Contraindications
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With an open spinal defect, there is no contraindication for closure, unless the infant is clinically unstable. In that case, closure is deferred until undergoing the procedure is possible. Severe congenital anomalies associated with overall short life expectancy should be evaluated in the respective ethical context.
Planning and positioning
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Clinical evaluation in a multidisciplinary approach (with clinicians in neonatology, neurology, neurosurgery, and orthopedics) should assess overall medical stability, neurologic function, and associated malformations. The presence of commonly associated conditions of hydrocephalus and Chiari malformation needs to be considered when developing a treatment plan for the newborn.
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Examination of the fontanelle and cranial ultrasound and cranial magnetic resonance imaging (MRI) should be performed to assess the degree of associated central nervous system abnormalities. The presence of hydrocephalus must be continuously monitored to plan for a timely shunt insertion. If manifest hydrocephalus exists, we plan the shunt insertion for the time of myelomeningocele closure.
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Spinal ultrasound or spinal MRI is advisable to assess anatomic conditions and to check for additional malformations (e.g., split cord, spinal lipoma).
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The infant is positioned prone with free abdomen to allow for breathing excursions. Hyperextension of the neck must be avoided in case of significant Chiari malformation. Special attention is directed to pad all pressure points and to apply appropriate warming to keep body temperature normal.
Figure 92-1:
Images of exemplary preoperative MRI (T2-weighted images) showing an infant with a lumbosacral myelomeningocele in the axial and sagittal planes. The laminar defect with the protruding spinal cord coursing toward its junction with the exposed placode (which is slightly rotated leftward) can be appreciated.
Figure 92-2:
Positioning of the infant for myelomeningocele repair. Soft gel cushions that leave the abdomen free for respiratory excursions support the chest and pelvis. A warming blanket is already placed under the infant. The arms and legs are wrapped with wadded bandages. All exposed body surfaces except the surgical field are covered with warming blankets.
Planning and positioning
- •
Clinical evaluation in a multidisciplinary approach (with clinicians in neonatology, neurology, neurosurgery, and orthopedics) should assess overall medical stability, neurologic function, and associated malformations. The presence of commonly associated conditions of hydrocephalus and Chiari malformation needs to be considered when developing a treatment plan for the newborn.
- •
Examination of the fontanelle and cranial ultrasound and cranial magnetic resonance imaging (MRI) should be performed to assess the degree of associated central nervous system abnormalities. The presence of hydrocephalus must be continuously monitored to plan for a timely shunt insertion. If manifest hydrocephalus exists, we plan the shunt insertion for the time of myelomeningocele closure.
- •
Spinal ultrasound or spinal MRI is advisable to assess anatomic conditions and to check for additional malformations (e.g., split cord, spinal lipoma).
- •
The infant is positioned prone with free abdomen to allow for breathing excursions. Hyperextension of the neck must be avoided in case of significant Chiari malformation. Special attention is directed to pad all pressure points and to apply appropriate warming to keep body temperature normal.
