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Pakkasjärvi N, Antila S, Mäkelä E, Taskinen S. Urological Outcomes in Post-Pubertal Patients With Myelomeningocele: A Single-Center Retrospective Study. J Pediatr Surg 2024; 59:1177-1181. [PMID: 38402132 DOI: 10.1016/j.jpedsurg.2024.02.003] [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: 08/14/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Recent decades have seen changes in the urological treatment of myelomeningocele (MMC). We aimed to evaluate the urological outcomes in post-pubertal patients and to clarify associations with walking status, hydrocephalus, and sex. METHODS A retrospective study of 103 MMC patients at their final pediatric urological control. Urological procedures, the necessity for Clean Intermittent Catheterization (CIC) and anticholinergic medication, the state of continence, renal ultrasound findings, and serum creatinine values were assessed. RESULTS The median age of the patients was 18 years (IQR 16.7-19.6), with 51 (49.5%) being female. Renal function was preserved in all but of one, who presented with mild hydronephrosis. 38 patients walked without assistance, 46 used wheelchairs. Most patients (93%) utilized CIC, and 83% had interventions for overactive or poorly compliant bladder, including anticholinergic medication (47%), Botox treatments (35%), or bladder augmentation (36%). Nearly half (45%) had undergone bladder neck procedures. Continence status revealed 55% fully continent, 18% were rarely incontinent, and 26% were incontinent daily, with most episodes limited to droplet leakage. Incontinence was not associated with the ambulatory status, hydrocephalus, or sex (p = 0.08, >0.99, and 0.07 respectively). CONCLUSIONS Renal function was effectively maintained with our treatment strategy; however, daily incontinence episodes occurred in one out of four patients, with an additional 18% experiencing occasional rare incontinence episodes. Incontinence, when present, was mostly mild. We found no association between patient characteristics, treatment approach, and continence. Emphasizing incontinence treatment becomes a mainstay in future studies. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Niklas Pakkasjärvi
- Department of Pediatric Surgery, New Children's Hospital, Helsinki University Hospital, University of Helsinki, HUS, Stenbäckinkatu 9, 00029 Helsinki, Finland.
| | - Sampo Antila
- Department of Pediatric Surgery, New Children's Hospital, Helsinki University Hospital, University of Helsinki, HUS, Stenbäckinkatu 9, 00029 Helsinki, Finland
| | - Eija Mäkelä
- Department of Pediatric Surgery, New Children's Hospital, Helsinki University Hospital, University of Helsinki, HUS, Stenbäckinkatu 9, 00029 Helsinki, Finland
| | - Seppo Taskinen
- Department of Pediatric Surgery, New Children's Hospital, Helsinki University Hospital, University of Helsinki, HUS, Stenbäckinkatu 9, 00029 Helsinki, Finland
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Zoghi S, Mosayebi MA, Feili M, Eskandari H, Jalalinezhad H, Masoudi MS, Taheri R. 2- to 20-year myelomeningocele follow-up outcomes from a referral center in Southern Iran: the Shiraz experience. Eur J Med Res 2024; 29:200. [PMID: 38528560 DOI: 10.1186/s40001-024-01667-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/12/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND The current convention for treatment of children with myelomeningocele (MMC) is timely surgical intervention combined with long-term follow-up by a multidisciplinary specialized team. This study aims to investigate the outcomes of MMC patients treated at Namazi Hospital. METHODS All children presenting to Namazi Hospital with myelomeningocele between May 2001 and August 2020 were eligible for this study. For those with a documented telephone number, follow-up phone surveys with the patient's caregivers, on top of the review of the medical documents were carried out to assess mortality, morbidities, and the functional outcome of the care provided to them. RESULTS A total of 125 patients were studied (62 females). All of the patients were followed up for a mean duration of 6.28 years (range 1-23 years). The majority were located in the lumbosacral area. All of the patients underwent postnatal surgical intervention for MMC in Namazi Hospital. Mean age at surgery was 9.51 days. There were statistically significant differences between urinary and bowel incontinence and presence of scoliosis, MMT grading of the lower limbs, school attendance, number of readmissions, and requirement of laminectomy at the initial surgical intervention. CONCLUSIONS This study is the first to characterize the long-term outcomes of MMC patients in Iran. This study illustrates that there is a great need for improved access to and coordination of care in antenatal, perioperative, and long-term stages to improve morbidity and mortality.
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Affiliation(s)
- Sina Zoghi
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Maryam Feili
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Eskandari
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
| | - Hadis Jalalinezhad
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
| | | | - Reza Taheri
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- School of Medicine, Fasa University of Medical Sciences, Fasa, Iran.
