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Talamonti G. Reflections upon the intrauterine repair of myelomeningocele. Childs Nerv Syst 2024; 40:1571-1575. [PMID: 38514517 DOI: 10.1007/s00381-024-06365-0] [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: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
The intrauterine repair of myelomeningocele presents certain advantages and has gained widespread acceptance. It significantly reduces the incidence of Chiari-2 anomalies and hydrocephalus, and it is thought to enhance the neurologic outcome. Nevertheless, several issues remain unsettled and there are no negligible disadvantages. After working with patients with myelomeningocele for 30 years, I thought about how we currently treat them. There are ethical, organizational, neurological, obstetrical, and postnatal aspects worth discussing.
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Affiliation(s)
- Giuseppe Talamonti
- Dep. of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
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2
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Marcati E, Meccariello G, Mastino L, Picano M, Giorgi PD, Talamonti G. Myelomeningocele: Long-Term Neurosurgical Management. Adv Tech Stand Neurosurg 2024; 49:95-122. [PMID: 38700682 DOI: 10.1007/978-3-031-42398-7_6] [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: 06/01/2024]
Abstract
Open spina bifida, also known as myelomeningocele (MMC), is the most challenging and severe birth defect of the central nervous system compatible with life and it is due to a failure in the dorsal fusion of the nascent neural tube during embryonic development. MMC is often accompanied by a constellation of collateral conditions, including hydrocephalus, Arnold - Chiari II malformation, brainstem disfunction, hydrosyringomyelia, tethered cord syndrome and scoliosis. Beyond early surgical repair of the dorsal defect, MMC requires lifelong cares. Several additional surgical procedures are generally necessary to improve the long-term outcomes of patients affected by MMC and multidisciplinary evaluations are crucial for early identification and management of the various medical condition that can accompany this pathology. In this chapter, the most common pathological entities associated with MMC are illustrated, focusing on clinical manifestations, treatment strategies and follow up recommendations.
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Affiliation(s)
- E Marcati
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy
| | - G Meccariello
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy
| | - L Mastino
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy
| | - M Picano
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy
| | - P D Giorgi
- Department of Orthopedics, ASST Niguarda Hospital, Milan, Italy
| | - G Talamonti
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy
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Khalil M, Bakhshi SK, Shah Z, Urooj F, Golani S, Musood H, Zahid N, Dewan MC, Shamim MS. Quality of life in children operated for spina bifida; low- and middle-income country perspective. Childs Nerv Syst 2023; 39:3155-3161. [PMID: 37198450 DOI: 10.1007/s00381-023-05993-2] [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: 09/27/2022] [Accepted: 05/11/2023] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Spina bifida is a potentially disabling congenital condition and affects the quality of life (QOL). We aimed to assess clinical outcomes and QOL in children who underwent spina bifida repair at our hospital. METHODS This was a retrospective cohort study on children who underwent spina bifida repair at our hospital over 10 years. Phone calls were made to parents of the children, and the Health Utility Index Mark 3 (HUI 3) score was used to assess QoL, and degree of disability. Demographics and clinical data were obtained from the medical chart review. Statistical analysis was done using SPSS (version 21). RESULTS Eighty children with a median age of 1.1 months (IQR 0.03-2.0) at the time of presentation, were included in this study. The mean follow-up period was 6.04 ± 2.54 years and the median HUI-3 score was 0.64 (IQR: 0.40 - 0.96) on a scale of 0 (dead) to 1 (perfectly healthy). Based on the severity of disability, 12 (23.1%) children had mild disability, 4 (7.7%) had moderate disability, and 23 (44.2%) had severe disability. Factors including a leaking spina bifida and paraplegia at presentation; radiological findings of hydrocephalus and Chiari malformation, were associated with a significantly low QOL. Children who required CSF diversion (EVD/ VP shunt) during the repair or at a later stage also had significantly low QOL. CONCLUSION In LMIC, children with myelomeningocele (MMC) born with lower limb weakness, hydrocephalus, Chiari malformation, and those presenting with leaking MMC, have a significantly low QoL at a mean follow-up of 6 years.
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Affiliation(s)
- Mujtaba Khalil
- Dean's Clinical Research Program, Aga Khan University, Karachi, Pakistan
| | - Saqib Kamran Bakhshi
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, 74800, Karachi, Pakistan
| | - Zara Shah
- Dean's Clinical Research Program, Aga Khan University, Karachi, Pakistan
| | | | | | - Hassaan Musood
- Dean's Clinical Research Program, Aga Khan University, Karachi, Pakistan
| | - Nida Zahid
- Department of Surgery, Aga Khan University, Karachi, Pakistan
| | | | - Muhammad Shahzad Shamim
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, 74800, Karachi, Pakistan.
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4
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Advances in Fetal Surgical Repair of Open Spina Bifida. Obstet Gynecol 2023; 141:505-521. [PMID: 36735401 DOI: 10.1097/aog.0000000000005074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/03/2022] [Indexed: 02/04/2023]
Abstract
Spina bifida remains a common congenital anomaly of the central nervous system despite national fortification of foods with folic acid, with a prevalence of 2-4 per 10,000 live births. Prenatal screening for the early detection of this condition provides patients with the opportunity to consider various management options during pregnancy. Prenatal repair of open spina bifida, traditionally performed by the open maternal-fetal surgical approach through hysterotomy, has been shown to improve outcomes for the child, including decreased need for cerebrospinal fluid diversion surgery and improved lower neuromotor function. However, the open maternal-fetal surgical approach is associated with relatively increased risk for the patient and the overall pregnancy, as well as future pregnancies. Recent advances in minimally invasive prenatal repair of open spina bifida through fetoscopy have shown similar benefits for the child but relatively improved outcomes for the pregnant patient and future childbearing.
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Thompson DNP, De Vloo P, Deprest J. Fetal Surgery for Myelomeningocele: Neurosurgical Perspectives. Adv Tech Stand Neurosurg 2023; 47:25-48. [PMID: 37640871 DOI: 10.1007/978-3-031-34981-2_2] [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] [Indexed: 08/31/2023]
Abstract
More than 30 years have elapsed since it was recognised that folic acid supplementation could substantially reduce the risk of open neural tube defects (ONTDs). During that time, many countries have adopted policies of food fortification with demonstrable reduction in the incidence of both cranial and spinal ONTDs. Improved prenatal detection and termination has also resulted in a reduction in the number of affected live births. Nonetheless, in the USA about 1500 children, and in the UK around 500 children are born each year with myelomeningocele (MMC) and so the management of MMC and its complications continues to constitute a significant clinical workload for many paediatric neurosurgical units around the world.Until recently, the options available following antenatal diagnosis of MMC were termination of pregnancy or postnatal repair. As a result of the MOMS trial, prenatal repair has become an additional option in selected cases (Adzick et al., N Engl J Med 364(11):993-1004, 2011). Fetal surgery for myelomeningocele is now offered in more than 30 centres worldwide. The aim of this chapter is to review the experimental basis of prenatal repair of MMC, to critically evaluate the neurosurgical implications of this intervention and to describe the technique of 'open' repair, comparing this with emerging minimally invasive alternatives.
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Affiliation(s)
- Dominic N P Thompson
- Department of Pediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK.
| | | | - Jan Deprest
- Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
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Shlobin NA, Yerkes EB, Swaroop VT, Lam S, McLone DG, Bowman RM. Multidisciplinary spina bifida clinic: the Chicago experience. Childs Nerv Syst 2022; 38:1675-1681. [PMID: 35870009 DOI: 10.1007/s00381-022-05594-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/23/2022] [Indexed: 11/03/2022]
Abstract
Open spina bifida (open SB) is the most complex congenital abnormality of the central nervous system compatible with long-term survival. Multidisciplinary care is required to address the effect of this disease on the neurological, musculoskeletal, genitourinary, and gastrointestinal systems, as well as the complex psychosocial impact on the developing child. Individuals with SB benefit from the involvement of neurosurgeons, orthopedic surgeons, urologists, physical medicine and rehabilitation specialists, pediatricians, psychologists, physical/occupational/speech therapists, social workers, nurse coordinators, and other personnel. Multidisciplinary clinics are the gold standard for coordinated, optimal medical and surgical care. Ann and Robert H. Lurie Children's Hospital, formerly known as Children's Memorial Hospital, was one of the first hospitals in the USA to manage patients with this complex disease in a multidisciplinary manner. We describe the longitudinal experience of the multidisciplinary Spina Bifida Center at our institution and highlight the advances that have arisen from this care model over time. This clinic serves as an exemplar of organized, effective, and patient-centered approach to the comprehensive care of people living with open SB.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elizabeth B Yerkes
- Department of Urology, Division of Pediatric Urology, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vineeta T Swaroop
- Department of Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sandi Lam
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David G McLone
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robin M Bowman
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Omar AT, Espiritu AI, Spears J. Endoscopic third ventriculostomy with or without choroid plexus coagulation for myelomeningocele-associated hydrocephalus: systematic review and meta-analysis. J Neurosurg Pediatr 2022; 29:435-443. [PMID: 35061994 DOI: 10.3171/2021.11.peds21505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While ventriculoperitoneal shunt (VPS) insertion is the standard treatment for myelomeningocele-associated hydrocephalus (MAH), it can be complicated by infection and shunt malfunction. As such, endoscopic third ventriculostomy (ETV), with or without choroid plexus coagulation (CPC), has been proposed as an alternative. The aim of this review was to determine the success, technical failure, and complication rates of ETV with or without CPC in patients with MAH. METHODS PubMed, Scopus, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 2020 for case series, cohort studies, or randomized controlled trials reporting success, technical failure, or complication rates. Random-effects analysis was performed to determine the estimates for these outcome measures. Studies were evaluated using the Newcastle-Ottawa Scale for quality and risk of bias. RESULTS Thirteen studies with a total of 325 patients who underwent either ETV or ETV+CPC were included in the review. Using random-effects modeling, the pooled estimate of the success rate was 56% (95% CI 44%-68%, I2 = 78%), while the technical failure rate was 2% (95% CI 0%-6%, I2 = 32%). The estimate for the success rate had high heterogeneity, due to the type of surgical intervention (ETV vs ETV+CPC, p < 0.001). Random-effects analysis of 9 studies with 117 patients who underwent ETV alone yielded an estimated success rate of 48% (95% CI 0.39-0.57, I2 = 0%), while analysis of 4 studies with 166 patients who underwent ETV+CPC revealed a success rate of 75% (95% CI 67%-82%, I2 = 21%). The estimates for the mild/moderate, severe, and fatal complication rates were 0 (95% CI 0%-4%, I2 = 0%), 2% (95% CI 0%-10%, I2 = 52%), and 0 (95% CI 0%-1%, I2 = 0%), respectively. CONCLUSIONS ETV+CPC was associated with a higher success rate than ETV alone for MAH in a meta-analysis of published studies. ETV, with or without CPC, was technically feasible and safe for this patient population.
