[Myelomeningocoele - how did the procedure during the first stage of surgical treatment change. Analysis of two groups of patients treated in the years 1986-1992 and 1999-2005].
Myelomeningocoele is a serious congenital deformity requiring multidisciplinary medical care, and parent' s aware cooperation. The accessibility and popularity of foetal ultrasonography enables early prenatal diagnosis which makes possible optimal management during pregnancy and treatment after birth.


OBJECTIVE
Evaluation of the treatment of newborns with myelomeningocoele in the last 20 years in relation to the changes in diagnostics and operative procedures.


METHODS
The evaluation was performed in 114 newborns, operated on because of myelomeningocoele between 1986-1992 (group I) and 1999-2005 (group II). Prenatal diagnosis, the term and kind of labour, anatomical description of deformity, the level of spinal cord damage were analyzed. Evaluation also included: the term and kind of operation, the presence of active hydrocephalus and its association with the anatomical picture of deformity, the strategy of shunt implantation and the number of deaths during the first hospitalization. Orthopaedic and urological problems were not evaluated.


RESULTS
During twenty years, reduction in the number of patients with myelomeningocoele was not observed, despite the introduction of the programme of women' s folic acid prophylaxis. In two analyzed periods there were 8 new cases treated each year. The number of prenatal diagnoses increased: in group I prenatal diagnosis was made only in 8 cases (14%), in group II in 25 cases (44%), but in most cases diagnosis was established late (in the last 3 months of pregnancy). Analysis of different anatomical forms of the deformity showed, that the number of thoracic myelomeningocoeles decreased from 32 cases in group I to 18 cases in group II. In both groups operation was performed during 24 hours following admission of the newborn to the Institute. The surgical technique has not change: large skin defects were closed with the use of rhomboidal muscle and skin flap (Limberg' s plasty). The number of complications in wound healing decreased from 26.4% to 7%. Active hydrocephalus was confirmed in 49 of 57 patients in group I (85%) and in 46 of 57 patients in group II (80%). Patients without active hydrocephalus (group I - 8 children, group II - 11 children) presented lumbo-sacral or sacral localization of defect. In the years 1999-2005 (group II), contemporary with the operation of myelomeningocoele, Rickham reservoir was implanted in 11 newborns with massive hydrocephalus. The shunt was added after the confirmation of active hydrocephalus and after a negative result of cerebrospinal fluid culture. Decrease of deaths during the first hospitalization was observed (8 in group I, 2 in group II). The principal cause of death in both groups was inborn infection.


CONCLUSIONS
1. On the basis of own investigations the authors did not find positive results of introducing of women' s folic acid prophylaxis programme in Poland in the decrease of number of newborns, treated surgically on spina bifida in the Institute of Mother and Child. In the last years more often sacral and lumbo-sacral type of defects and, in consequence, more patients without active hydrocephalus are observed, which may be the result of parent' s decision about terminating of pregnancy in cases of high (thoracic) deformity. 2. In the years 1999-2005 the increasing number of prenatal ultrasonography is observed. However, the prenatal diagnosis of myelomeningocele in most cases is established late (in the third trimester). 3. Significant fall in the number of local and general complications of treatment is responsible for the decrease in mortality of the newborns with myelomeningoloele. The method of closing large skin defects using cutaneo-muscular rhomboidal flap, introduced in 1986, showed to be very effective in the prophylaxis of complications of wound healing. 4. Congenital intrauterine infection was the main cause of death of neonates with this deformity, what points to the necessity of regular bacteriological and serological diagnostics during pregnancy and proper perinatal treatment.
Boczar
Maria
M
Klinika Chirurgii Dzieci i Młodziezy, Instytut Matki i Dziecka w Warszawie, 01-211 Warszawa. mariaboczar@vp.pl
Sawicka
Ewa
E
Piwowar
Włodzimierz
W
D005260:Female; D005492:Folic Acid / Q000627:therapeutic use; D006801:Humans; D015994:Incidence; D007231:Infant, Newborn; D008297:Male; D008591:Meningomyelocele / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000517:prevention & control / Q000601:surgery*; D011044:Poland / Q000453:epidemiology; D011247:Pregnancy; D016216:Ultrasonography, Prenatal
D005492:Folic Acid