Are the selection criteria for the conservative management in spina bifida still applicable?

Management of spina bifida is still controversial. At one extreme is the policy of total care in all cases while some form of selection is practised in many centres. We reviewed 104 patients treated over the last five years. Forty-nine patients, who had one or more adverse criteria, were managed conservatively. Twenty-four of these 49 patients required VP shunt insertions subsequently. Four patients had delayed closure of back lesions, three of them were followed by shunts. There was an overall increased (57%) incidence of surgical intervention in conservatively managed patients over the last five years as compared with 34% from our previous report. We found no difference in the timing of insertion of shunts in actively and conservatively managed patients in this study. The mortality in the actively and conservatively managed patients was 7% and 47% respectively. Eighty-five per cent of the patients who had no surgery died at an average age of 23 days. Patients who died without surgical intervention did not survive long enough to warrant surgery, while the mortality was 20% and had among those who survived surgical intervention. Paraplegia alone was not a predictor of high mortality but the presence of two or more adverse criteria were more accurate indicators of poor prognosis. As 78% of all the deaths in conservatively managed patients occurred within three months, reappraisal of management policy is necessary in the infants surviving beyond three months of age as death is less likely after this time.