The reliability of prediction of outcome in spina bifida

The clinical findings in 85 neonates with spina bifida were given to two neurosurgeons and two paediatricians, who were asked to predict from them the length of survival and quality of survival with regard to intellect, locomotion and continence, without their knowing the actual outcome. All four clinicians correctly predicted the survival of infants with meningocele, closed myelocele and encephalocele. The paediatricians correctly predicted the survival of all infants with open myelocele who actually survived, but also included some who had died. The surgeons correctly predicted the deaths of all those with open myelocele who actually died, but expected a considerable number to die who in fact survived. All four clinicians were similar in their predictions of intellect: they underestimated the outcome in patients with successfully shunted hydrocephalus, they overestimated the intellect in patients who had developed intracranial infection and shunt blockage, and they largely underestimated the outcome in the patients who did not require shunts. They made correct predictions for limb and sphincter function in nearly all the survivors. This investigation underlines the problem of selection for treatment caused by the inability to predict the complications of hydrocephalus and infection. Reasons for the differences between the expectations of the paediatricians and surgeons, and the implications of the results of this study for selection for surgery are discussed. It is suggested that limb paralysis and incontinence ought not to be considered as factors excluding infants from treatment.