Orthopedic management of spina bifida

Abstract

The management of orthopedic problems in spina bifida has seen a dramatic change over the past 10 years. The negative effects of spasticity, poor balance, and the tethered cord syndrome on ambulatory function are better appreciated. There is less emphasis on the hip radiograph and more emphasis on the function of the knee and the prevention of knee pain. The importance of the hip abductor muscle and its influence on gait and knee function has been realized. Important developments in the treatment of spinal deformity include the use of pedicle screws which allow better correction. The role of anterior-only spinal surgery has been defined, which allows motion at the lumbo-sacral junction and has a lower postoperative infection rate than posterior surgery. Functional outcome assessments provide better feedback for surgeons and families in regards to which patients may benefit most from surgery. Overall, the past 10 years has seen the increased use of functional outcome measures such as Motion Analysis, oxygen consumption, and patient-based outcome assessments rather than traditional radiographic measures (e.g., hip dislocation or subluxation). This progress has resulted in a better understanding of spina bifida and, more importantly, improved outcomes for our patients. Additional research is likely to further enhance outcomes by establishing additional evidence-based interventions.

Who needs surgery for pediatric myelomeningocele? A retrospective study and literature review

“…4 This study was designed to define the number and type of surgeries performed in patients with MMC. Considering that the functional motor level of a patient with spina bifida (SB) is the primary determinant of neurological alterations, major orthopedic deformities, ambulatory status, treatment, outcome, and ultimate prognosis, 5 we intended to define a pattern of surgeries according to the neurological level of involvement. We also undertook a review to find indications for surgery for MMC, attempting to select areas in which additional knowledge has been lacking, in order to instigate worldwide discussion.…”

Response of Scoliosis in Children with Myelomeningocele to Surgical Release of Tethered Spinal Cord

“…[15][16][17][18][19][20] Symptomatic tethering of the spinal cord following primary myelomeningocele repair occurs in 2.8% to 27% of patients. 9,16,18,19,21 The association of tethered cord with scoliosis has long been assumed. In a study by McLone et al, 17 43 out of 91 patients with myelomeningocele who had surgical release of their symptomatic tethered cord had scoliosis as one of the signs of deterioration.…”

“…[1][2][3][4][5][6][7] It is characterized by early onset and rapid progression. 1,[4][5][6][7][8][9] The pathogenesis of scoliosis in myelomeningocele is considered to be multifactorial, involving neurological level, congenital vertebral anomalies, hydrocephalus and shunt malfunction, Chiari malformation, tethered cord, and hydromyelia. 2,[9][10][11][12][13][14] The level of last intact laminar arch/spinal dysraphism as well as the clinical level of paralysis are highly correlated with the occurrence of scoliosis, 2,5,7,8 with almost all patients with thoracic level lesions (87% to 100%) having scoliosis.…”

Inpatient care for children, ages 1–20 years, with spina bifida in the United States

“…Many children live quite far from the nearest subspecialist [16]. This is especially important because children with spina bifida frequently required services from surgical subspecialist such as orthopedists, neurosurgeons, and urologists [4,[17][18][19]. For example, the distribution of pediatric orthopedic surgeons is heavily weighted toward hospitals with a medical school and not community hospitals, in which only 2% of pediatric orthopedic surgeons practice [20].…”