cm (area, 13.4 cm2) to 9×7 cm (area, 49.5 cm2), with an average of 26.2 cm2. Ten meningomyelocele defects were a vertically oriented oval shape, 16 defects were a transversely oriented oval shape, and 2 defects were circular. In addition, unilateral keystone flap was used in 7.1% of the patients (2 patients), bilateral keystone flap in 28.6% (8 patients), and rotation advancement keystone flaps in 64.3% (18 patients). According to these findings, an algorithm was created based on the defect shape. This algorithmic approach is used as a decision-making guide to select the correct type of keystone flaps to repair myelomeningocele according to the defect shape.

Meningomyelocele Reconstruction: Comparison of Repair Methods via Systematic Review

PURPOSE

The purpose of this article was to appraise the various methods of reconstruction for meningomyelocele (MMC) defects.

METHODS

A systematic review of the literature was performed to evaluate all reconstructions for MMC. The method of reconstruction was categorized by: primary closure with and without fascial flaps, random pattern flaps, VY advancement flaps (VY), perforator flaps, and myocutaneous flaps. Perforator flaps were subsequently subcategorized based on the type of flap.

RESULTS

Upon systematic review, 567 articles were screened with 104 articles assessed for eligibility. Twenty-nine articles were further reviewed and included for qualitative synthesis. Two hundred seventy patients underwent MMC repair. The lowest rates of major wound complications (MWC) were associated with myocutaneous and random pattern flaps. A majority of MWC was in the lumbrosacral/sacral region (87.5% of MWC). In this region, random patterns and perforator flaps demonstrated the lowest rate of MWC (4.5, 8.1%).

CONCLUSIONS

Plastic surgery consultation should be strongly considered for MMC with defects in the lumbosacral/sacral region. Perforator flaps are excellent options for the reconstruction of these defects.

Repair of spina bifida cystica: an institutional experience

Objective

Although most cases with spina bifida cystica could be closed by primary skin closure with or without undermining its edges, about 25% of patients have large defects not amenable for closure by these simple methods. We conducted this study to review our techniques in closing spina bifida cystica defects.

Methods

We retrospectively reviewed the data of consecutive 21 patients diagnosed with spina bifida cystica in our setting. According to the surface area of the defect, the approach was decided; primary closure for small defects (11 cases) and flap-based approach for large defects (10 patients).

Results

The age of the included pediatric patients ranged between 3 and 75 days. For the primary closure cases, a vertical incision was done in seven cases. For the flap-based group, bilateral rotation transposition flap was done for circular defects (7 cases) while elliptical ones were repaired via bilateral V–Y flap. Complete skin healing was achieved after two weeks (range 12–18 days) in most cases. Complications were as follows; for the primary closure group, cerebrospinal fluid leakage (18.18%%), partial wound dehiscence (18.18%) and superficial surgical site infection (9.09%). In the flap-based group, CSF leakage (20%), superficial surgical site infection (10%), and distal flap necrosis (30%) were detected. Reoperation for wound complication was needed only in one case in the flap-based group.

Conclusions

Flap-based procedures are recommended for patients with large spina bifida cystica defects because of less tissue dissection and low complication rates. Primary closure should be kept for small defects.

Closure of a large lumbosacral myelomeningocele defect with a human pericardial graft: a case report

INTRODUCTION

Myelomeningocele (MMC) is a complex congenital defect resulting from incomplete closure of the neural tube. The aim of this study is to present an unusual technique for the closure of a large defect.

CASE REPORT

Here we report a patient that was prenatally diagnosed with MMC. At birth, a skin defect of approximately 5 x 7 cm was observed. To repair the defect, a Z-plasty was performed; however, necrosis of the flap developed 3 days after the surgery. The devitalized tissue was removed, and a human pericardial graft was used to cover the defect.

DISCUSSION

Different techniques have been described for the repair of MMC with a large skin defect, such as rotation skin flaps as well as synthetic and biological grafts. In our patient, a new technique without prior experience consisting of the application of human cadaveric pericardial graft was used with good results and no complications.

CONCLUSION

Closure of MMC is often a surgical challenge. Here we describe a surgical technique for the closure of large skin defects.

Closure of meningomyelocele defects using various types of keystone-design perforator island flaps

Background

Various methods have been described to close large meningomyelocele defects, but no technique has been proven superior to others. This study presents cases of meningomyelocele defect closure with a keystone-design perforator island flap.

Methods

A retrospective study was performed on 14 patients with meningomyelocele defects closed using various types of keystone flaps.

Results

The median age of the patients at surgery was 10.5 days (range, 1–369 days) and the average defect size was 22.5 cm² (range, 7.1–55.0 cm²). The average operative time for defect closure was 89.6 minutes (range, 45–120 minutes). Type IV bilateral keystone flaps were used for four defects, type IV unilateral flaps for six defects, type IIA flaps for two defects, and type III flaps for two defects.

Conclusions

All the defects healed completely with no major complications. The keystone-design perforator island flap is a reliable, easy, and fast technique to close large meningomyelocele defects.