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Affiliation(s)
- Abdelsimar T Omar
- 1Division of Neurosurgery, Department of Surgery, University of Toronto.,2Division of Neurosurgery, St. Michael's Hospital, Toronto.,3Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila
| | - Adrian I Espiritu
- 4Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila; and.,5Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Philippines.,6Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Julian Spears
- 1Division of Neurosurgery, Department of Surgery, University of Toronto.,2Division of Neurosurgery, St. Michael's Hospital, Toronto
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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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9
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Licci M, Zaed I, Beuriat PA, Szathmari A, Guibaud L, Mottolese C, Di Rocco F. CSF shunting in myelomeningocele-related hydrocephalus and the role of prenatal imaging. Childs Nerv Syst 2021; 37:3417-3428. [PMID: 34076708 DOI: 10.1007/s00381-021-05217-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/13/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Hydrocephalus is commonly associated with myelomeningocele (MMC). Indication and timing of cerebrospinal fluid (CSF) shunting are still a topic of discussion. The aim of this study was to investigate whether the analysis of prenatal cerebral imaging studies could provide information that is predictive of the necessity of CSF shunting in the postnatal period. MATERIAL AND METHODS Among 73 infants operated on because of MMC between January 2003 and June 2020, 50 had undergone prenatal and postnatal MRI studies and were considered for analysis. For each patient, frontal horn width, atrial ventricle diameter, third ventricle diameter, and subarachnoid spaces (sinocortical width, craniocortical width, and the interhemispheric width) have been measured on prenatal, postnatal, and a follow-up MRI study. The need of CSF shunting device placement in relation to prenatal and early postnatal MRI data was investigated. RESULTS Of the 50 infants, 31 (62%) developed a progressive hydrocephalus. Of these, 30 needed a CSF shunt and the majority of them (n=29) was operated on within 28 days after birth. One patient needed CSF shunt implantation at 45 days after birth and one child developed a late progressive hydrocephalus, successfully treated by ETV alone, at 14.2 months of age. All patients with an atrial ventricle diameter greater than 1.9 cm and a 3rd ventricle diameter larger than 0.3 cm on antenatal third trimester imaging have undergone CSF shunting within 1 month after birth. Conversely, all the children that did not undergo a CSF shunt placement showed an atrial cerebral ventricle diameter inferior to 1.2 cm and a 3rd ventricle width < 0.3 cm on antenatal imaging. Frontal horn width and subarachnoid CSF spaces' evolution did not seem to play a role. CONCLUSION The prenatal MRI assessment of the associated prenatal ventriculomegaly in MMC provides parameters that have a predictive value heralding the probability of a CSF diversion procedure after birth. In the same way, the analysis of intrauterine MRI studies may identify those subjects that are less at risk of developing a progressive hydrocephalus after birth, therefore encouraging a more cautious attitude towards the early implantation of CSF shunting devices in the current clinical practice.
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Affiliation(s)
- Maria Licci
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France
| | - Ismail Zaed
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France
| | - Pierre-Aurélien Beuriat
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France
| | - Alexandru Szathmari
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France.,Department of Pediatric Radiology, Hôpital Femme Mère-Enfant, Hospices civils de Lyon, 69003, Lyon, France
| | - Laurent Guibaud
- Department of Pediatric Radiology, Hôpital Femme Mère-Enfant, Hospices civils de Lyon, 69003, Lyon, France
| | - Carmine Mottolese
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France.,Department of Pediatric Radiology, Hôpital Femme Mère-Enfant, Hospices civils de Lyon, 69003, Lyon, France
| | - Federico Di Rocco
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France.
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WORLEY GORDON, GREENBERG RACHELG, ROCQUE BRANDONG, LIU TIEBIN, DICIANNO BRADE, CASTILLO JONATHANP, WARD ELISABETHA, WILLIAMS TONYAR, BLOUNT JEFFREYP, WIENER JOHNS. Neurosurgical procedures for children with myelomeningocele after fetal or postnatal surgery: a comparative effectiveness study. Dev Med Child Neurol 2021; 63:1294-1301. [PMID: 33386749 PMCID: PMC8603138 DOI: 10.1111/dmcn.14792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2020] [Indexed: 12/17/2022]
Abstract
AIM To compare the frequencies of neurosurgical procedures to treat comorbid conditions of myelomeningocele in patients who underwent fetal surgery versus postnatal surgery for closure of the placode. METHOD By utilizing the National Spina Bifida Patient Registry in a comparative effectiveness study, 298 fetal surgery patients were matched by birthdate (±3mo) and spina bifida clinic site with one to three postnatal surgery patients (n=648). Histories were obtained by record review on enrollment and yearly subsequently. Multivariable Poisson regression was used to compare frequencies of procedures between cohorts, with adjustments for sex, ethnicity, insurance status, spinal segmental level of motor function, age at last visit recorded in the Registry, and, for shunt revision in shunted patients, age at cerebrospinal fluid (CSF) diversion. RESULTS The median age at last visit was 4 years. In fully adjusted analyses in patients aged at least 12 months old, fetal surgery was associated with decreased frequency of CSF diversion for hydrocephalus by ventriculoperitoneal shunt insertion or endoscopic third ventriculostomy compared with postnatal surgery (46% vs 79%; incidence rate ratio=0.61; 95% confidence interval [CI] 0.53-0.71; p<0.01). Over all ages, fetal surgery was associated with decreased frequency of Chiari decompression for brainstem dysfunction (3% vs 7%; incidence rate ratio=0.41; 95% CI 0.19-0.88; p=0.02). Also over all ages, differences were not significant in frequencies of shunt revision in shunted patients (53% vs 55%; incidence rate ratio=0.87; 95% CI 0.69-1.11; p=0.27), nor tethered cord release for acquired spinal cord dysfunction (18% vs 16%; incidence rate ratio=1.11; 95% CI 0.84-1.47; p=0.46). INTERPRETATION Even with the variations inherent in clinical practice, fetal surgery was associated with lower frequencies of CSF diversion and of Chiari decompression, independent of covariates. What this paper adds Fetal surgery was associated with lower frequencies of cerebrospinal fluid diversion and decompression of Chiari II malformation than postnatal surgery. Frequencies of ventriculoperitoneal shunt revision and tethered cord release were not significantly different between cohorts.
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Affiliation(s)
- GORDON WORLEY
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - RACHEL G GREENBERG
- Division of Neonatology, Department of Pediatrics, Duke University Medical Center, Durham, NC;,Duke Clinical Research Institute, Durham, NC
| | - BRANDON G ROCQUE
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Children’s Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL
| | - TIEBIN LIU
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - BRAD E DICIANNO
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - JONATHAN P CASTILLO
- Division of Developmental Pediatrics, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - ELISABETH A WARD
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - TONYA R WILLIAMS
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - JEFFREY P BLOUNT
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Children’s Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL
| | - JOHN S WIENER
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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11
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Abstract
Hydrocephalus is the most important co-morbidity in myelomeningocele from a neurosurgical perspective. Historically, 75-80% of patients with myelomeningocele have required treatment with a shunt but recent advances including intra-uterine myelomeningocele closure and ETV-CPC are reducing this burden. The expression of hydrocephalus differs between patients and across the life span. Hydrocephalus impacts the clinical expression of other important co-morbidities including the Chiari II malformation and tethered spinal cord. Shunt failure is often the key stress to prompt symptomatic worsening of these other conditions. Shunt failure may occur with minimal ventricular change on CT or MRI in Spina Bifida patients. Waiting for radiographic changes in symptomatic SB patients with shunts may result in hydrocephalus related fatalities. It is hypothesized but not proven that shunt failure may contribute to respiratory insufficiency and be a risk factor for sudden death in adult patients with spina bifida. Excellence in hydrocephalus management in MMC is essential for proper care, good outcomes, and quality of life for patients and families.
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Affiliation(s)
- Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Al. USA 35233, USA
| | - Pedram Maleknia
- UAB School of Medicine, University of Alabama at Birmingham, Birmingham, Al. USA 35233, USA
| | - Betsy D Hopson
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Al. USA 35233, USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Al. USA 35233, USA
| | - W Jerry Oakes
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Al. USA 35233, USA
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12
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Postnatal Repair of Open Neural Tube Defects: A Single Center with 90-Month Interdisciplinary Follow-Up. J Clin Med 2021; 10:jcm10194510. [PMID: 34640534 PMCID: PMC8509614 DOI: 10.3390/jcm10194510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/23/2021] [Accepted: 09/28/2021] [Indexed: 11/30/2022] Open
Abstract
After publication of the Management of Myelomeningocele Study (MOMS) there is confusion regarding which treatment of open neural tube defects (NTD) is best. We report our results of postnatally repaired open NTDs born between 2007–2018 (n = 36) in critical reflection of the MOMS study. Neurosurgical, orthopedic, and urologic data were assessed. We also introduce a new entity: “status post prenatal repair”. FU ranged from 29 to 161 months (mean: 89.1 m) in 7 cases of myeloschisis and 24 myelomeningoceles in the final collective n = 31. The shunt rate was 41.9%, and the endoscopic third ventriculostomy rate was 16.1%. Hydrocephalus requiring treatment was not associated with the anatomical level, but with premature birth (p = 0.048). Myeloschisis was associated with shunt placement (p = 0.008). ROC analysis revealed birth <38.5th week predicts the necessity for hydrocephalus treatment (sensitivity: 89%; specificity: 77%; AUC= 0.71; p = 0.055). Eight (25.8%), patients are wheelchair-bound, 2 (6.5%) ambulate with a posterior walker, 10 (32.3%) with orthosis and 11 (35.5%) independently. One (3.2%) patient underwent detethering at 5.5 years. A total of three patients underwent five Chiari decompressions (9.6%). Further, nineteen orthopedic procedures were performed in nine patients (29.0%). A total of 17 (54.8%) patients self-catheterize, which was associated with an anatomical lesion at L3 or below (p = 0.032) and 23 (74.2%) take anticholinergic medication. In conclusion, shunt dependency is associated with myeloschisis, not with the anatomical defect level. Hydrocephalus treatment is associated with premature birth. In this postnatal cohort with significantly longer follow-up data than the MOMs study, the ambulation rate is better, the shunt rate lower and the secondary tethered cord rate better compared to the MOMS study.
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El Ghoul AMF, Hamdy Ashry A, El-Sissy MH, Lotfy IMI. Clinical and Radiological Predictors of Ventriculoperitoneal Shunt Insertion in Myelomeningocele Patients. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Myelomeningocele (MMC) is one of the most common developmental anomalies of the CNS. Many of these patients develop hydrocephalus (HCP). The rate of cerebrospinal fluid diversion in these patients varies significantly in literature, from 52% to 92%. MMC repair conventionally occurs in the post-natal period. With the technological advances in surgical practice and fetal surgeries, intra uterine MMC repair IUMR is adopted in some centers. Cerebrospinal fluid shunting has numerous complications, most notably shunt failure and shunt infection. Studies have suggested that patients with greater numbers of shunt revisions have poorer performance on neuropsychological testing. There is also good evidence to suggest that the IQs of patients with MMC who do not undergo shunt placement are higher than that of their shunt treated counterparts.
AIM: In this study, we are trying to identify strong clinical and radiological predictors for the need of ventriculoperitoneal (VP) shunt insertion in patients with MMC who underwent surgical repair and closure of the defect initially. This will decrease the overall rate of shunt placement in this group of patients through applying a strict policy adopting only shunt insertion for the desperately needing patient.
METHODS: Prospective clinical study conducted on 96 patients with MMC presented to Aboul Reish Pediatric Specialized Hospital, Cairo University. After confirming the diagnosis through clinical and radiological aids, patients are carefully examined, if HCP is evident clinically and radiologically a shunt is inserted together with MMC repair at the same session after excluding sepsis or cerebrospinal fluid (CSF) infection, (GROUP A). If there are no signs of increased ICP, MMC repair shall be done alone (GROUP B). Those patients shall be monitored carefully postoperatively and after discharge and shall be followed up regularly to early detect and promptly manage latent HCP. Multiple clinical and radiological indices were used throughout the follow-up period and statistical significance of each was measured.
RESULTS: Shunt placement was required in 45 (46.88%) of the 96 patients. Eighteen patients (18.75%) needed the shunt as soon as they presented to us (GROUP A), because they were having clinically active HCP. Twenty-seven (28.13%) patients were operated on by MMC repair initially without shunt placement because they did not have signs of increased ICP at the time of presentation. Yet, they developed latent HCP requiring shunt placement during the follow-up period (GROUP B2). Fifty-one patients of the study population (53.13%) underwent surgical repair of the MMC without the need of further VP insertion and they were followed up for 6 months period after the repair without developing latent HCP (GROUP B1). Patients of GROUP B were the study population susceptible for the development of latent HCP. Out of 78 patients in GROUP B, only 27 patients (34.62%) needed a VP shunt.