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Agrawal S, Hobson EV, Hart AR. Family experiences of antenatal counselling of spina bifida: a systematic review. Arch Dis Child Fetal Neonatal Ed 2023; 109:59-64. [PMID: 37433589 DOI: 10.1136/archdischild-2023-325391] [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: 01/26/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE To describe families' experiences of antenatal counselling of spina bifida. DESIGN Systematic review. METHODS MEDLINE, CINAHL, PsycINFO and Embase databases were searched using a combination of Medical Subject Headings and text/abstract terms. Case reports, survey results and qualitative interview data were included. The quality of research was evaluated using the Critical Appraisal Skills Programme checklist. RESULTS 8 papers were included. Families described shock and grief at diagnosis, with some immediately offered termination of pregnancy (TOP) even though they knew little about the condition. Positive and negative aspects of care were found. Teams that were gentle, kind and empathetic, who did not use jargon, and highlighted positive and negative aspects of the baby's life were seen favourably. Callous language, and overly negative or incorrect counselling was not, particularly if there was pressure to agree to TOP. Families based their decisions on how they would cope, the effect on siblings and the baby's likely quality of life. Prenatal surgery was viewed positively. The views of families who chose TOP, were happy with their care, partners, families, and the LGBTQ+ community were under-represented in the literature. CONCLUSIONS Unlike other conditions where limited data on outcome exist or the spectrum is genuinely broad, the outcomes of children with spina bifida is well described. Poor aspects of antenatal counselling were described frequently by families, and further work is needed to capture the full spectrum of views on antenatal counselling, how it can be improved, and what training and resources healthcare professionals need to perform it better.
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Affiliation(s)
- Shreya Agrawal
- The University of Sheffield Medical School, Sheffield, UK
| | - Esther V Hobson
- Department of Neurology, The University of Sheffield Institute for Translational Neuroscience, Sheffield, UK
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Nonaka M, Komori Y, Isozaki H, Ueno K, Kamei T, Takeda J, Nonaka Y, Yabe I, Zaitsu M, Nakashima K, Asai A. Current status and challenges of neurosurgical procedures for patients with myelomeningocele in real-world Japan. Childs Nerv Syst 2023; 39:3137-3145. [PMID: 35907006 DOI: 10.1007/s00381-022-05613-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little is known about the real-world status of neurosurgical treatment of myelomeningocele patients. OBJECTIVE To investigate the real-world status of neurosurgical treatment of myelomeningocele patients, medical claims data provided by the Japan Medical Data Center (JMDC) were analyzed. METHODS The health claims data of 556 patients with myelomeningoceles from January 2005 to March 2020 were examined. The number of neurosurgical procedures, including myelomeningocele repair, tethered cord release, cerebrospinal fluid (CSF) shunt, CSF drainage, and endoscopic third ventriculostomy (ETV), was determined. RESULTS A total of 313 neurosurgical procedures were performed for 135 patients in 74 institutions during the study period. The shunt survival rate was most affected by shunts that were revised when the patient was less than 1 year old, which had a significantly lower survival rate than all of the initial shunts performed when the patient was less than on1 year old; the 1-year shunt survival rate was 35 vs 64% (P = 0.0102). The survival rate was significantly lower in patients younger than 1 year who had CSF drainage before shunting compared to those younger than 1 year who did not have CSF drainage before shunting; the 1-year shunt survival rate was 27 vs 59% (P = 0.0196), and 81% of patients remained free of tethered cord release 10 years later. CONCLUSIONS In this study, a revised shunt of less than 1 year of age and CSF drainage before shunting were the factors that lowered the shunt survival rate in the real world for CSF shunts for hydrocephalus associated with myelomeningocele.
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Affiliation(s)
- Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan.
| | - Yumiko Komori
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Haruna Isozaki
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Katsuya Ueno
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Takamasa Kamei
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Junichi Takeda
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Yuichiro Nonaka
- Department of Neurosurgery, Jikei Medical University, Minato-Ku, Tokyo, Japan
| | - Ichiro Yabe
- Department of Neurology, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Masayoshi Zaitsu
- Center for Research of the Aging Workforce, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Kenji Nakashima
- National Hospital Organization, Matsue Medical Center, Matsue, Shimane, Japan
| | - Akio Asai
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
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Bowman RM, Lee JY, Yang J, Kim KH, Wang KC. Myelomeningocele: the evolution of care over the last 50 years. Childs Nerv Syst 2023; 39:2829-2845. [PMID: 37417984 DOI: 10.1007/s00381-023-06057-1] [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: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE Myelomeningocele (MMC) is one of the representative anomalies in the field of pediatric neurosurgery. During the 50 years of ISPN history, MMC had a tremendous changes in its incidence, clinical management and outcome with advanced understanding of its pathogenesis. We reviewed the changes in MMC during the period. METHODS We reviewed the literature review and collected our experiences. RESULTS During the 50 years, major changes happened in many aspects of MMC including incidence, pathoembryogenesis, folate deficiency, prevention, prenatal diagnosis, mode of delivery, treatment policy with ethical considerations, clinical treatment including fetal surgery, latex allergy, retethering, management outcome, multidisciplinary team approach, and socioeconomic and family issues. CONCLUSIONS There was a great advance in the management and research of MMC during the 50 years. It is a monumental achievement of pediatric neurosurgeons and colleagues of the related fields.
