Low level myelomeningoceles: do they need prenatal surgery?
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Postnatal closure of a myelomeningocele remains the standard of care in many countries. The prenatal closure has given hope for decreasing the damage to the neural placode and has challenged classic management. However, this technique presents potential sources of complications. Patients with MMC with an anatomical level of L4 and below have a better functional prognosis than higher level malformations. Are they still candidates for prenatal surgery?
To evaluate outcome of MMC with an anatomical level of L4 and below and discuss, with support of the literature, the indications to perform prenatal closure in this particular group of patients.
Materials and methods
Twenty-nine children were included in this observational study. The level of the vertebral malformation was sacral in 12 cases (41.4%) or lumbar (level ≤ L4) in 17 cases (58.6%). All the patients was operated postnatally for closure of the MMC with microsurgical technique as soon as possible after clinical evaluation (range 0–97 days).
Only 11 out of 29 patients (37.9%) needed of a CSF diversion. A Chiari II malformation was present before MMC closure in 17 patients (58.6%) and only in 5 (17%) after. Twenty-six patients (89.7%) were able to walk. Seven (23%) and 16 (55%) of our patients have a normal bladder and bowel control, respectively. All school-aged children attend school.
The functional outcome for low-level MMC is good when managed with modern microneurosurgical techniques with a low risk for the patient and the mother. Therefore, we do not suggest prenatal surgery for subgroup of infant with MM.
KeywordsSpinal dysraphism Multidisciplinary management Pediatric Postnatal surgery Myelomeningocele Prenatal surgery
Chiari type II malformation
Choroid plexus coagulation
Cerebro spinal fluid
Endoscopic third ventriculostomy
Gross motor function classification system
Management of myelomeningocele study
Magnetic resonance imaging
scan ultra-sound scan
Shunt ventriculo-peritoneal Shunt
Week of gestation
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