CONCLUSION: In our study, we found that the rate of shunt insertion in patients with MMC is lower than the previously reported rate in the literature. A more thorough evaluation of the patient’s post-operative need for a shunt is mandatory. We suggest that we could accept postoperative (after MMC repair) ventriculomegaly provided it does not mean any deterioration in the patient’s clinical or developmental state. We assume that reduction of shunt insertion rate will eventually reduce what has previously been an enormous burden for a significant proportion of children with MMC.
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14
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Abstract
BACKGROUND Myelomeningocele (MMC) is a congenital malformation that results from a failure in the process of neurulation. A multidisciplinary follow-up is required to manage and treat all associated sequelae. The aim of the study was to present the epidemiological data and the results of the multidisciplinary follow-up of children born in Slovenia with myelomeningocele (MMC) between 2007 and 2017. METHODS We presented a retrospective analysis of all children born in Slovenia with between 2007 and 2017. The multidisciplinary follow-up included neurosurgical, urological, neurological, endocrinological and orthopedic expertise. RESULTS Twenty children were treated in Slovenia for MMC from 2007 to 2017 (mean follow-up of 7.7 years). 9 MMC were thoracic, 2 higher lumbar, 5 lower lumbar and 4 sacral. Thirteen children needed a CSF shunt, 1 was treated with endoscopic ventriculostomy (ETV). Four children needed a craniocervical decompression and 2 needed a detethering procedure. 14 children had a neurogenic bladder and 17 referred bowel continence. Orthopedic correction of the lower limbs was required in 9 cases. 4 children had seizures, 10 had endocrinological deficits. Among 16 children attending school, 11 were inserted in special educational classes. CONCLUSIONS The prevalence of MMC in Slovenia between 2007 and 2017 was 1/10000 births. Our follow-up results are comparable with those of previous, larger studies and confirm the efficacy of treating hydrocephalus with ETV in selected cases and with CSF shunt only in cases of clearly increased intracranial pressure. By adopting this strategy, we reduced the CSF shunt rate to 65%.
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Affiliation(s)
- Peter Spazzapan
- Unit of Pediatric Neurosurgery, Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana, Slovenia -
| | - Tomaž Velnar
- Unit of Pediatric Neurosurgery, Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Shunt timing in meningomyelocele and clinical results: analysis of 80 cases. Childs Nerv Syst 2021; 37:107-113. [PMID: 32632579 DOI: 10.1007/s00381-020-04786-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Meningomyelocele is a serious pathology that requires immediate surgical treatment. Its management is difficult due to accompanying other pathologies and hydrocephalus. Shunt timing is still controversial. Therefore, this study retrospectively assessed 80 patients in order to improve the shunt timing and management of patients with meningomyelocele. METHODS A total of 80 patients were followed up for 18-48 (average, 23) months. Patients were analyzed for the following variables: delivery method and time, head circumference monitoring, shunt timing, complication rates of patients who underwent shunting, during the early or follow-up period, accompanying pathologies, size, and localization of lesion. RESULTS Patients including 46 males and 34 females have been operated. In 40% of patients, the accompanying pathology was determined. Approximately 85% of patients had hydrocephalus, and a ventriculoperitoneal shunt was placed on 36 symptomatic and 22 patients with hydrocephalus that developed during the follow-up. Differences in shunt-related and general complications were not significant between patients who underwent shunt placement during the same session and patients who underwent shunt placement during the follow-up. However, the incidence of cerebrospinal fluid fistula formation from the wound in patients who underwent shunt placement during the same session was significantly lower than those who underwent shunt placement during follow-up. CONCLUSIONS Immediate surgery (within the first 48 h) provides positive results, which is consistent with the existing literature. According to the logistic regression analysis, the placement of the meningomyelocele sac in the lumbosacral region is decisive in shunt insertion. Placing the shunt in the same session for patients with hydrocephalus and later for patients who developed hydrocephalus during the follow-up is recommended as a favorable treatment.
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Weaver KJ, McDowell MM, White MD, Tempel ZJ, Zwagerman NT, Deibert CP, Bonfield CM, Johnson S, Greene S. Comparison of Follow-Up Length-Matched Single-Center Myelomeningocele Postnatal Closure Cohort to the Management of Myelomeningocele Study (MOMS) Trial Results. Pediatr Neurosurg 2021; 56:229-238. [PMID: 33849030 DOI: 10.1159/000515038] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We sought to compare our large single-institution cohort of postnatal myelomeningocele closure to the 2 arms of the Management of Myelomeningocele Study (MOMS) trial at the designated trial time points, as well as assess outcomes at long-term follow-up among our postnatal cohort. METHODS A single-institutional retrospective review of myelomeningocele cases presenting from 1995 to 2015 at Children's Hospital of Pittsburgh was performed. We compared outcomes at 12 and 30 months to both arms of the MOMS trial and compared our cohort's outcomes at those designated time points to our long-term outcomes. Univariate statistical analysis was performed as appropriate. RESULTS One-hundred sixty-three patients were included in this study. All patients had at least 2-year follow-up, with a mean follow-up of 10 years (range 2-20 years). There was no difference in the overall distribution of anatomic level of defect. Compared to our cohort, the prenatal cohort had a higher rate of tethering at 12 months of age, 8 versus 1.8%. Conversely, the Chiari II decompression rate was higher in our cohort (10.4 vs. 1.0%). At 30 months, the prenatal cohort had a higher rate of independent ambulation, but our cohort demonstrated the highest rate of ambulation with or without assistive devices among the 3 groups. When comparing our cohort at these early time points to our long-term follow-up data, our cohort's ambulatory function decreased from 84 to 66%, and the rate of detethering surgery increased almost 10-fold. CONCLUSIONS This study demonstrated that overall ambulation and anatomic-functional level were significantly better among our large postnatal cohort, as well as having significantly fewer complications to both fetus and mother, when compared to the postnatal cohort of the MOMS trial. Our finding that ambulatory ability declined significantly with age in this patient population is worrisome for the long-term outcomes of the MOMS cohorts, especially given the high rates of cord tethering at early ages within the prenatal cohort. These findings suggest that the perceived benefits of prenatal closure over postnatal closure may not be as substantial as presented in the original trial, with the durability of results still remaining a concern.
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Affiliation(s)
- Kristin J Weaver
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Michael M McDowell
- Department of Neurosurgery, Children's Hospital of Pittsburgh University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael D White
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Nathan T Zwagerman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | | | - Stephen Johnson
- Department of Neurosurgery, Rutgers University, Newark, New Jersey, USA
| | - Stephanie Greene
- Department of Neurosurgery, Children's Hospital of Pittsburgh University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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17
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Khalatbari H, Perez FA, Lee A, Shaw DW. Rapid Magnetic Resonance Imaging of the Spine in Neonates with Spinal Dysraphism. World Neurosurg 2020; 144:e648-e659. [DOI: 10.1016/j.wneu.2020.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 11/29/2022]
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Endoscopic third ventriculostomy in patients with myelomeningocele after shunt failure. Childs Nerv Syst 2020; 36:3047-3052. [PMID: 32248278 DOI: 10.1007/s00381-020-04596-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 03/27/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Myelomeningocele (MMC) is the most frequent form of spina bifida. Moreover, 90% of patients with MMC have hydrocephalus and require shunt placement. However, shunt failure management in such patients typically involves several shunt revisions, increasing the risk for morbidity and mortality. In this study, we report our experience with endoscopic third ventriculostomy (ETV) in MMC patients with shunts in a Brazilian institution. METHODS Patients with MMC who presented with shunt failure and underwent ETV alone between January 1996 and December 2016 were included in this study. Patients who had undergone endoscopic choroid plexus cauterization (CPC) or had non-shunted MMC hydrocephalus were excluded. Various data related to the ETV procedure were collected for each patient, including features, operative characteristics, complications, and ETV success. The follow-up period for the patients was 6-12 months. ETV success scores (ETVSSs) were calculated retrospectively for each patient to compare the predicted success of the procedure with the actual success at 6 months after ETV. RESULTS Forty-three MMC patients with shunt failure were included in this study. Of them, 16 (37.2%) had a previous central nervous system (CNS) infection and 4 (9.3%) had complications. Two neuroendoscopies were interrupted, one because of anatomic impossibility due to thickening of the interthalamic adhesion, obliterating the floor of the third ventricle, and another because of intraoperative hemorrhage. One patient developed hyponatremia during the postoperative period, whereas another developed reversible paresis of the oculomotor nerve. The ETVSS predicted a success rate of 49.6% compared with the actual ETV success rate of 53.48% (23 patients) at 6 months. At 12 months, the actual success rate was 41.9% (18 patients). All patients survived the procedure. CONCLUSION Our findings indicate that ETV is an effective procedure for managing MMC-related hydrocephalus after shunt failure. The expertise of the neurosurgeon in neuroendoscopy procedures is often the deciding factor when choosing a management option. Accordingly, less experienced neurosurgeons should be warned of the risks of this procedure.