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Affiliation(s)
- Robin M Bowman
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Neurosurgery Department, Northwestern University, Chicago, IL, USA
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
- Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul, Korea
| | - Jeyul Yang
- Department of Neurosurgery, Myongji Hospital, Goyang, Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Kyu-Chang Wang
- Center for Rare Cancers, Neuro-oncology Clinic, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, Kyounggi-do, 10408, Republic of Korea.
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Caceres A, Jimenez-Chaverri AL, Alpizar-Quiros PA, Wong-McClure R. Pre and postnatal care characteristics and management features of children born with myelomeningocele in the post-folate fortification era of staple foods in Costa Rica (2004-2022). Childs Nerv Syst 2023; 39:1755-1764. [PMID: 37129604 DOI: 10.1007/s00381-023-05951-y] [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: 02/27/2023] [Accepted: 04/05/2023] [Indexed: 05/03/2023]
Abstract
PURPOSE To describe the clinical characteristics of pre- and postnatal care of children born with myelomeningocele in Costa Rica from 2004 to 2022 after the introduction of mandatory fortification of four major staple foods, describing the clinical features of this cohort including the size of the meningomyelocele, neurological level, presence of symptomatic Chiari II at birth, kyphosis, and the severity of hydrocephalus requiring cerebrospinal fluid (CSF) shunting. These results were compared against the pre-fortification historical data to determine favorable outcomes from this health policy. METHODS We performed a retrospective review of the clinical records of patients with myelomeningocele at the spina bifida clinic from the National Children's Hospital of Costa Rica who were born between 2004 and 2022, a period when staple food fortification was implemented in the country for four food staples (wheat and corn flour, rice, and dairy products). Pre and postnatal care data pertaining to the number of obstetric ultrasound studies, the trimester in which they were performed, the detection of myelomeningocele and associated hydrocephalus, gestational age and route of delivery, neurological level, myelomeningocele defect size, associated kyphosis and symptomatic Chiari II malformation at birth, time periods of myelomeningocele repair, and CSF shunting were examined. A descriptive comparative frequency analysis between myelomeningocele (MMC) defect size, CSF shunt insertion, symptomatic Chiari II, and kyphosis between the different functional levels was performed with the estimation of the Fisher's exact chi-square test by contingency tables, and 0.05 was set as significance level. Additionally, the postnatal features of this cohort were compared against pre-fortification historical data obtained from 100 live-born patients between 1995 and 1996. RESULTS A total of 215 patients that were live born between 2004 and 2022 were eligible for analysis with a follow up ranging from 1 to 19 years (median follow up: 7.9 years). Among 99.1% of the mothers of patients who had prenatal consultations, 95.8% had an average of 3.8 obstetric ultrasound studies which led to a 59% prenatal detection rate of myelomeningocele. The pre and post fortification features showed a male/female ratio that changed from 0.92 to 1.25 respectively. Among these newborns, there was an increase from 54 to 64% cesarean sections as method for delivery. Only 26% of the pre fortification patients had the MMC defect repaired in the first 24 h, 32% from 24 to 72 h, 20% from 72 h to 1 week, and 22% later than 10 days respectively which deeply contrasted with the post fortification cohort where 7.5% had the MMC defect repaired in less than 8 h, 12.2% from 8 to 12 h, 66.5% 12-24 h, and 12.7% from 24 to 48 h and 1% later than 48 h, respectively (P < 0.01). Regarding the post fortification myelomeningocele anatomic and functional characteristics, defect size was measured as less than 3 cm in 7% of cases, 3 to 5 cm in 50% of cases, 5 to 7 cm in 42% of cases, and greater than 7 cm in 1% of cases. Thirteen percent of the cases had paraplegia due to a thoracic level, 10% had a high lumbar level, 58% had a middle lumbar level, 13% a lower lumbar level, and 6% only sacral compromise. When the data from the pre and post fortification cohorts were adjusted and compared, there was a reduction from thoracic/high lumbar cases from 26 to 23% (P < 0.56), with an increase of middle lumbar cases from 43 to 58% and a reduction from 25 to 13% of low lumbar cases (P < 0.01) while there was no change in the 6% percentage of sacral cases respectively. Lesions that were considered too extensive or larger than 7 cm decreased from 7 to 1% while associated kyphotic deformities decreased from 6 to 1.4% (P < 0.01); symptomatic Chiari II malformation at birth also decreased from 7 to 2% in the pre- and post-fortification cohorts respectively with all these changes being statistically significant (P < 0.01). Seventy-nine percent and 80% of the pre and post FAF cohorts required CSF VP shunting with a mean time for insertion of 10 days after spinal defect closure with no significant statistical change between the two groups. CONCLUSIONS This study describes a four-staple folate fortified population of live-born patients with myelomeningocele lesions whose neurological level, defect size, and associated deformities such as spinal kyphosis and symptomatic Chiari II at birth suggest that folate fortification could have diminished the severity of this congenital disease.
