title: Spinal lesion level in spina bifida: a source of neural and cognitive heterogeneity.
abstract: OBJECTIVE
  The aim of this study was to evaluate whether the level of a spinal lesion is associated with variations in anomalous brain development and neurobehavioral outcomes in children suffering from the meningomyelocele form of spina bifida and hydrocephalus (SBM-H).
  
  
  METHODS
  Two hundred sixty-eight children with SBM-H were divided into upper (T-12 and above; 82 patients) and lower (L-1 and below; 186 patients) lesion-level groups. Magnetic resonance images were qualitatively coded by radiologists and quantitatively segmented for cerebrum and cerebellum volumes. Psychometric assessments of handedness, intelligence, academic skills, and adaptive behavior were compared between lesion-level groups and also used to determine the number of children who met research-based criteria for mental retardation, attention deficit hyperactivity disorder, and learning disabilities. The magnetic resonance images obtained in children with upper-level spinal lesions demonstrated more qualitative abnormalities in the midbrain and tectum, pons, and splenium, although not in the cerebellum, compared with images obtained in children with lower-level spinal lesions. Upper-level lesions were also associated with reductions in cerebrum and cerebellum volumes, lower scores on measures of intelligence, academic skills, and adaptive behavior, and with a higher frequency of individuals meeting the criteria for mental retardation. Hispanic children (who were also more economically disadvantaged) were more likely to have upper-level lesions and poorer neurobehavioral outcomes, but lesion-level effects were generally independent of ethnicity.
  
  
  CONCLUSIONS
  A higher level of spinal lesion in SBM-H is a marker for more severe anomalous brain development, which is in turn associated with poorer neurobehavioral outcomes in a wide variety of domains that determine levels of independent functioning for these children at home and school.
authors.affiliation: Departments of Pediatrics and Radiology, University of Texas Health Science Center at Houston, Texas 77030, USA. jack.fletcher@uth.tmc.edu
authors.forename: Jack M
authors.initials: JM
authors.lastname: Fletcher
authors.forename: Kim
authors.initials: K
authors.lastname: Copeland
authors.forename: Jon A
authors.initials: JA
authors.lastname: Frederick
authors.forename: Susan E
authors.initials: SE
authors.lastname: Blaser
authors.forename: Larry A
authors.initials: LA
authors.lastname: Kramer
authors.forename: Hope
authors.initials: H
authors.lastname: Northrup
authors.forename: H Julia
authors.initials: HJ
authors.lastname: Hannay
authors.forename: Michael E
authors.initials: ME
authors.lastname: Brandt
authors.forename: David J
authors.initials: DJ
authors.lastname: Francis
authors.forename: Grace
authors.initials: G
authors.lastname: Villarreal
authors.forename: James M
authors.initials: JM
authors.lastname: Drake
authors.forename: John P
authors.initials: JP
authors.lastname: Laurent
authors.forename: Irene
authors.initials: I
authors.lastname: Townsend
authors.forename: Susan
authors.initials: S
authors.lastname: Inwood
authors.forename: Amy
authors.initials: A
authors.lastname: Boudousquie
authors.forename: Maureen
authors.initials: M
authors.lastname: Dennis
mesh_terms: D000293:Adolescent; D001289:Attention Deficit Disorder with Hyperactivity / Q000175:diagnosis* / Q000503:physiopathology; D001921:Brain / Q000002:abnormalities* / Q000473:pathology / Q000503:physiopathology; D002531:Cerebellum / Q000002:abnormalities / Q000473:pathology / Q000503:physiopathology; D002557:Cerebrospinal Fluid Shunts; D002648:Child; D003627:Data Interpretation, Statistical; D002658:Developmental Disabilities / Q000175:diagnosis / Q000503:physiopathology; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000175:diagnosis* / Q000601:surgery; D007091:Image Processing, Computer-Assisted; D008607:Intellectual Disability / Q000175:diagnosis* / Q000503:physiopathology; D007360:Intelligence / Q000502:physiology*; D007859:Learning Disabilities / Q000175:diagnosis* / Q000503:physiopathology; D008279:Magnetic Resonance Imaging; D008297:Male; D008591:Meningomyelocele / Q000175:diagnosis* / Q000503:physiopathology; D009460:Neurologic Examination / Q000706:statistics & numerical data; D009483:Neuropsychological Tests / Q000706:statistics & numerical data; D011594:Psychometrics; D013116:Spinal Cord / Q000473:pathology* / Q000503:physiopathology; D013223:Statistics as Topic; D013687:Telencephalon / Q000002:abnormalities / Q000473:pathology / Q000503:physiopathology