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Donepudi R, Brock C, Schulte S, Bundock E, Fletcher S, Johnson A, Papanna R, Chauhan S, Tsao K. Trend in ventricle size during pregnancy and its use for prediction of ventriculoperitoneal shunt in fetal open neural tube defect. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:678-683. [PMID: 31763720 DOI: 10.1002/uog.21928] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 11/03/2019] [Accepted: 11/14/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Fetal surgery for repair of open neural tube defect (ONTD) typically results in decreased need for a ventriculoperitoneal shunt (VPS). Our objectives were to determine the trend in ventricle size (VS) during pregnancy and whether VS and change in VS, as assessed by ultrasound, were predictive of the need for VPS in pregnancy with ONTD. METHODS This was a retrospective analysis of prospectively collected data of consecutive pregnancies with ONTD, evaluated in a single center from January 2012 to May 2018. Two groups were identified: the first consisted of pregnancies that underwent in-utero repair (IUR) and the second those that had postnatal repair (PNR). Penalized B splines were used to determine the trend in VS, across 2-week gestational-age (GA) epochs, between 24 and 36 weeks of gestation. VS at each GA epoch and the change in VS between each GA epoch were compared between the IUR and PNR groups. To determine whether VS at any GA was predictive of VPS, receiver-operating-characteristics (ROC) curves were used and the optimal cut-off at each GA epoch was identified. Univariate analysis and multiple logistic regression were used for further analysis. RESULTS ONTD was diagnosed in 110 fetuses, of whom 69 underwent IUR and 41 had PNR. Fetuses in the IUR group were more likely to have Chiari II malformation (100.0% vs 82.9%; P < 0.01), lower GA at delivery (34.9 ± 3.2 vs 37.1 ± 2.1 weeks; P < 0.01) and lower rates of VPS within the first year postpartum (36.2% vs 61.0%; P = 0.02) compared with the PNR group. In both groups, VS increased steadily with GA from the initial evaluation to delivery. In the IUR group, there was a significant change in VS between the 24 + 0 to 25 + 6-week and the 26 + 0 to 27 + 6-week epochs (2.3 (95% CI, 0.4-4.1) mm; P = 0.02). There was a positive trend in the change in VS at later GAs, but this was not significant. Although there was no significant change in VS in the PNR group before 30 weeks, there was a positive trend after that time. On multivariate analysis, each week of advancing GA was associated with a mean increase of 0.74 mm in VS (P < 0.0001) in both groups. VS was not associated with the level or type of lesion, but presence of Chiari II malformation was associated with a mean increase of 5.88 mm (P < 0.0001) in VS in both the IUR and PNR groups. VS was modestly predictive of need for VPS in both groups, with area under ROC curves between 0.68 and 0.76 at the different GA epochs. Change in VS between the first and last measurements was also modestly predictive of the need for VPS, with better performance in the PNR group. CONCLUSIONS VS increased with advancing GA in all fetuses with ONTD, although in the IUR group this increase occurred immediately after fetal surgery and in the PNR group it occurred after 30 weeks of gestation. In-utero surgery was associated with a decreased rate of VPS and was more predictive of need for VPS than was VS. Postnatal factors resulting in increased need for VPS in the PNR group need to be assessed further. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Donepudi
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - C Brock
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S Schulte
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - E Bundock
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S Fletcher
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Pediatric Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - A Johnson
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - R Papanna
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - K Tsao
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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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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21
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Riley JS, Antiel RM, Flake AW, Johnson MP, Rintoul NE, Lantos JD, Traynor MD, Adzick NS, Feudtner C, Heuer GG. Pediatric neurosurgeons' views regarding prenatal surgery for myelomeningocele and the management of hydrocephalus: a national survey. Neurosurg Focus 2020; 47:E8. [PMID: 31574481 DOI: 10.3171/2019.7.focus19406] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Management of Myelomeningocele Study (MOMS) compared prenatal with postnatal surgery for myelomeningocele (MMC). The present study sought to determine how MOMS influenced the clinical recommendations of pediatric neurosurgeons, how surgeons' risk tolerance affected their views, how their views compare to those of their colleagues in other specialties, and how their management of hydrocephalus compares to the guidelines used in the MOMS trial. METHODS A cross-sectional survey was sent to all 154 pediatric neurosurgeons in the American Society of Pediatric Neurosurgeons. The effect of surgeons' risk tolerance on opinions and counseling of prenatal closure was determined by using ordered logistic regression. RESULTS Compared to postnatal closure, 71% of responding pediatric neurosurgeons viewed prenatal closure as either "very favorable" or "somewhat favorable," and 51% reported being more likely to recommend prenatal surgery in light of MOMS. Compared to pediatric surgeons, neonatologists, and maternal-fetal medicine specialists, pediatric neurosurgeons viewed prenatal MMC repair less favorably (p < 0.001). Responders who believed the surgical risks were high were less likely to view prenatal surgery favorably and were also less likely to recommend prenatal surgery (p < 0.001). The management of hydrocephalus was variable, with 60% of responders using endoscopic third ventriculostomy in addition to ventriculoperitoneal shunts. CONCLUSIONS The majority of pediatric neurosurgeons have a favorable view of prenatal surgery for MMC following MOMS, although less so than in other specialties. The reported acceptability of surgical risks was strongly predictive of prenatal counseling. Variation in the management of hydrocephalus may impact outcomes following prenatal closure.
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Affiliation(s)
- John S Riley
- 1Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ryan M Antiel
- 2Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alan W Flake
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania.,4The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Pennsylvania
| | - Mark P Johnson
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania.,4The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Pennsylvania
| | - Natalie E Rintoul
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania.,4The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Pennsylvania
| | - John D Lantos
- 5Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri; and
| | | | - N Scott Adzick
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania.,4The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Pennsylvania
| | - Chris Feudtner
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania
| | - Gregory G Heuer
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania.,4The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Pennsylvania.,6Division of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
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22
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Tamber MS, Flannery AM, McClung-Smith C, Assassi N, Bauer DF, Beier AD, Blount JP, Durham SR, Klimo P, Nikas DC, Rehring P, Tyagi R, Mazzola CA. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Incidence of Shunt-Dependent Hydrocephalus in Infants With Myelomeningocele After Prenatal Versus Postnatal Repair. Neurosurgery 2020; 85:E405-E408. [PMID: 31418039 DOI: 10.1093/neuros/nyz262] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/11/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Myelomeningocele (MM) is a condition that is responsible for considerable morbidity in the pediatric population. A significant proportion of the morbidity related to MM is attributable to hydrocephalus and the surgical management thereof. Postnatal repair remains the most common form of treatment; however, increased rates of prenatal diagnosis, advances in fetal surgery, and a hypothesis that neural injury continues in utero until the MM defect is repaired have led to the development and evaluation of prenatal surgery as a means to improve outcomes in afflicted infants. OBJECTIVE The objective of this guideline is to systematically evaluate the literature to determine whether there is a difference in the proportion of patients who develop shunt-dependent hydrocephalus in infants who underwent prenatal MM repair compared to infants who had postnatal repair. METHODS The Guidelines Task Force developed search terms and strategies used to search PubMed and Embase for relevant literature published between 1966 and September 2016. Strict inclusion/exclusion criteria were used to screen abstracts and to develop a list of relevant articles for full-text review. Full-text articles were then reviewed, and when appropriate, included as evidence. RESULTS A total of 87 abstracts were identified and reviewed by 3 independent reviewers. Thirty-nine full-text articles were selected for analysis. Three studies met selection criteria and were included in the evidence table. CONCLUSION Class I evidence from 1 study and class III evidence from 2 studies suggest that, in comparison to postnatal repair, prenatal surgery for MM reduces the risk of developing shunt-dependent hydrocephalus. Therefore, prenatal repair of MM is recommended for those fetuses who meet specific criteria for prenatal surgery to reduce the risk of developing shunt-dependent hydrocephalus (level I). Differences between prenatal and postnatal repair with respect to the requirement for permanent cerebrospinal fluid diversion should be considered alongside other relevant maternal and fetal factors when deciding upon a preferred method of MM closure. The full guideline can be found at https://www.cns.org/guidelines/guidelines-spina-bifida-chapter-2.
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Affiliation(s)
- Mandeep S Tamber
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Ann Marie Flannery
- Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana
| | - Catherine McClung-Smith
- Department of Neurological Surgery, Palmetto Health USC Medical Group, Columbia, South Carolina
| | - Nadege Assassi
- Department of Surgery, Division of Neurosurgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - David F Bauer
- Department of Surgery, Division of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexandra D Beier
- Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Susan R Durham
- The University of Vermont Medical Center, Burlington, Vermont
| | - Paul Klimo
- Semmes Murphey, Memphis, Tennessee
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Dimitrios C Nikas
- Division of Pediatric Neurosurgery, Advocate Children's Hospital, Oak Lawn, Illinois
| | | | - Rachana Tyagi
- Department of Neurosurgery, Mercer University Medical School, Macon, Georgia
| | - Catherine A Mazzola
- Goryeb Children's Hospital, Morristown, NJ; Rutgers Department of Neurological Surgery, Newark, New Jersey
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Blount JP, Durham SR, Klimo P, Assassi N, Bauer DF, Beier AD, Flannery AM, McClung-Smith C, Nikas DC, Rehring P, Tamber MS, Tyagi R, Mazzola CA. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Management of Patients With Myelomeningocele: Whether Persistent Ventriculomegaly Adversely Impacts Neurocognitive Development. Neurosurgery 2020; 85:E414-E416. [PMID: 31418036 DOI: 10.1093/neuros/nyz265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/11/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Myelomeningocele (MM) is the most common congenital anomaly to affect the nervous system and affects 1500-2000 newborn infants per year in the United States. It is accompanied by symptomatic hydrocephalus in approximately 70%-80% of patients. Different treatment strategies for hydrocephalus characteristically result in different effects on the size of the ventricles. OBJECTIVE The objective of this systematic review was to determine whether persistent ventricular enlargement adversely impacts neurocognitive development in patients with MM. METHODS The PubMed National Library of Medicine Medline database and Embase were queried using MeSH headings and keywords relevant to neurocognitive or intellectual development and ventricular size or morphology. Abstracts were reviewed by the authors to identify which studies met strict inclusion criteria. An evidence table was constructed that summarized the included studies and reflected the quality of evidence (Classes I-III) that each represented. A recommendation was made that is based on the quality of the evidence. RESULTS An initial abstract review utilizing strict inclusion/exclusion criteria yielded 48 studies, 9 of which underwent full-text review. There is limited and conflicting Class III evidence from 2 studies. CONCLUSION Currently, there is insufficient data to conclude that ventricular size and morphology impact neurocognitive development.The full guideline can be found at https://www.cns.org/guidelines/guidelines-spina-bifida-chapter-5.
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Affiliation(s)
- Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Susan R Durham
- Division of Neurosurgery, University of Vermont, Burlington, Vermont
| | - Paul Klimo
- Semmes Murphey, Memphis, Tennesse.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennesse.,Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Nadege Assassi
- Department of Surgery, Division of Neurosurgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - David F Bauer
- Department of Surgery, Division of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshirt
| | - Alexandra D Beier
- Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida
| | - Ann Marie Flannery
- Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana
| | - Catherine McClung-Smith
- Department of Neurological Surgery, Palmetto Health USC Medical Group, Columbia, South Carolina
| | - Dimitrios C Nikas
- Division of Pediatric Neurosurgery, Advocate Children's Hospital, Oak Lawn, Illinois
| | | | - Mandeep S Tamber
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Rachana Tyagi
- Department of Neurosurgery, Mercer University Medical School, Macon, Georgia
| | - Catherine A Mazzola
- Goryeb Children's Hospital, Morristown, New Jersey.,Rutgers Department of Neurological Surgery, Newark, New Jersey
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Weiner HL, Adelson PD, Brockmeyer DL, Maher CO, Gupta N, Smyth MD, Jea A, Blount JP, Riva-Cambrin J, Lam SK, Ahn ES, Albert GW, Leonard JR. Prenatal counseling for myelomeningocele in the era of fetal surgery: a shared decision-making approach. J Neurosurg Pediatr 2020; 25:640-647. [PMID: 32109872 PMCID: PMC7164397 DOI: 10.3171/2019.12.peds19449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Management of Myelomeningocele Study demonstrated that fetal surgery, as compared to postnatal repair, decreases the rate of hydrocephalus and improves expected motor function. However, fetal surgery is associated with significant maternal and neonatal risks including uterine wall dehiscence, prematurity, and fetal or neonatal death. The goal of this study was to provide information about counseling expectant mothers regarding myelomeningocele in the era of fetal surgery. METHODS The authors conducted an extensive review of topics pertinent to counseling in the setting of myelomeningocele and introduce a new model for shared decision-making to aid practitioners during counseling. RESULTS Expectant mothers must decide in a timely manner among several potential options, namely termination of pregnancy, postnatal surgery, or fetal surgery. Multiple factors influence the decision, including maternal health, fetal heath, financial resources, social support, risk aversion, access to care, family planning, and values. In many cases, it is a difficult decision that benefits from the guidance of a pediatric neurosurgeon. CONCLUSIONS The authors review critical issues of prenatal counseling for myelomeningocele and discuss the process of shared decision-making as a framework to aid expectant mothers in choosing the treatment option best for them.