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Affiliation(s)
- Adrian Caceres
- Neurosurgery Department, Hospital Nacional de Niños, "Dr. Carlos Sáenz Herrera", San José, Costa Rica.
| | | | | | - Roy Wong-McClure
- Epidemiology Surveillance Unit, Caja Costarricense de Seguro Social, San José, Costa Rica
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Spoor JKH, Kik CC, van Veelen MLC, Dirven C, Miller JL, Groves ML, DeKoninck PLJ, Baschat AA, Eggink AJ. Potential higher risk of tethered spinal cord in children after prenatal surgery for myelomeningocele: A systematic review and meta-analysis. PLoS One 2023; 18:e0287175. [PMID: 37379312 DOI: 10.1371/journal.pone.0287175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/31/2023] [Indexed: 06/30/2023] Open
Abstract
INTRODUCTION We performed a systematic review and meta-analysis on the incidence of secondary tethered spinal cord (TSC) between prenatal and postnatal closure in patients with MMC. The objectives was to understand the incidence of secondary TSC after prenatal surgery for MMC compared to postnatal surgery for MMC. MATERIAL AND METHODS On May 4, 2023, a systematic search was conducted in Medline, Embase, and the Cochrane Library to gather relevant data. Primary studies focusing on repair type, lesion level, and TSC were included, while non-English or non-Dutch reports, case reports, conference abstracts, editorials, letters, comments, and animal studies were excluded. Two reviewers assessed the included studies for bias risk, following PRISMA guidelines. TSC frequency in MMC closure types was determined, and the relationship between TSC occurrence and closure technique was analyzed using relative risk and Fisher's exact test. Subgroup analysis revealed relative risk differences based on study designs and follow-up periods. A total of ten studies, involving 2,724 patients, were assessed. Among them, 2,293 patients underwent postnatal closure, while 431 received prenatal closure for the MMC defect. In the prenatal closure group, TSC occurred in 21.6% (n = 93), compared to 18.8% (n = 432) in the postnatal closure group. The relative risk (RR) of TSC in patients with prenatal MMC closure versus postnatal MMC closure was 1.145 (95%CI 0.939 to 1.398). Fisher's exact test indicated a statistically non-significant association (p = 0.106) between TSC and closure technique. When considering only RCT and controlled cohort studies, the overall RR for TSC was 1.308 (95%CI 1.007 to 1.698) with a non-significant association (p = .053). For studies focusing on children up until early puberty (maximum 12 years follow-up), the RR for tethering was 1.104 (95%CI 0.876 to 1.391), with a non-significant association (p = 0.409). CONCLUSION AND DISCUSSION This review found no significant increase in relative risk of TSC between prenatal and postnatal closure in MMC patients, but a trend of increased TSC in the prenatal group. More long-term data on TSC after fetal closure is needed for better counseling and outcomes in MMC.
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Affiliation(s)
- Jochem K H Spoor
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Charlotte C Kik
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marie-Lise C van Veelen
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Clemens Dirven
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynaecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Mari L Groves
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynaecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Alex J Eggink
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Cools MJ, Tang AR, Pruthi S, Koh TH, Braun SA, Bennett KA, Wellons JC. A comparison of MRI appearance and surgical detethering rates between intrauterine and postnatal myelomeningocele closures: a single-center pilot matched cohort study. Childs Nerv Syst 2023; 39:647-653. [PMID: 35927592 DOI: 10.1007/s00381-022-05627-z] [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: 06/05/2022] [Accepted: 07/25/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Intrauterine myelomeningocele repair (IUMR) and postnatal myelomeningocele repair (PNMR) differ in terms of both setting and surgical technique. A simplified technique in IUMR, in which a dural onlay is used followed by skin closure, has been adopted at our institution. The goal of this study was to compare the rates of clinical tethering in IUMR and PNMR patients, as well as to evaluate the appearance on MRI. METHODS We conducted a retrospective review of 36 patients with MMC repaired at our institution, with 2:1 PNMR to IUMR matching based on lesion level. A pediatric neuroradiologist blinded to the clinical details reviewed the patients' lumbar spine MRIs for the distance from neural tissue to skin and the presence or absence of a syrinx. An EMR review was then done to evaluate for detethering procedures and need for CSF diversion. RESULTS Mean age at MRI was 4.0 years and mean age at last follow-up was 6.1 years, with no significant difference between the PNMR and IUMR groups. There was no significant difference between groups in the distance from neural tissue to skin (PNMR 13.5 mm vs IUMR 17.6 mm; p = 0.5). There was no difference in need for detethering operations between groups (PNMR 12.5% vs IUMR 16.7%; RR 0.75; CI 0.1-5.1). CONCLUSIONS There was no significant difference between postnatal- and intrauterine-repaired myelomeningocele on MRI or in need for detethering operations. These results imply that a more straightforward and time-efficient IUMR closure technique does not lead to an increased rate of tethering when compared to the multilayered PNMR.
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Affiliation(s)
- Michael J Cools
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Ave S, Suite T-4224, Nashville, TN, USA.
- Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
| | - Alan R Tang
- Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sumit Pruthi
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tae Ho Koh
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephane A Braun
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly A Bennett
- The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John C Wellons
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Ave S, Suite T-4224, Nashville, TN, USA
- Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
- The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
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Zamłyński M, Olejek A, Horzelska E, Horzelski T, Zamłyński J, Bablok R, Maruniak-Chudek I, Olszak-Wąsik K, Pastuszka A. Decreased Maternal Morbidity and Improved Perinatal Results of Magnesium-Free Tocolysis and Classical Hysterotomy in Fetal Open Surgery for Myelomeningocele Repair: A Single-Center Study. Biomedicines 2023; 11:biomedicines11020392. [PMID: 36830929 PMCID: PMC9953469 DOI: 10.3390/biomedicines11020392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
Fetal and maternal risks associated with open fetal surgery (OFS) in the management of meningomyelocele (MMC) are considerable and necessitate improvement. A modified technique of hysterotomy (without a uterine stapler) and magnesium-free tocolysis (with Sevoflurane as the only uterine muscle relaxant) was implemented in our new magnesium-free tocolysis and classical hysterotomy (MgFTCH) protocol. The aim of the study was to assess the introduction of the MgFTCH protocol in reducing maternal and fetal complications. The prospective study cohort (SC) included 64 OFS performed with MgFTCH at the Fetal Surgery Centre Bytom (FSCB) (2015-2020). Fetal and maternal outcomes were compared with the retrospective cohort (RC; n = 46), and data from the Zurich Center for Fetal Diagnosis and Therapy (ZCFDT; n = 40) and the Children's Hospital of Philadelphia (CHOP; n = 100), all using traditional tocolysis. The analysis included five major perinatal complications (Clavien-Dindo classification, C-Dc) which developed before the end of 34 weeks of gestation (GA, gestational age). None of the newborns was delivered before 30 GA. Only two women presented with grade 3 complications and none with 4th or 5th grade (C-Dc). The incidence of perinatal death (3.3%) was comparable with the RC (4.3%) and CHOP data (6.1%). MgFTCH lowers the risk of major maternal and fetal complications.
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Affiliation(s)
- Mateusz Zamłyński
- Department of Gynecology, Obstetrics and Oncological Gynecology, Bytom, Medical University of Silesia, 41-902 Katowice, Poland
- Correspondence:
| | - Anita Olejek
- Department of Gynecology, Obstetrics and Oncological Gynecology, Bytom, Medical University of Silesia, 41-902 Katowice, Poland
| | - Ewa Horzelska
- Department of Gynecology, Obstetrics and Oncological Gynecology, Bytom, Medical University of Silesia, 41-902 Katowice, Poland
| | - Tomasz Horzelski
- Department of Gynecology, Obstetrics and Oncological Gynecology, Bytom, Medical University of Silesia, 41-902 Katowice, Poland
| | - Jacek Zamłyński
- Department of Gynecology, Obstetrics and Oncological Gynecology, Bytom, Medical University of Silesia, 41-902 Katowice, Poland
| | - Rafał Bablok
- Department of Gynecology, Obstetrics and Oncological Gynecology, Bytom, Medical University of Silesia, 41-902 Katowice, Poland
| | - Iwona Maruniak-Chudek
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Katarzyna Olszak-Wąsik
- Department of Gynecology, Obstetrics and Oncological Gynecology, Bytom, Medical University of Silesia, 41-902 Katowice, Poland
| | - Agnieszka Pastuszka
- Department of Gynecology, Obstetrics and Oncological Gynecology, Bytom, Medical University of Silesia, 41-902 Katowice, Poland
- Department of Pediatric Surgery and Urology Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
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10
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Fetoscopic Myelomeningocele Repair with Complete Release of the Tethered Spinal Cord Using a Three-Port Technique: Twelve-Month Follow-Up-A Case Report. Diagnostics (Basel) 2022; 12:diagnostics12122978. [PMID: 36552985 PMCID: PMC9776674 DOI: 10.3390/diagnostics12122978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/29/2022] Open
Abstract
Open spina bifida is one of the most common congenital defects of the central nervous system. Open fetal surgery, which is one of the available therapeutic options, remains the gold standard for prenatal repairs. Fetoscopic closure may lower the number of maternal complications associated with open fetal surgery. Regardless of the approach, the outcome may be compromised by the development of tethered spinal cord (TSC) syndrome. At 24.2 weeks of gestation, a primipara was admitted due to fetal myelomeningocele and was deemed eligible for fetoscopic repair. Fetal surgery was performed at 25.0 weeks of gestation. It was the first complete untethering of the spinal cord and anatomic reconstruction (dura mater, spinal erectors, skin) achieved during a fetoscopic repair of spina bifida. Cesarean section due to placental abruption was performed at 31.1 weeks of gestation. VP shunting, with no need for revision, was performed at 5 weeks postdelivery due to progressing ventriculomegaly. No clinical or radiological signs of secondary tethering were observed. Neurological examination at 11 months postdelivery revealed cranial nerves without any signs of damage, axial hypotonia, decreased muscle tone in the lower extremities, and absent pathological reflexes. Motor development was slightly retarded. Complete untethering of the neural structures should always be performed, regardless of the surgical approach, as it is the only course of action that lowers the risk for developing secondary TSC.
