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Neurosurgical procedures for children with myelomeningocele after fetal or postnatal surgery: a comparative
Gordon Worley1, Rachel G Greenberg2,3, Brandon G Rocque4
1Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.
Insights
Fetal surgery for myelomeningocele is linked to fewer neurosurgical procedures, including cerebrospinal fluid diversion and Chiari decompression, compared to postnatal surgery. Shunt revisions and tethered cord releases showed no significant differences between groups.
Area of Science:
- Neurosurgery
- Developmental Biology
- Pediatric Surgery
Background:
- Myelomeningocele is a complex birth defect requiring neurosurgical intervention.
- Fetal surgery offers potential benefits by addressing the condition before birth.
- Comparing surgical outcomes is crucial for optimizing patient care.
Purpose of the Study:
- To compare the rates of subsequent neurosurgical procedures in patients who underwent fetal closure versus postnatal closure of myelomeningocele.
- To evaluate the effectiveness of fetal surgery in reducing the need for interventions for associated conditions.
Main Methods:
- A comparative effectiveness study using the National Spina Bifida Patient Registry.
- Matching 298 fetal surgery patients with 648 postnatal surgery patients based on birthdate and clinic site.
- Utilizing multivariable Poisson regression to analyze procedure frequencies, adjusting for multiple covariates.
Main Results:
- Fetal surgery was associated with a significantly lower frequency of cerebrospinal fluid (CSF) diversion for hydrocephalus (46% vs. 79%; p<0.01).
- Fetal surgery also showed a decreased frequency of Chiari decompression for brainstem dysfunction (3% vs. 7%; p=0.02).
- No significant differences were found in the frequencies of shunt revision or tethered cord release between the fetal and postnatal surgery groups.
Conclusions:
- Fetal surgery for myelomeningocele is associated with reduced rates of CSF diversion and Chiari decompression compared to postnatal surgery.
- These findings suggest potential long-term benefits of in-utero repair for specific neurosurgical complications.
- Further research may explore the impact on quality of life and long-term neurodevelopmental outcomes.
Aim:
To compare the frequencies of neurosurgical procedures to treat comorbid conditions of myelomeningocele in patients who underwent fetal surgery versus postnatal surgery for closure of the placode.
Method:
By utilizing the National Spina Bifida Patient Registry in a comparative effectiveness study, 298 fetal surgery patients were matched by birthdate (±3mo) and spina bifida clinic site with one to three postnatal surgery patients (n=648). Histories were obtained by record review on enrollment and yearly subsequently. Multivariable Poisson regression was used to compare frequencies of procedures between cohorts, with adjustments for sex, ethnicity, insurance status, spinal segmental level of motor function, age at last visit recorded in the Registry, and, for shunt revision in shunted patients, age at cerebrospinal fluid (CSF) diversion.
Results:
The median age at last visit was 4 years. In fully adjusted analyses in patients aged at least 12 months old, fetal surgery was associated with decreased frequency of CSF diversion for hydrocephalus by ventriculoperitoneal shunt insertion or endoscopic third ventriculostomy compared with postnatal surgery (46% vs 79%; incidence rate ratio=0.61; 95% confidence interval [CI] 0.53-0.71; p<0.01). Over all ages, fetal surgery was associated with decreased frequency of Chiari decompression for brainstem dysfunction (3% vs 7%; incidence rate ratio=0.41; 95% CI 0.19-0.88; p=0.02). Also over all ages, differences were not significant in frequencies of shunt revision in shunted patients (53% vs 55%; incidence rate ratio=0.87; 95% CI 0.69-1.11; p=0.27), nor tethered cord release for acquired spinal cord dysfunction (18% vs 16%; incidence rate ratio=1.11; 95% CI 0.84-1.47; p=0.46).
Interpretation:
Even with the variations inherent in clinical practice, fetal surgery was associated with lower frequencies of CSF diversion and of Chiari decompression, independent of covariates. What this paper adds Fetal surgery was associated with lower frequencies of cerebrospinal fluid diversion and decompression of Chiari II malformation than postnatal surgery. Frequencies of ventriculoperitoneal shunt revision and tethered cord release were not significantly different between cohorts.
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