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Affiliation(s)
- Howard L. Weiner
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - P. David Adelson
- Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children’s Hospital, University of Arizona College of Medicine, Phoenix, Arizona
| | - Douglas L. Brockmeyer
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Cormac O. Maher
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan
| | - Nalin Gupta
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, UCSF Benioff Children’s Hospital, University of California, San Francisco, California
| | - Matthew D. Smyth
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, St. Louis Children’s Hospital, Washington University School of Medicine in St. Louis, Missouri
| | - Andrew Jea
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey P. Blount
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s of Alabama, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta, Canada
| | - Sandi K. Lam
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Edward S. Ahn
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s Center, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Gregory W. Albert
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Jeffrey R. Leonard
- Department of Neurological Surgery, Section of Neurosurgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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25
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Concepts in the neurosurgical care of patients with spinal neural tube defects: An embryologic approach. Birth Defects Res 2019; 111:1564-1576. [DOI: 10.1002/bdr2.1588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 02/04/2023]
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26
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Alford EN, Hopson BD, Safyanov F, Arynchyna A, Bollo RJ, Hankinson TC, Rocque BG, Blount JP. Care management and contemporary challenges in spina bifida: a practice preference survey of the American Society of Pediatric Neurosurgeons. J Neurosurg Pediatr 2019; 24:539-548. [PMID: 31470398 DOI: 10.3171/2019.5.peds18738] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neurosurgical management preferences related to myelomeningocele (MMC) care demonstrate significant variability. The authors sought to evaluate variability in practice patterns across a group of senior pediatric neurosurgeons. The purpose of this study was to identify the extent of variability and of consensus with regard to neurosurgical management of MMC and associated hydrocephalus, Chiari II malformation, and tethered spinal cord. METHODS A 43-question survey was distributed electronically to the members of the American Society of Pediatric Neurosurgeons (ASPN). The survey covered domains such as clinic case volume, newborn management, hydrocephalus management, transition to adulthood, clinical indications for shunt revision, Chiari II malformation decompression (C2MD), and tethered cord release (TCR). Ninety responses were received from 200 active ASPN members, for an overall response rate of 45%. RESULTS The majority (58%) of respondents closed 5-15 new cases of open MMC per year. Nearly all (98%) respondents perform back closure within 48 hours of birth, with the majority imbricating the placode and striving for a 3- to 4-layer closure. The most consistent indications for surgical intervention in early hydrocephalus were CSF leak from the back (92%), progressive ventricular enlargement (89%), and brainstem symptoms, including apnea/bradycardia (81%), stridor (81%), and dysphagia (81%). Eighty percent of respondents indicated that spina bifida care is delivered through multidisciplinary clinics, with neurosurgery, orthopedic surgery, urology, physical therapy, and social work as the most common disciplines included. One-third of clinics see both pediatric and adult patients, one-third offer a formal transition program to adult care, and one-third have no transition program. The vast majority of respondents offer prenatal counseling (95%), referral for in utero closure (66%), and endoscopic third ventriculostomy/choroid plexus cauterization (72%). Respondents were more willing to perform shunt revision for symptoms alone than for image changes alone. An asymptomatic broken shunt without ventricular enlargement produced responses evenly divided between observation, intervention, and further investigation. Operative shunt exploration was always performed before C2MD by 56% of respondents and performed sometimes by 40% of respondents. Symptoms of brainstem dysfunction were the strongest clinical triggers reported for C2MD, while declines in urinary continence, leg strength or sensation, or ambulation were the most consistent thresholds for TCR. CONCLUSIONS Significant disparities exist surrounding key areas of decision making regarding treatment for patients with MMC, though there are central areas of agreement among ASPN members. Additionally, there is significant variation in the clinical management of chronic hydrocephalus, C2MD, and TCR, underscoring the need for further research into these specific areas.
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Affiliation(s)
- Elizabeth N Alford
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 2Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
| | - Betsy D Hopson
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 2Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
| | | | - Anastasia Arynchyna
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 2Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
| | - Robert J Bollo
- 4Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City
- 5Primary Children's Hospital, Salt Lake City, Utah; and
| | - Todd C Hankinson
- 6Pediatric Neurosurgery, Children's Hospital Colorado, and
- 7Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brandon G Rocque
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 2Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
| | - Jeffrey P Blount
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 2Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
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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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Kim I, Hopson BD, Aban I, Rizk EB, Dias MS, Bowman R, Ackerman LL, Partington M, Castillo H, Castillo J, Peterson PR, Blount JP, Rocque BG. Treated hydrocephalus in individuals with myelomeningocele in the National Spina Bifida Patient Registry. J Neurosurg Pediatr 2018; 22:646-651. [PMID: 30141753 PMCID: PMC8927992 DOI: 10.3171/2018.5.peds18161] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 05/25/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAlthough the majority of patients with myelomeningocele have hydrocephalus, reported rates of hydrocephalus treatment vary widely. The purpose of this study was to determine the rate of surgical treatment for hydrocephalus in patients with myelomeningocele in the National Spina Bifida Patient Registry (NSBPR). In addition, the authors explored the variation in shunting rates across NSBPR institutions, examined the relationship between hydrocephalus, and the functional lesion level of the myelomeningocele, and evaluated for temporal trends in rates of treated hydrocephalus.METHODSThe authors queried the NSBPR to identify all patients with myelomeningoceles. Individuals were identified as having been treated for hydrocephalus if they had undergone at least 1 hydrocephalus-related operation. For each participating NSBPR institution, the authors calculated the proportion of patients with treated hydrocephalus who were enrolled at that site. Logistic regression was performed to analyze the relationship between hydrocephalus and the functional lesion level of the myelomeningocele and to compare the rate of treated hydrocephalus in children born before 2005 with those born in 2005 or later.RESULTSA total of 4448 patients with myelomeningocele were identified from 26 institutions, of whom 3558 patients (79.99%) had undergone at least 1 hydrocephalus-related operation. The rate of treated hydrocephalus ranged from 72% to 96% among institutions enrolling more than 10 patients. This difference in treatment rates between centers was statistically significant (p < 0.001). Insufficient data were available in the NSBPR to analyze reasons for the different rates of hydrocephalus treatment between sites. Multivariate logistic regression demonstrated that more rostral functional lesion levels were associated with higher rates of treated hydrocephalus (p < 0.001) but demonstrated no significant difference in hydrocephalus treatment rates between children born before versus after 2005.CONCLUSIONSThe rate of hydrocephalus treatment in patients with myelomeningocele in the NSBPR is 79.99%, which is consistent with the rates in previously published literature. The authors' data demonstrate a clear association between functional lesion level of the myelomeningocele and the need for hydrocephalus treatment.
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Affiliation(s)
- Irene Kim
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Betsy D. Hopson
- Department of Neurosurgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, Alabama
| | - Inmaculada Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Elias B. Rizk
- Department of Neurological Surgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Mark S. Dias
- Department of Neurological Surgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Robin Bowman
- Pediatric Neurosurgery, Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Laurie L. Ackerman
- Goodman Campbell Brain and Spine Division of Pediatric Neurosurgery, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Heidi Castillo
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jonathan Castillo
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - Jeffrey P. Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, Alabama
| | - Brandon G. Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, Alabama
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Leidinger A, Piquer J, Kim EE, Nahonda H, Qureshi MM, Young PH. Experience in the Early Surgical Management of Myelomeningocele in Zanzibar. World Neurosurg 2018; 121:e493-e499. [PMID: 30268549 DOI: 10.1016/j.wneu.2018.09.145] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Neural tube defects are a large health burden for East African countries. Health strategies in the prevention of this disease include nutritional prophylaxis, prenatal diagnosis, and availability of early neonatal neurosurgery. The main objective of this study is to describe our experience in the early surgical management of neural tube defects in the Zanzibar archipelago. METHODS From December 2016 to December 2017, we prospectively collected data on all patients admitted with the diagnosis of myelomeningocele. We collected variables regarding demographics, maternal health, preoperative imaging, surgical procedures, and complications at follow-up. RESULTS We collected data on 19 patients. Mean age was 9.8 ± 18.7 days. Of these patients, 52.6% were male and 47.3% were female; 47.3% patients were from Unguja, 42.0% from Pemba, and 5.2% from mainland Tanzania; 68.4% of all mothers were found to have undergone prenatal ultrasonography and 89.5% of all patients received surgery. Surgical wound infection was present in 29.4% of all surgical patients and 52.9% developed secondary hydrocephalus. CONCLUSIONS Neural tube defects are a prevailing condition in East Africa. We believe that more health initiatives should address its prevention, mainly through maternal nutrition. On the basis of our findings, we consider early neonatal neurosurgery as the most important factor in reducing immediate morbidity and mortality.
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Affiliation(s)
- Andreas Leidinger
- Neurosurgery Education and Development (NED) Foundation, Valencia, Spain; Neurosurgery Education and Development (NED) Institute, Mnazi Mmoja Hospital, Stonetown, Tanzania.
| | - Jose Piquer
- Neurosurgery Education and Development (NED) Foundation, Valencia, Spain; Chair of Neuroscience Vithas CEU University, Valencia, Spain
| | - Eliana E Kim
- Neurosurgery Education and Development (NED) Foundation, Valencia, Spain
| | - Hadia Nahonda
- Neurosurgery Education and Development (NED) Institute, Mnazi Mmoja Hospital, Stonetown, Tanzania
| | | | - Paul H Young
- Section of Neurosurgery, Department of Surgery, St Louis University, St. Louis, Missouri, USA
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Mukherjee S, Pasulka J. Care for Adults with Spina Bifida: Current State and Future Directions. Top Spinal Cord Inj Rehabil 2018; 23:155-167. [PMID: 29339892 DOI: 10.1310/sci2302-155] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The care for adults with spina bifida is an important area to study. As increasing numbers of patients with spina bifida survive into adulthood, they expect to thrive and receive the best possible care into adulthood to maintain their health. Understanding the health needs in this emerging and changing population will help clinicians provide the best anticipatory care for adults with spina bifida and continue to improve outcomes. This will also impact pediatric care by improving the ability to determine preventive methods from early on and understand the impacts of pediatric care and decisions over the lifespan.
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Affiliation(s)
- Shubhra Mukherjee
- Department of Physical Medicine and Rehabilitation, Rehabilitation Institute of Chicago, Chicago, Illinois
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Al-Hakim S, Schaumann A, Schneider J, Schulz M, Thomale UW. Experience in shunt management on revision free survival in infants with myelomeningocele. Childs Nerv Syst 2018; 34:1375-1382. [PMID: 29582171 DOI: 10.1007/s00381-018-3781-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/16/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Depending on the etiology of hydrocephalus in childhood, the shunt therapy still remains challenging due to frequent shunt complications leading to possible revisions such as shunt infection or shunt malfunction. In myelomeningocele (MMC) patients who often require shunt therapy, higher revisions rates were reported. In a single-center retrospective study, experiences on shunt regimen on hydrocephalus associated with MMC are presented. METHODS Data of 160 infant hydrocephalus cases younger than 1 year of age at the time of implantation were retrospectively reviewed from the hospital database. These patients received an adjustable differential pressure valve with gravitational unit and antibiotic impregnated catheters as a primary or secondary implant during the time period of April 2007 to July 2015. The subgroup of infants cases with MMC (n = 44; age 50.6 ± 80.6 days) were compared to the remaining cohort of other hydrocephalus etiology (control group). The shunt and valve revision free survival rates were recorded until July 2017. RESULTS During the mean follow-up of 48.7 ± 19.2 (7-114) months, the shunt revision free survival was 87% at 1 year and 49% at 60 months in the MMC cohort. The control group showed a shunt survival rate of 68% at 1 year and 39% at 60 months. Similarly, the valve revision free survival rate showed a significant higher rate of 92% at 1 year and 69% at 60 months in the MMC group compared to the control group (75% at 1 year and 51% at 60 months; p < 0.05). During the entire follow-up period, 37% of the MMC infants underwent a revision operation in contrast to the control group of 40%. CONCLUSION The presented shunt strategy showed improved revision free survival rates in infants with a MMC-related hydrocephalus in comparison to other etiologies of hydrocephalus in infants, which might relate to infection prophylaxis and high drainage resistance integrated in the shunt system.
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Affiliation(s)
- Sara Al-Hakim
- Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Andreas Schaumann
- Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Joanna Schneider
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Matthias Schulz
- Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany. .,Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenberger Platz 1, 13353, Berlin, Germany.