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11
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Fairchild B, Cepeda A, Maiorino E, Shah MN, Sandberg DI, Fletcher SA, Nguyen PD, Greives MR. Back to the Beginning: An Algorithmic Approach to Neonatal Myelomeningocele Repair. Ann Plast Surg 2022; 89:82-88. [PMID: 34864746 DOI: 10.1097/sap.0000000000003043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Myelomeningoceles are formed by prenatal failure of neural tube closure and can cause hydrocephalus, motor abnormalities, and developmental delay. Although small defects are amenable to primary closure, larger defects often require complex reconstruction. Our goal was to identify factors associated with postoperative soft tissue complications and develop a systematic approach for myelomeningocele closure. METHODS A retrospective review was performed at the Children's Memorial Hermann Hospital from January 2013 to January 2019. Patients were identified using International Classification of Diseases, Ninth Revision/Tenth Revision , codes for myelomeningocele. Cohorts were stratified by reconstruction type and defect location. Primary outcomes were incidence of complications including cerebrospinal fluid leak, superficial and deep infection, and wound dehiscence. In addition, we developed an algorithm to standardize closure approach for patients with myelomeningoceles. RESULTS A total of 172 patients with myelomeningocele were identified with 73 patients undergoing postnatal repair. Overall, 72% of defects were >5 cm. Defects were in the lumbar (9%), sacral (8%), and junctional (83%) regions. Overall, 30.1% patients underwent lumbar myofascial repair with 39.7% requiring fasciocutaneous flaps. Larger defects (>5 cm) were more likely to be closed with complex fasciocutaneous flaps (82.8% vs 66.0%, P = 0.11). No significant differences were observed in complication rates. CONCLUSIONS In this series, patients with larger myelomeningoceles appear to benefit from complex flap closure. We propose a 5-layer closure for patients with myelomeningocele including the routine use of a myofascial layer. Cutaneous closure technique should be tailored based on specific defect characteristics as outlined in our algorithm. This approach streamlines myelomeningocele repair while optimizing outcomes and decreasing downstream complications.
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Affiliation(s)
- Berry Fairchild
- From the Division of Plastic Surgery, Department of Surgery, and Division of Pediatric Neurosurgery, Department Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX
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12
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Closure of a large lumbosacral myelomeningocele defect with a human pericardial graft: a case report. Childs Nerv Syst 2022; 38:851-854. [PMID: 34143293 DOI: 10.1007/s00381-021-05262-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/18/2021] [Indexed: 11/27/2022]
Abstract
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.
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13
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Hart AR, Vasudevan C, Griffiths PD, Foulds N, Piercy H, de Lacy P, Boxall S, Howe D, Vollmer B. Antenatal counselling for prospective parents whose fetus has a neurological anomaly: part 2, risks of adverse outcome in common anomalies. Dev Med Child Neurol 2022; 64:23-39. [PMID: 34482539 DOI: 10.1111/dmcn.15043] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 07/31/2021] [Accepted: 08/02/2021] [Indexed: 12/14/2022]
Abstract
After diagnosis of a fetal neurological anomaly, prospective parents want to know the best and worst-case scenarios and an estimation of the risk to their infant of having an atypical developmental outcome. The literature on developmental outcomes for fetal neurological anomalies is poor: studies are characterized by retrospective design, small sample size, often no standardized assessment of development, and differing definitions of anomalies. This review provides an aide-memoir on the risks of adverse neurodevelopmental outcome for ventriculomegaly, cortical anomalies, microcephaly, macrocephaly, agenesis of the corpus callosum, posterior fossa anomalies, and myelomeningocele, to assist healthcare professionals in counselling. The data in this review should be used alongside recommendations on counselling and service design described in part 1 to provide antenatal counselling.
