Article
Myelomeningocele management: open fetal surgery and fetoscopic repair versus postnatal surgery
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Authors
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Elke Januschek
- Neurosurgical Department, Sana Klinikum Offenbach GmbH, Offenbach, Germany; Neurosurgical Department, Asklepios Children`s Hospital, Sankt Augustin, Germany
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Andreas Röhrig
- Neurosurgical Department, Asklepios Children`s Hospital, Sankt Augustin, Germany
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Sandra Kunze
- Neurosurgical Department, Asklepios Children`s Hospital, Sankt Augustin, Germany
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Christian Fremerey
- Department of Neonatology and Pediatric Intensive Care Medicine, Asklepios Children’s Hospital, Sankt Augustin, Germany
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Bea Wiebe
- Department of Neonatology and Pediatric Intensive Care Medicine, Asklepios Children’s Hospital, Sankt Augustin, Germany
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Martina Messing-Jünger
- Neurosurgical Department, Asklepios Children`s Hospital, Sankt Augustin, Germany
| Published: | June 8, 2016 |
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Outline
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Objective: Despite folic acid prophylaxis spina bifida prevalence in Germany is still about 2.6 per 1000 births. Myelomeningocele (MMC) is often associated with Chiari II malformation and hydrocephalus (63-91%), as well as other comorbidities. The goal of treatment is to improve the motor function and the impact of comorbidities.
Method: In order to compare MMC a thorough literature review as well as a retrospective analysis of 49 cases (1/2007 -10/2015) with postnatal closure was performed. For each of the 3 operative techniques, associated comorbidities, motor function, maternal and fetal/neonatal risk factors have been analyzed.
Results: In our series no neonatal death or additional maternal morbidity was seen. 49 children (25m, 24f) with NTD were included with a follow up of 1 - 106 months (2 LOF). The average gestational age at birth was 38.2 weeks. In 36 children (73%) Chiari malformation type II (CMII) was found. 85,7% suffered from hydrocephalus requiring a shunt. 23 of 33 patients (70%) are ambulatory w/wo orthotics or devices. 14 children < 2 years were assessed separately (6 no paresis, 4 incomplete paraparesis, 1 paraplegia, 1 hypotonia, 1 able to stand up, 1 foot paresis only). The MOMS included 183 patients, 78 got open prenatal surgery. In this group 2 perinatal death occurred and average gestational age was 34.1 weeks. There were significant maternal complications. Shunt implantation rate was 44%, hindbrain herniation rate 65%. Walking w/wo ortheses and devices was possible in 71%. 51 cases with percutaneous fetoscopic surgery are published by the German group. 4 fetal/neonatal deaths are reported, but no information on HC or hindbrain herniation. Significant maternal morbidity was seen. In 2011 19 cases of the same group were published with a death rate of 15.8% and iatrogenic hemorrhages in 3 cases, associated Chiari II in 85%, preliminary shunt rate of 31%. A secondary tethered cord was found in 38.5%. Beside a high rate of fetal complications, a better sensorimotor function compared to a reference group was found.
Conclusions: Although both methods of fetal surgery suggest a slightly improved motor function, reduction of HC and tonsillar herniation, we could not find significant differences compared to our data e.g. regarding ambulation and motor function. Regarding fetal, neonatal and maternal risks, postnatal repair is safer with low morbidity and no mortality.
