Survey on Current Postnatal Surgical Management of Myelomeningocele in Germany

Abstract

Background and Study Aims Although postnatal surgery can be regarded as the standard of care for open myelomeningocele (MMC), there is no uniform treatment for this condition in Germany. This study assessed the current situation regarding the management of open MMC, a first and essential step toward the development of standards of practice.

Patients and Methods In the second half of 2009, we had sent standardized questionnaires to 139 neurosurgery departments and 73 pediatric surgery departments (number of returned questionnaires: 98 and 62, respectively) to identify the principles of MMC management. Newborns with open MMC are treated in 57 of the neurosurgery departments and in 18 of the pediatric surgery departments.

Results Overall, 41 of the 57 neurosurgery departments and 16 of the 18 pediatric surgery departments providing care for newborns with MMC perform MMC closure within 24 hours of delivery. In 52 neurosurgery departments and 15 pediatric surgery departments, infants with spina bifida are delivered by planned cesarean section. The diagnostic investigations performed between the time of caesarean delivery and plastic surgical closure vary from none to magnetic resonance imaging of the spine. The criteria underlying the placement of shunts and the time to plastic surgical closure are highly variable.

Conclusions The type of treatment that infants with open MMC receive in Germany differs from institution to institution. Clear and consistent guidelines must be established using an interdisciplinary approach to improve treatment and standardize the care provided by surgical specialists for infants with MMC.

Keywords

myelomeningocele - spina bifida - pediatric surgery - neurosurgery

• References

• 1 Queisser-Luft A, Spranger J. Fehlbildungen bei Neugeborenen. Dtsch Arztebl 2006; 103: 2464-2471
• 2 Simpson JL, Greene MF. Fetal surgery for myelomeningocele?. N Engl J Med 2011; 364 (11) 1076-1077
• 3 Gilbert JN, Jones KL, Rorke LB, Chernoff GF, James HE. Central nervous system anomalies associated with meningomyelocele, hydrocephalus, and the Arnold-Chiari malformation: reappraisal of theories regarding the pathogenesis of posterior neural tube closure defects. Neurosurgery 1986; 18 (5) 559-564
• 4 Mauer UM, Unterreithmeir L, Jahn A, Wagner W, Kunz U, Schulz C. A survey on current practice in the neurosurgical management of preterm infants with posthemorrhagic hydrocephalus in Germany. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (2) 82-86
• 5 Anteby EY, Yagel S. Route of delivery of fetuses with structural anomalies. Eur J Obstet Gynecol Reprod Biol 2003; 106 (1) 5-9
• 6 Merrill DC, Goodwin P, Burson JM, Sato Y, Williamson R, Weiner CP. The optimal route of delivery for fetal meningomyelocele. Am J Obstet Gynecol 1998; 179 (1) 235-240
• 7 Cochrane D, Aronyk K, Sawatzky B, Wilson D, Steinbok P. The effects of labor and delivery on spinal cord function and ambulation in patients with meningomyelocele. Childs Nerv Syst 1991; 7 (6) 312-315
• 8 Luthy DA, Wardinsky T, Shurtleff DB , et al. Cesarean section before the onset of labor and subsequent motor function in infants with meningomyelocele diagnosed antenatally. N Engl J Med 1991; 324 (10) 662-666
• 9 Cuppen I, Eggink AJ, Lotgering FK, Rotteveel JJ, Mullaart RA, Roeleveld N. Influence of birth mode on early neurological outcome in infants with myelomeningocele. Eur J Obstet Gynecol Reprod Biol 2011; 156 (1) 18-22
• 10 van Ham MA, van Dongen PW, Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997; 74 (1) 1-6
• 11 Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS ; Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ 2007; 176 (4) 455-460
• 12 Bailit JL, Garrett JM, Miller WC, McMahon MJ, Cefalo RC. Hospital primary cesarean delivery rates and the risk of poor neonatal outcomes. Am J Obstet Gynecol 2002; 187 (3) 721-727
• 13 Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008; 336 (7635) 85-87
• 14 Quiroz LH, Chang H, Blomquist JL, Okoh YK, Handa VL. Scheduled cesarean delivery: maternal and neonatal risks in primiparous women in a community hospital setting. Am J Perinatol 2009; 26 (4) 271-277
• 15 Di Rocco C, Trevisi G, Massimi L. Myelomeningocele: an overview. World Neurosurg 2014; 81 (2) 294-295
• 16 Nguyen The Tich S, Anderson PJ, Shimony JS, Hunt RW, Doyle LW, Inder TE. A novel quantitative simple brain metric using MR imaging for preterm infants. AJNR Am J Neuroradiol 2009; 30 (1) 125-131
• 17 Charney EB, Melchionni JB, Antonucci DL. Ventriculitis in newborns with myelomeningocele. Am J Dis Child 1991; 145 (3) 287-290
• 18 Pang D. Surgical complications of open spinal dysraphism. Neurosurg Clin N Am 1995; 6 (2) 243-257
• 19 Caldarelli M, Di Rocco C. Myelomeningocele primary repair surgical technique. In: Özek M, Cinalli G, Maixner W, eds. The Spina Bifida: Management and Outcome. Milan, Berlin, Heidelberg, New York: Springer; 2008: 143-155
• 20 Cinalli G, Spennato P, Buonocore M, Cianciulli E, Vinchon M, Sgouros S. Pathophysiology of hydrocephalus. In: Özek M, Cinalli G, Maixner W, eds. The Spina Bifida: Management and Outcome. Milan, Berlin, Heidelberg, New York: Springer; 2008: 215-224
• 21 Radmanesh F, Nejat F, El Khashab M, Ghodsi SM, Ardebili HE. Shunt complications in children with myelomeningocele: effect of timing of shunt placement. Clinical article. J Neurosurg Pediatr 2009; 3 (6) 516-520
• 22 Caldarelli M, Di Rocco C, La Marca F. Shunt complications in the first postoperative year in children with meningomyelocele. Childs Nerv Syst 1996; 12 (12) 748-754