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Affiliation(s)
- Anthony R Hart
- Department of Perinatal and Paediatric Neurology, Sheffield Children's NHS Foundation Trust, Ryegate Children's Centre, Sheffield, UK
| | - Chakra Vasudevan
- Department of Neonatology, Bradford Royal Infirmary, Bradford, UK
| | - Paul D Griffiths
- Academic Unit of Radiology, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Nicola Foulds
- Department of Clinical Genetics, Princess Anne Hospital, University Southampton NHS Foundation Trust, Southampton, UK
| | - Hilary Piercy
- The Centre for Health and Social Care, Sheffield Hallam University, Sheffield, UK
| | - Patricia de Lacy
- Department of Paediatric Neuosurgery, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Sally Boxall
- Wessex Fetal Medicine Unit, Princess Anne Hospital, Southampton, UK
| | - David Howe
- Wessex Fetal Medicine Unit, Princess Anne Hospital, Southampton, UK
| | - Brigitte Vollmer
- Clinical and Experimental Sciences, Faculty of Medicine, Paediatric and Neonatal Neurology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK
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14
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Paslaru FG, Panaitescu AM, Iancu G, Veduta A, Gica N, Paslaru AC, Gheorghiu A, Peltecu G, Gorgan RM. Myelomeningocele Surgery over the 10 Years Following the MOMS Trial: A Systematic Review of Outcomes in Prenatal versus Postnatal Surgical Repair. ACTA ACUST UNITED AC 2021; 57:medicina57070707. [PMID: 34356988 PMCID: PMC8307221 DOI: 10.3390/medicina57070707] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 12/04/2022]
Abstract
Background and Objectives: Myelomeningocele is the most severe form of spina bifida, a congenital neural tube defect arising from an incomplete neural tube closure during early development with damage worsening with advancing gestational age. The Management of Myelomeningocele Study (MOMS) Trial proved that surgery performed before 26 weeks of gestation significantly improved the prognosis, significantly changing treatment paradigms. This article aims to provide a review of the changes and updates in spina bifida repair over the 10-year period following the MOMS Trial. Material and methods: We performed a systematic review in the PubMed and Cochrane databases as well as a hand-search of high-impact journals using the reference list of all identified articles, searching for randomized controlled trials and observational studies. Results: We identified 27 articles published between 2011 and 2021 that fulfilled the inclusion criteria and review them in the present study. Conclusions: With growing experience and with the improvement of prenatal open and fetoscopic techniques, the outcome of SB-associated conditions could be improved and the risks to both the mother and the fetus reduced. A continuous follow-up of the treated infants and further randomized trials are essential to study the complications and advantages or disadvantages of any given treatment strategy.
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Affiliation(s)
- Francesca Gabriela Paslaru
- Neurosurgical Department, “Bagdasar-Arseni” Clinical Emergency Hospital, 041915 Bucharest, Romania; (F.G.P.); (A.G.); (R.M.G.)
- Neurosurgery Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Anca Maria Panaitescu
- Filantropia Clinical Hospital, 11171 Bucharest, Romania; (G.I.); (A.V.); (N.G.); (G.P.)
- Obstetrics and Gynecology Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence: ; Tel.: +40-23188930
| | - George Iancu
- Filantropia Clinical Hospital, 11171 Bucharest, Romania; (G.I.); (A.V.); (N.G.); (G.P.)
- Obstetrics and Gynecology Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Alina Veduta
- Filantropia Clinical Hospital, 11171 Bucharest, Romania; (G.I.); (A.V.); (N.G.); (G.P.)
| | - Nicolae Gica
- Filantropia Clinical Hospital, 11171 Bucharest, Romania; (G.I.); (A.V.); (N.G.); (G.P.)
- Obstetrics and Gynecology Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Alexandru Catalin Paslaru
- Physiology Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Anamaria Gheorghiu
- Neurosurgical Department, “Bagdasar-Arseni” Clinical Emergency Hospital, 041915 Bucharest, Romania; (F.G.P.); (A.G.); (R.M.G.)
| | - Gheorghe Peltecu
- Filantropia Clinical Hospital, 11171 Bucharest, Romania; (G.I.); (A.V.); (N.G.); (G.P.)
- Obstetrics and Gynecology Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Radu Mircea Gorgan
- Neurosurgical Department, “Bagdasar-Arseni” Clinical Emergency Hospital, 041915 Bucharest, Romania; (F.G.P.); (A.G.); (R.M.G.)
- Neurosurgery Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
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15
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Yuan W, Stevenson CB, Altaye M, Jones BV, Leach J, Lovha M, Rennert N, Mangano FT. Diffusion tensor imaging in children following prenatal myelomeningocele repair and its predictive value for the need and timing of subsequent CSF diversion surgery for hydrocephalus. J Neurosurg Pediatr 2021; 27:391-399. [PMID: 33545679 DOI: 10.3171/2020.9.peds20570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to investigate diffusion tensor imaging (DTI), an objective and noninvasive neuroimaging technique, for its potential as an imaging biomarker to predict the need and timing of CSF diversion surgery in patients after prenatal myelomeningocele (MMC) repair. METHODS This was a retrospective analysis of data based on 35 pediatric patients after prenatal MMC repair (gestational age at birth 32.68 ± 3.42 weeks, range 24-38 weeks; 15 females and 20 males). A logistic regression analysis was used to classify patients to determine the need for CSF diversion surgery. The model performance was compared between using the frontooccipital horn ratio (FOHR) alone and using the FOHR combined with DTI values (the genu of the corpus callosum [gCC] and the posterior limb of the internal capsule [PLIC]). For patients who needed to be treated surgically, timing of the procedure was used as the clinical outcome to test the predictive value of DTI acquired prior to surgery based on a linear regression analysis. RESULTS Significantly lower fractional anisotropy (FA) values in the gCC (p = 0.014) and PLIC (p = 0.037) and higher mean diffusivity (MD) values in the gCC (p = 0.013) were found in patients who required CSF diversion surgery compared with those who did not require surgery (all p values adjusted for age). Based on the logistic regression analysis, the FOHR alone showed an accuracy of performance of 0.69 and area under the receiver operating characteristic curve (AUC) of 0.60. The performance of the model was higher when DTI measures were used in the logistic regression model (accuracy = 0.77, AUC = 0.84 for using DTI values in gCC; accuracy = 0.75, AUC = 0.84 for using DTI values in PLIC). Combining the DTI values of the gCC or PLIC and FOHR did not improve the model performance when compared with using the DTI values alone. In patients who needed CSF diversion surgery, significant correlation was found between DTI values in the gCC and the time interval between imaging and surgery (FA: ρ = 0.625, p = 0.022; MD: ρ = -0.6830, p = 0.010; both adjusted for age and FOHR). CONCLUSIONS The authors' data demonstrated that DTI could potentially serve as an objective biomarker differentiating patients after prenatal MMC repair regarding those who may require surgery for MMC-associated hydrocephalus. The predictive value for the need and timing of CSF diversion surgery is highly clinically relevant for improving and optimizing decision-making for the treatment of hydrocephalus in this patient population.