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Alatas I, Canaz G, Kayran NA, Kara N, Canaz H. Shunt revision rates in myelomeningocele patients in the first year of life: a retrospective study of 52 patients. Childs Nerv Syst 2018; 34:919-923. [PMID: 29159427 DOI: 10.1007/s00381-017-3663-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 11/14/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE Shunt placement indications are stringent and require confirmation of clinical and radiological evidence of hydrocephalus (HC). The aim of this study was to determine the rate of shunting and discuss the outcome in the first year of life in patients with myelomeningocele (MMC) on the basis of review of the literature. METHODS All patients who underwent postnatal repair of MMC at our institution between March 2014 and March 2015 were evaluated. Patients were only included if they underwent both MMC repair and ventriculoperitoneal (VP) shunt insertion at our institution and were followed up for at least 12 months. The mean ages for repair of MMC, MMC levels, timing of VP shunt placement, shunt revisions, and causes of shunt revisions were documented. RESULTS Fifty-two patients with MMC were included in this study. The average gestational age at birth was 38 weeks. The level of MMC was thoracolumbar in 13 cases, 11 times lumbar, 21 times lumbosacral, and 7 times sacral. Thirty-one patients (59.61%) suffered from hydrocephalus and required placement of a shunt. When we evaluate the lesion levels of patients who require shunting, 13 cases were thoracolumbar, 6 cases were lumbar, and 11 cases were lumbosacral. None of the sacral cases needed VP shunt. Seven patients (13.4%) had shunt revision within the first year of life. The cause of shunt revision was wound problem in one patient (1.9%), underdrainage in two patients (3.8%), infection in three patients (5.7%), and mechanical obstruction in another one patient (1.9%). CONCLUSION MMC closure and management of the associated HC are one of the most basic, but never simple, legs of the pediatric neurosurgery around the world. As clinicians and neurosurgeons, we are obligated to analyze recent evidences and evaluate present approaches to achieve optimization in this subject until further technologies or approaches became more advantageous for our patients.
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Affiliation(s)
- Ibrahim Alatas
- Department of Neurosurgery, Spina Bifida Center, Florence Nightingale Hospital, Istanbul Bilim University, Abide-i Hurriyet Cad. No:163, 34381, Sisli, Istanbul, Turkey
| | - Gokhan Canaz
- Department of Neurosurgery, Bakirkoy Research and Training Hospital for Neurology, Neurosurgery and Psychiatry, Istanbul, Turkey
| | - Nesrin Akkoyun Kayran
- Department of Neurosurgery, Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
| | - Nursu Kara
- Department of Neonatology, Florence Nightingale Hospital, Istanbul Bilim University, Istanbul, Turkey
| | - Huseyin Canaz
- Department of Neurosurgery, Spina Bifida Center, Florence Nightingale Hospital, Istanbul Bilim University, Abide-i Hurriyet Cad. No:163, 34381, Sisli, Istanbul, Turkey.
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Udayakumaran S, Rathod CT. Tailored Strategies to Manage Cerebrospinal Fluid Leaks or Pseudomeningocele After Surgery for Tethered Cord Syndrome. World Neurosurg 2018; 114:e1049-e1056. [PMID: 29605699 DOI: 10.1016/j.wneu.2018.03.144] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leaks are a dreaded complication after surgery for tethered cord and are associated with significant patient morbidity. Although many strategies for managing postoperative CSF leaks exist, this problem is still daunting, especially in very young patients. In this study, we compared different management techniques for CSF leaks or significant pseudomeningocele in patients with tethered cord syndrome (TCS). METHODS We analyzed a cohort of children who underwent surgery for TCS from January 2011 to March 2016 (n = 260) and postoperatively experienced either a CSF leak or significant pseudomeningocele. A subset of patients presented with CSF leak (n = 25). We analyzed patient age, sex, presentation, leak appearance, management, and outcome. The different techniques of management were compared for efficacy and morbidity. RESULTS The diseases associated with leak formation included lipomyelomeningocele (n = 16), myelocystocele (n = 4), and myelomeningocele (n = 5). Three children also had hydrocephalus. Management techniques included cystoperitoneal shunt (CPS) (n = 15), primary resuturing with local rotation flap of muscle (n = 3), external ventricular drain placement (n = 1), ventriculoperitoneal shunt (n = 3), external ventricular drainage (n = 1), and a combination of techniques (rotation flap with external drain; n = 1). Five patients who underwent primary wound revision experienced a leak and required a secondary intervention, but none of the patients who underwent CPS had any complications. CONCLUSIONS In carefully selected cases, CPS performed early after CSF leakage is highly successful with low morbidity. The primary closure can be attempted for low-pressure leaks without an associated pseudomeningocele.
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Affiliation(s)
- Suhas Udayakumaran
- Division of Pediatric Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India.
| | - Chetan T Rathod
- Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
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Norkett W, McLone DG, Bowman R. Current Management Strategies of Hydrocephalus in the Child With Open Spina Bifida. Top Spinal Cord Inj Rehabil 2018; 22:241-246. [PMID: 29339864 DOI: 10.1310/sci2204-241] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Symptomatic hydrocephalus is a common condition associated with myelomeningocele (open spina bifida). Traditionally, hydrocephalus was treated with insertion of a ventriculo-peritoneal (VP) shunt. This has been the standard of treatment since the introduction of the Holter shunt valve for the VP shunt in the late 1950s. Now there are other treatments that offer alternatives to VP shunt diversion for hydrocephalus. This article is a review of hydrocephalus associated with myelomeningocele and its treatment options. Treatment in the form of a VP shunt, endoscopic third ventriculostomy (ETV), and conservative management are discussed.
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Affiliation(s)
| | - David G McLone
- Ann and Robert H. Lurie Children's Hospital of Chicago.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robin Bowman
- Ann and Robert H. Lurie Children's Hospital of Chicago.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kuhn EN, Hopson B, Conklin MJ, Blount JP. Intradural spine surgery may not carry an increased risk of shunt revision compared with extradural spine surgery in pediatric patients with myelomeningocele. J Neurosurg Pediatr 2018; 21:11-15. [PMID: 29053056 DOI: 10.3171/2017.7.peds17274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with myelomeningocele are often affected by scoliosis and tethered cord syndrome, and frequently require spine surgery. Intradural spine surgeries may carry an inherently higher risk of inducing shunt malfunction due to entry into the subarachnoid space. In this study, the authors sought to compare rates of shunt malfunction after intradural and extradural spine surgeries among pediatric patients with myelomeningocele. METHODS The authors reviewed records of the National Spina Bifida Program Registry for Children's Hospital of Alabama. The Exago reporting function was used to identify patients who had received at least one of the following procedures: shunt revision, tethered cord release (TCR), or spinal fusion for deformity. The registry records were reviewed for all identified patients to determine if a shunt revision was performed within the 1st year after TCR or spinal fusion. RESULTS Final analyses included 117 patients, of whom 39 underwent spinal fusion and 78 underwent TCR. Among patients who underwent spinal fusion, shunt revision was performed within 30 days in 2 patients (5.1%), within 60 days in 2 (5.1%), within 90 days in 4 (10.3%), and within 1 year in 5 (12.8%). Among patients who underwent TCR, shunt revision was performed within 30 days in 7 patients (9.0%), within 60 days in 10 (12.8%), within 90 days in 11 (14.1%), and within 1 year in 17 (21.8%). Using the log-rank test, there was no significant difference in Kaplan-Meier curves between intradural and extradural groups (p = 0.59). CONCLUSIONS In a review of single-institution registry data, the authors found no statistically significant difference in the risk of shunt malfunction after intradural and extradural spine surgeries.
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Affiliation(s)
| | - Betsy Hopson
- 2Division of Pediatric Neurosurgery, Department of Neurosurgery; and
| | - Michael J Conklin
- 3Division of Orthopedic Surgery, Department of Orthopedic Surgery, University of Alabama at Birmingham, Alabama
| | - Jeffrey P Blount
- 1Department of Neurosurgery.,2Division of Pediatric Neurosurgery, Department of Neurosurgery; and
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Bevan R, Wilson-Jones N, Bhatti I, Patel C, Leach P. How much do plastic surgeons add to the closure of myelomeningoceles? Childs Nerv Syst 2018; 34:737-740. [PMID: 29222684 PMCID: PMC5856885 DOI: 10.1007/s00381-017-3674-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 11/27/2017] [Indexed: 11/23/2022]
Abstract
PURPOSE This study reviews the outcomes of children undergoing myelomeningocele (MMC) repair in the paediatric neurosurgical department in Cardiff. These procedures are historically performed by paediatric neurosurgeons with occasional support from plastic surgeons for the larger lesions. We reviewed the postoperative outcomes over a 9-year period to assess the efficacy of having a plastic surgeon present at all MMC closures. METHODS Analysis of a prospectively collected database of all MMC closures performed at University Hospital Wales from April 2009 to August 2017 was used. Comparison was made with the published literature especially with regard to complications. RESULTS Thirty-one children, 13 males and 18 females, underwent MMC closure over the 9-year period. Twenty-four (77.4%) defects were closed by direct approximation. Seven patients (22.5%) required a more complex plastic procedure to obtain closure. Two patients (6.5%) had a wound complication, one wound infection and one flap edge necrosis both healing with dressings alone. Two patients had cerebrospinal fluid (CSF) leaks that responded to ventriculo-peritoneal shunting. Two patients died from unrelated conditions during the study period. CONCLUSION In our series, 7/31 (22.5%) cases involved a more complex closure in keeping with the literature. The authors feel that having the plastic surgeon at all closures has led to a low wound complication rate.
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Affiliation(s)
- Rhian Bevan
- University Hospital of Wales College of Medicine, Cardiff, UK.
| | | | - Imran Bhatti
- 0000 0001 0169 7725grid.241103.5Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Chirag Patel
- 0000 0001 0169 7725grid.241103.5Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Paul Leach
- 0000 0001 0169 7725grid.241103.5Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
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Houtrow AJ, Burrows PK, Thom EA. Comparing neurodevelopmental outcomes at 30 months by presence of hydrocephalus and shunt status among children enrolled in the MOMS trial. J Pediatr Rehabil Med 2018; 11:227-235. [PMID: 30507586 DOI: 10.3233/prm-170481] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To evaluate for differences in neurodevelopmental outcomes at 30 months of age for children enrolled in the Management of Myelomeningocele Study (MOMS) based on the presence of hydrocephalus and cerebral shunts. METHODS Children with no hydrocephalus (N= 27), children with shunted hydrocephalus (N= 108), and children with unshunted hydrocephalus (N= 36) were compared at 30 months of age on the Bayley II Mental and Psychomotor Indices, the Peabody Developmental Motor Scales-2 and the Preschool Language Scale, 4th edition. Generalized linear models were used to adjust for factors significantly different between the groups at baseline. Additional analyses were conducted to evaluate the impact of the severity of hydrocephalus. RESULTS In unadjusted comparisons, statistically significant differences were noted between the three groups on the Peabody Gross Motor Quotient and thus the Total Motor Quotient. After adjustment, no statistically significant differences were identified. In subanalyses, children with more severe hydrocephalus fared worse on the Peabody Fine Motor Quotient (median 88 versus 94, p= 0.005), the Total Motor Quotient (median 70 versus 73, p= 0.02) and both Preschool Language Scale subtests (auditory comprehension: median 93 versus 104, p= 0.02 and expressive communication: median 95 versus 104.5, p= 0.01) and thus the total score (median 92 versus 105, p= 0.004). These results remained significant in the multivariable adjusted model. CONCLUSION No neurodevelopmental differences were noted with children enrolled in MOMS across the three hydrocephalus/shunt groups, although severity of hydrocephalus was associated with poorer outcomes.
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Affiliation(s)
- Amy J Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pamela K Burrows
- The George Washington University Biostatistics Center, Rockville, MD, USA
| | - Elizabeth A Thom
- The George Washington University Biostatistics Center, Rockville, MD, USA
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Huang GO, Belfort MA, Whitehead WE, Olutoye OO, Castillo J, Castillo H, Ostermaier KK, Koh CJ, Tu DD. Early postnatal bladder function in fetoscopic myelomeningocele repair patients. J Pediatr Rehabil Med 2017; 10:327-333. [PMID: 29125525 DOI: 10.3233/prm-170465] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Prenatal repair of myelomeningocele (MMC) via hysterotomy has demonstrated neurosurgical and motor benefits, when compared to postnatal repairs. Urologic benefits, however, remain to be seen. The purpose of this study was to review early postnatal bladder function in patients undergoing a novel endoscopic approach for MMC repair using an exteriorized uterus. METHODS A prospective urologic assessment of patients undergoing fetoscopic MMC repair and receiving subsequent care at our facility, was performed. Patients were managed and urodynamic studies risk-stratified according to the Centers for Disease Control and Prevention Urologic and Renal Protocol for the Newborn and Young Child with Spina Bifida. RESULTS Fetoscopic MMC repair was performed in 14 patients. No patients had hydronephrosis or bladder thickening at birth. Detrusor overactivity was observed in nine (64.3%) patients. Impaired compliance was seen in eight (57.1%) patients. No patients had a detrusor leak point pressure of > 40 cm H2O or evidence of detrusor sphincter dyssynergia. Three (21.4%) patients had vesicoureteral reflux, seven (50.0%) had an open bladder neck, and none had trabeculated bladders. CONCLUSION In this early experience with fetoscopic MMC repair, postnatal bladder function does not appear to be any worse than that of previously reported prenatal or postnatal closures.
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Affiliation(s)
- Gene O Huang
- Division of Urology, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - William E Whitehead
- Department of Neurosurgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Oluyinka O Olutoye
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Jonathan Castillo
- Division of Developmental Pediatrics, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Heidi Castillo
- Division of Developmental Pediatrics, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Kathryn K Ostermaier
- Division of Developmental Pediatrics, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Chester J Koh
- Division of Urology, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Duong D Tu
- Division of Urology, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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First 60 fetal in-utero myelomeningocele repairs at Saint Louis Fetal Care Institute in the post-MOMS trial era: hydrocephalus treatment outcomes (endoscopic third ventriculostomy versus ventriculo-peritoneal shunt). Childs Nerv Syst 2017; 33:1157-1168. [PMID: 28470384 DOI: 10.1007/s00381-017-3428-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The published results of the Management of Myelomeningocele Study (MOMS) trial in 2011 showed improved outcomes (reduced need for shunting, decreased incidence of Chiari II malformation, and improved scores of mental development and motor function) in the fetal prenatal repair group compared to the postnatal group. Historically, endoscopic third ventriculostomy (ETV) remains as a controversial hydrocephalus treatment option with high failure rates in pediatric patients with a history of myelomeningocele (MMC). We report hydrocephalus treatment outcomes in the fetal in-utero myelomeningocele repair patients who underwent repair at our Saint Louis Fetal Care Institute following the MOMS trial. We looked carefully at ETV outcomes in this patient population and we identified risk factors for failure. METHODS At our Saint Louis Fetal Care Institute, we followed the maternal and fetal inclusion and exclusion criteria used by the MOMS trial. The records of our first 60 fetal MMC repairs performed at our institute between 2011 and 2017 were examined. We retrospectively reviewed the charts, prenatal fetal magnetic resonance imaging (MRI) and ultrasound (US) imaging findings, postnatal brain MRI, and Bayley neurodevelopment testing results for infants and children who underwent surgical treatment of symptomatic hydrocephalus (VP shunt versus ETV). Multiple variables possibly related to ETV failure were considered for identifying risk factors for ETV failure. RESULTS Between May 2011 and March 2017, 60 pregnant female patients underwent the prenatal MMC repair for their fetuses between 20 and 26 weeks' gestational age (GA) utilizing the standard hysterotomy for exposure of the fetus, and microsurgical repair of the MMC defect. All MMC defects underwent successful in-utero repair, with subsequent progression of the pregnancy. At the time of this study, 58 babies have been born, 56 are alive since there were 2 mortalities in the neonatal period due to prematurity. One patient was excluded given lack of consent for research purposes. From the remaining 55 patient included in this study, a total of 30 infants and toddlers underwent treatment of hydrocephalus (ETV and VPS groups). Twenty-five patients underwent ETV (24 primary ETV and 1 after shunt failure). Nineteen patients underwent shunt placements (6 primary/13 after ETV failure). Mean GA at time of MMC repair for the ETV group was 24 + 6/7 weeks (range 22 + 4/7 to 25 + 6/7). Mean follow up for patients who had a successful ETV was 17.25 months (range 4-57 months). Bayley neurodevelopmental testing results were examined pre- and post-ETV. Overall ETV success rate was 11/24 (45.8%) at the time of this study. The total number of patients who underwent shunt placement was 19/55 (34.5%), while shunting rate was 40% in the MOMS trial. Using a simple logistic regression analysis to identify predictors of ETV failure, ETV age ≤6 months and gestational age ≥23 weeks at repair of myelomeningocele were significant predictors for ETV failure while in-utero ventricular stability ≤4 mm and in-utero ventricular size post-repair ≤15.5 mm were significant predictors for ETV success. None of the listed variables independently predicted classification into ETV success versus ETV failure groups when entered into multiple logistic regression analysis. CONCLUSIONS ETV, as an alternative to initial shunting, may continue to show promising results for treating fetal MMC repair patient population who present with symptomatic hydrocephalus during infancy and early childhood. Although our overall CSF diversion rate (ETV and VPS groups) in our fetal MMC group is higher than the MOMS trial, our shunting rate is lower given our higher incidence of patients with successful ETV. To our knowledge, this is the largest reported ETV series in patients who underwent fetal MMC repair. ETV deserves a closer look in the setting of improved hindbrain herniation in fetal in-utero MMC repair patients. In our series, young age (less than 6 months) and late GA at time of fetal MMC repair (after 23 weeks GA) were predictors for ETV failure, while in-utero stability of ventricular size (less than 4 mm) and in-utero ventricular size post-repair ≤15.5 mm were predictors for ETV success. Larger series and potential prospective randomized studies are required for further evaluation of risk factors for ETV failure in the fetal MMC patient population.
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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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Dupepe EB, Hopson B, Johnston JM, Rozzelle CJ, Jerry Oakes W, Blount JP, Rocque BG. Rate of shunt revision as a function of age in patients with shunted hydrocephalus due to myelomeningocele. Neurosurg Focus 2017; 41:E6. [PMID: 27798984 DOI: 10.3171/2016.8.focus16257] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE It is generally accepted that cerebrospinal fluid shunts fail most frequently in the first years of life. The purpose of this study was to describe the risk of shunt failure for a given patient age in a well-defined cohort with shunted hydrocephalus due to myelomeningocele (MMC). METHODS The authors analyzed data from their institutional spina bifida research database including all patients with MMC and shunted hydrocephalus. For the entire population, the number of shunt revisions in each year of life was determined. Then the number of patients at risk for shunt revision during each year of life was calculated, thus enabling them to calculate the rate of shunt revision per patient in each year of life. In this way, the timing of all shunt revision operations for the entire clinic population and the likelihood of having a shunt revision during each year of life were calculated. RESULTS A total of 655 patients were enrolled in the spina bifida research database, 519 of whom had a diagnosis of MMC and whose mean age was 17.48 ± 11.7 years (median 16 years, range 0-63 years). Four hundred seventeen patients had had a CSF shunt for the treatment of hydrocephalus and thus are included in this analysis. There were 94 shunt revisions in the 1st year of life, which represents a rate of 0.23 revisions per patient in that year. The rate of shunt revision per patient-year initially decreased as age increased, except for an increase in revision frequency in the early teen years. Shunt revisions continued to occur as late as 43 years of age. CONCLUSIONS These data substantiate the idea that shunt revision surgeries in patients with MMC are most common in the 1st year of life and decrease thereafter, except for an increase in the early teen years. A persistent risk of shunt failure was observed well into adult life. These findings underscore the importance of routine follow-up of all MMC patients with shunted hydrocephalus and will aid in counseling patients and families.
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Affiliation(s)
| | - Betsy Hopson
- Section of Pediatric Neurosurgery, Children's Hospital of Alabama and the University of Alabama at Birmingham, Alabama
| | - James M Johnston
- Department of Neurosurgery, and.,Section of Pediatric Neurosurgery, Children's Hospital of Alabama and the University of Alabama at Birmingham, Alabama
| | - Curtis J Rozzelle
- Department of Neurosurgery, and.,Section of Pediatric Neurosurgery, Children's Hospital of Alabama and the University of Alabama at Birmingham, Alabama
| | - W Jerry Oakes
- Department of Neurosurgery, and.,Section of Pediatric Neurosurgery, Children's Hospital of Alabama and the University of Alabama at Birmingham, Alabama
| | - Jeffrey P Blount
- Department of Neurosurgery, and.,Section of Pediatric Neurosurgery, Children's Hospital of Alabama and the University of Alabama at Birmingham, Alabama
| | - Brandon G Rocque
- Department of Neurosurgery, and.,Section of Pediatric Neurosurgery, Children's Hospital of Alabama and the University of Alabama at Birmingham, Alabama
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Sims-Williams HJ, Sims-Williams HP, Kabachelor EM, Fotheringham J, Warf BC. Ten-year survival of Ugandan infants after myelomeningocele closure. J Neurosurg Pediatr 2017; 19:70-76. [PMID: 27767901 DOI: 10.3171/2016.7.peds16296] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Myelomeningocele (MM) is a neural tube defect complicated by neurological deficits below the level of the spinal lesion and, in many cases, hydrocephalus. Long-term survival of infants treated for MM in a low- and middle-income country has never been reported. This retrospective cohort study reports 10-year outcomes and factors affecting survival for infants undergoing MM repair at CURE Children's Hospital of Uganda. METHODS Patients were traced by telephone or home visit. Survival was estimated using the Kaplan-Meier method. Multivariate survival was analyzed using the Cox proportional hazards model, investigating the following variables: sex, age at surgery, weight-for-age at surgery, motor level, and presence and management of hydrocephalus. RESULTS A total of 145 children underwent MM repair between 2000 and 2004; complete data were available for 133 patients. The probability of 10-year survival was 55%, with 78% of deaths occurring in the first 5 years. Most of the deaths were not directly related to MM; infection and neglect were most commonly described. Lesions at motor level L-2 or above were associated with increased mortality (HR 3.176, 95% CI 1.557-6.476). Compared with repair within 48 hours of birth, surgery at 15-29 days was associated with increased mortality (HR 9.091, 95% CI 1.169-70.698). CONCLUSIONS Infants in low- and middle-income countries with MM can have long-term survival with basic surgical intervention. Motor level and age at surgery were significant factors influencing outcome. Education of local health care workers and families to ensure both urgent referral for initial treatment and subsequent access to basic medical care are essential to survival.