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Affiliation(s)
- Weihong Yuan
- 1Pediatric Neuroimaging Research Consortium, Radiology, and.,5University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Charles B Stevenson
- Divisions of2Pediatric Neurosurgery.,5University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mekibib Altaye
- 3Biostatistics and Epidemiology, and.,5University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Blaise V Jones
- 4Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati.,5University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James Leach
- 4Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati.,5University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Noa Rennert
- 7Department of Neurosurgery, Sheba Medical Center, Ramat-Gan, Israel
| | - Francesco T Mangano
- Divisions of2Pediatric Neurosurgery.,5University of Cincinnati College of Medicine, Cincinnati, Ohio
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16
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Soon WC, Das JM, Baig A, Gallo P, Rodrigues D, Lo WB. Atlantoaxial limited dorsal myeloschisis: A report of two cases and review of literature. BRAIN AND SPINE 2021; 1:100298. [PMID: 36247398 PMCID: PMC9560655 DOI: 10.1016/j.bas.2021.100298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/29/2021] [Accepted: 09/13/2021] [Indexed: 11/05/2022]
Abstract
Introduction Limited dorsal myeloschisis (LDM) is a rare form of spinal dysraphism that is characterised by a distinctive fibroneural stalk connecting the spinal cord to the overlying skin lesion. The skin lesions associated with LDM can appear benign clinically and careful evaluation with an MRI scan is essential for diagnosing LDM and to differentiate this entity from other forms of spinal dysraphism and benign causes of skin lesions. Research question There is a lack of reported atlantoaxial LDM in the literature. We sought to report the clinical presentation, radiological features and surgical management of the first two reported atlantoaxial LDM. Material and methods Clinical findings and radiological images of the two cases of atlantoaxial LDM that underwent surgical intervention at our institution were retrieved from the medical notes, operative records and imaging system. Results Both cases of atlantoaxial LDM (C0-1 and C1-2 respectively) underwent successful resection of the overlying cutaneous lesions and stalks to release the tethered spinal cords. Discussion The surgical management of LDM have been associated with good outcomes and consists of resecting the fibroneural stalk close to the underlying cord, releasing the tethered spinal cord and removing the overlying cutaneous lesion. Conclusion These are the first two reported cases of atlantoaxial LDM in the literature. We aim to raise awareness of this pathological entity and highlight the importance of establishing the correct diagnosis to guide definitive management, and report the favourable neurological outcome in these cases despite the rostral location. Limited dorsal myeloschisis is a rare form of closed spinal dysraphism. These are the first two reported cases of atlantoaxial limited dorsal myeloschisis. Favourable surgical outcomes can be achieved despite the rostral location. Dorsal midline cutaneous lesions should be investigated further with MRI scan. The fibroneural stalk connects the overlying cutaneous lesion to the spinal cord.
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17
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Schnitzler ER, Schneck MJ. Therapeutic Pitfalls in the Transition of Neurologic Patients from Pediatric to Adult Health Care Providers. Neurol Clin 2020; 39:243-256. [PMID: 33223087 DOI: 10.1016/j.ncl.2020.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Transitions of care from the pediatric to adult setting are fraught with difficulty. For patients whose neurologic problems began in childhood, there is often a lack of organized multidisciplinary care with the desired neurologic expertise in the adult setting. This monograph highlights those difficulties, reviewing disease-specific instances of the problems with transition from pediatric to adult neurologic care. The use of an arbitrary chronologic age cutoff for transition from pediatric to adult expertise in specific disease state may be a disservice in provision of care, and the disease-specific expertise of providers may outweigh the benefit of an age-related provider focus.
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Affiliation(s)
- Eugene R Schnitzler
- Department of Neurology, Division of Pediatric Neurology, Loyola University Chicago, Stritch School of Medicine, Maguire Building Suite 2700, 2160 South First Avenue, Maywood, IL 60153, USA; Department of Pediatrics, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
| | - Michael J Schneck
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA; Department of Neurosurgery, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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