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Affiliation(s)
| | | | | | - James Fotheringham
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Cherian J, Staggers KA, Pan IW, Lopresti M, Jea A, Lam S. Thirty-day outcomes after postnatal myelomeningocele repair: a National Surgical Quality Improvement Program Pediatric database analysis. J Neurosurg Pediatr 2016; 18:416-422. [PMID: 27258591 DOI: 10.3171/2016.1.peds15674] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Due to improved nutrition and early detection, myelomeningocele repair is a relatively uncommon procedure. Although previous studies have reviewed surgical trends and predictors of outcomes, they have relied largely on single-hospital experiences or on databases centered on hospital admission data. Here, the authors report 30-day outcomes of pediatric patients undergoing postnatal myelomeningocele repair from a national prospective surgical outcomes database. They sought to investigate the association between preoperative and intraoperative factors on the occurrence of 30-day complications, readmissions, and unplanned return to operating room events. METHODS The 2013 American College of Surgeons National Surgical Quality Improvement Program Pediatric database (NSQIP-P) was queried for all patients undergoing postnatal myelomeningocele repair. Patients were subdivided on the basis of the size of the repair (< 5 cm vs > 5 cm). Preoperative variables, intraoperative characteristics, and postoperative 30-day events were tabulated from prospectively collected data. Three separate outcomes for complication, unplanned readmission, and return to the operating room were analyzed using univariate and multivariate logistic regression. Rates of associated CSF diversion operations and their timing were also analyzed. RESULTS A total of 114 patients were included; 54 had myelomeningocele repair for a defect size smaller than 5 cm, and 60 had repair for a defect size larger than 5 cm. CSF shunts were placed concurrently in 8% of the cases. There were 42 NSQIP-defined complications in 31 patients (27%); these included wound complications and infections, in addition to others. Postoperative wound complications were the most common and occurred in 27 patients (24%). Forty patients (35%) had at least one subsequent surgery within 30 days. Twenty-four patients (21%) returned to the operating room for initial shunt placement. Unplanned readmission occurred in 11% of cases. Both complication and return to operating room outcomes were statistically associated with age at repair. CONCLUSIONS The NSQIP-P allows examination of 30-day perioperative outcomes from a national prospectively collected database. In this cohort, over one-quarter of patients undergoing postnatal myelomeningocele repair experienced a complication within 30 days. The complication rate was significantly higher in patients who had surgical repair within the first 24 hours of birth than in patients who had surgery after the 1st day of life. The authors also highlight limitations of investigating myelomeningocele repair using NSQIP-P and advocate the importance of disease-specific data collection.
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Affiliation(s)
- Jacob Cherian
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Kristen A Staggers
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - I-Wen Pan
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Melissa Lopresti
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Andrew Jea
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Pedreira DAL, Reece EA, Chmait RH, Kontopoulos EV, Quintero RA. Fetoscopic repair of spina bifida: safer and better? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:141-147. [PMID: 27273812 PMCID: PMC5113790 DOI: 10.1002/uog.15987] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 05/31/2023]
Affiliation(s)
- D A L Pedreira
- Fetal Therapy Program, Albert Einstein Hospital, São Paulo, Brazil
| | - E A Reece
- Office of the Dean and Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - R H Chmait
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - E V Kontopoulos
- Department of Obstetrics and Gynecology, University of Missouri, Kansas City, MO, USA
- Elizabeth J. Ferrell Fetal Health Center, Fetal Therapy, Children's Mercy Hospital, Kansas City, MO, USA
| | - R A Quintero
- Elizabeth J. Ferrell Fetal Health Center, Fetal Therapy, Children's Mercy Hospital, Kansas City, MO, USA
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Harris DA, Cherian J, LoPresti M, Jea A, Lam S. Trends in epidemiology and hospitalization utilization for myelomeningocele repair from 2000 to 2009. Childs Nerv Syst 2016; 32:1273-9. [PMID: 27112355 DOI: 10.1007/s00381-016-3091-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 04/13/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Although the incidence of myelomeningocele (MMC) has declined over the past decades with folic acid supplementation and prenatal screening, neural tube defects remain the most common birth defect in the USA. A majority of affected neonates require surgical repair. To characterize US trends in the epidemiology and hospital utilization of MMC repair over the past decade, we analyzed a nationally representative database. METHODS We queried the Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) for all discharges with procedure code for MMC repair for the years 2000, 2003, 2006, and 2009. The cohorts from these time points were compared for their demographic and in-hospital variables. Results are reported as estimated frequencies and means with 95 % confidence intervals (CI). RESULTS Sex, race, insurance status, family income level, and mortality of affected infants have not changed significantly over the decade. A majority of neonatal MMC repairs occur in larger hospital bed size and more specialized children's hospital centers. Of patients, 52.3 to 60 % receive VPS placement during the same admission as the primary MMC repair. Total hospital costs for the MMC hospitalizations have remained relatively stable from 42,843 dollars in 2003 to 46,749 dollars in 2009 (adjusted to 2009 dollars). CONCLUSION Demographics of children having MMC repair have not changed significantly over the past decade, while these surgeries have become more concentrated in pediatric-specialized centers. There appears to be a plateau in public health and access advances with relatively stable cost of MMC hospital care.
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Affiliation(s)
- Dominic A Harris
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA.,Department of Neurosurgery, Baylor College of Medicine, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA
| | - Jacob Cherian
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA.,Department of Neurosurgery, Baylor College of Medicine, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA
| | - Melissa LoPresti
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA.,Department of Neurosurgery, Baylor College of Medicine, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA
| | - Andrew Jea
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA.,Department of Neurosurgery, Baylor College of Medicine, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA. .,Department of Neurosurgery, Baylor College of Medicine, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA.
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Role of Endoscopic Third Ventriculostomy in the Management of Myelomeningocele-Related Hydrocephalus: A Retrospective Study in a Single French Institution. World Neurosurg 2016; 87:484-93. [DOI: 10.1016/j.wneu.2015.07.071] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 12/20/2022]
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Tulipan N, Wellons JC, Thom EA, Gupta N, Sutton LN, Burrows PK, Farmer D, Walsh W, Johnson MP, Rand L, Tolivaisa S, D'alton ME, Adzick NS. Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement. J Neurosurg Pediatr 2015; 16:613-20. [PMID: 26369371 PMCID: PMC5206797 DOI: 10.3171/2015.7.peds15336] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The Management of Myelomeningocele Study (MOMS) was a multicenter randomized trial comparing the safety and efficacy of prenatal and postnatal closure of myelomeningocele. The trial was stopped early because of the demonstrated efficacy of prenatal surgery, and outcomes on 158 of 183 pregnancies were reported. Here, the authors update the 1-year outcomes for the complete trial, analyze the primary and related outcomes, and evaluate whether specific prerandomization risk factors are associated with prenatal surgery benefit. METHODS The primary outcome was a composite of fetal loss or any of the following: infant death, CSF shunt placement, or meeting the prespecified criteria for shunt placement. Primary outcome, actual shunt placement, and shunt revision rates for prenatal versus postnatal repair were compared. The shunt criteria were reassessed to determine which were most concordant with practice, and a new composite outcome was created from the primary outcome by replacing the original criteria for CSF shunt placement with the revised criteria. The authors used logistic regression to estimate whether there were interactions between the type of surgery and known prenatal risk factors (lesion level, gestational age, degree of hindbrain herniation, and ventricle size) for shunt placement, and to determine which factors were associated with shunting among those infants who underwent prenatal surgery. RESULTS Ninety-one women were randomized to prenatal surgery and 92 to postnatal repair. The primary outcome occurred in 73% of infants in the prenatal surgery group and in 98% in the postnatal group (p < 0.0001). Actual rates of shunt placement were only 44% and 84% in the 2 groups, respectively (p < 0.0001). The authors revised the most commonly met criterion to require overt clinical signs of increased intracranial pressure, defined as split sutures, bulging fontanelle, or sunsetting eyes, in addition to increasing head circumference or hydrocephalus. Using these modified criteria, only 3 patients in each group met criteria but did not receive a shunt. For the revised composite outcome, there was a difference between the prenatal and postnatal surgery groups: 49.5% versus 87.0% (p < 0.0001). There was also a significant reduction in the number of children who had a shunt placed and then required a revision by 1 year of age in the prenatal group (15.4% vs 40.2%, relative risk 0.38 [95% CI 0.22-0.66]). In the prenatal surgery group, 20% of those with ventricle size < 10 mm at initial screening, 45.2% with ventricle size of 10 up to 15 mm, and 79.0% with ventricle size ≥ 15 mm received a shunt, whereas in the postnatal group, 79.4%, 86.0%, and 87.5%, respectively, received a shunt (p = 0.02). Lesion level and degree of hindbrain herniation appeared to have no effect on the eventual need for shunting (p = 0.19 and p = 0.13, respectively). Similar results were obtained for the revised outcome. CONCLUSIONS Larger ventricles at initial screening are associated with an increased need for shunting among those undergoing fetal surgery for myelomeningocele. During prenatal counseling, care should be exercised in recommending prenatal surgery when the ventricles are 15 mm or larger because prenatal surgery does not appear to improve outcome in this group. The revised criteria may be useful as guidelines for treating hydrocephalus in this group.
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Affiliation(s)
| | | | - Elizabeth A Thom
- The Biostatistics Center, George Washington University, Washington, DC;
| | | | | | - Pamela K Burrows
- The Biostatistics Center, George Washington University, Washington, DC;
| | | | - William Walsh
- Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark P Johnson
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Pennsylvania
| | - Larry Rand
- Obstetrics and Gynecology, University of California, San Francisco, California
| | - Susan Tolivaisa
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; and
| | - Mary E D'alton
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Pennsylvania
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Melo JRT, Pacheco P, Melo END, Vasconcellos Â, Passos RK. Clinical and ultrasonographic criteria for using ventriculoperitoneal shunts in newborns with myelomeningocele. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:759-63. [DOI: 10.1590/0004-282x20150110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective Hydrocephalus is one of the main complications associated with myelomeningocele (MM). This study aimed to identify clinical and ultrasonographic criteria for using ventriculoperitoneal (VP) shunts in this group of patients.Method A retrospective cohort study, based on established protocol for VP shunt implant in hydrocephalic children with MM. Parameters used to guide the indication of VP shunts included measurement of head circumference (HC), evaluation of fontanels, and measurement of lateral ventricular atrium (LVA) width by transcranial ultrasonography.Results 43 children were included in the analysis, of which 74% had hydrocephalus and required a VP shunt. These children had LVA width ≥ 15 mm, showed increased HC, or had bulging fontanels.Conclusion VP shunt is required in children with increased HC (≥ 2 standard deviation regarding age group), bulging fontanels, or LVA width of ≥ 15 mm after the closure of MM.
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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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Rocque BG, Bishop ER, Scogin MA, Hopson BD, Arynchyna AA, Boddiford CJ, Shannon CN, Blount JP. Assessing health-related quality of life in children with spina bifida. J Neurosurg Pediatr 2015; 15:144-9. [PMID: 25415252 DOI: 10.3171/2014.10.peds1441] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study is to explore various aspects of health-related quality of life (HRQOL) in children with spinal dysraphism. METHODS The authors enrolled a prospective cohort of 159 patients from the multidisciplinary spina bifida clinic. Surveys were distributed to caregivers of patients with spina bifida who were 5 years old and older. Data were collected using the Health Utilities Index Mark 3 focusing on vision, speech, hearing, dexterity, ambulation, cognition, emotions, and pain. Each participant received an overall HRQOL utility score and individual domain subscores. These were correlated with demographic and treatment variables. Analysis was done using SPSS statistics (version 21). RESULTS There were 125 patients with myelomeningocele, 25 with lipomyelomeningocele, and 9 with other dysraphisms. Among patients with myelomeningocele, 107 (86%) had CSF shunts in place, 14 (11%) had undergone Chiari malformation Type II decompression, 59 (47%) were community ambulators, and 45 (36%) were nonambulatory. Patients with myelomeningocele had significantly lower overall HRQOL scores than patients with closed spinal dysraphism. Among patients with myelomeningocele, younger patients had higher HRQOL scores. Patients with impaired bowel continence had lower overall HRQOL scores. History of a ventriculoperitoneal shunt was associated with worse HRQOL (overall score, ambulation, and cognition subscores). History of Chiari malformation Type II decompression was associated with worse overall, speech, and cognition scores. Patients who could ambulate in the community had higher overall and ambulation scores. A history of tethered cord release was correlated with lower pain subscore. No association was found between sex, race, insurance type, or bladder continence and HRQOL. CONCLUSIONS Patients with myelomeningocele have significantly lower HRQOL scores than those with other spinal dysraphisms. History of shunt treatment and Chiari decompression correlate with lower HRQOL scores.
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Affiliation(s)
- Brandon G Rocque
- Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
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