title: Fetal endoscopic myelomeningocele closure preserves segmental neurological function.
abstract: OBJECTIVE
  Our aim was to compare the effect of prenatal endoscopic with postnatal myelomeningocele closure (fetally operated spina bifida aperta [fSBA]) versus neonatally operated spina bifida aperta [nSBA]) on segmental neurological leg condition.
  
  
  METHODS
  Between 2003 and 2009, the fetal surgical team (Department of Obstetrics, University of Bonn, Germany) performed 19 fetal endoscopic procedures. Three procedures resulted in fetal death, three procedures were interrupted by iatrogenic hemorrhages and 13 procedures were successful. We matched each successfully treated fSBA infant with another nSBA infant of the same age and level of lesion, resulting in 13 matched pairs (mean age 14 mo; SD 16 mo; f/m=1.6; female-16, male-10). Matched fSBA and nSBA pairs were compared in terms of segmental neurological function and leg muscle ultrasound density (MUD). We also determined intraindividual difference in MUD (dMUD) between myotomes caudal and cranial to the myelomeningocele (reflecting neuromuscular damage by the myelomeningocele) and compared dMUD between fSBA and nSBA infants. Finally, we correlated dMUD with segmental neurological function.
  
  
  RESULTS
  We found that, on average, the fSBA group were born at a lower gestational age than the nSBA group (median 32 wks [range 25-34 wks] vs 39 wks [34-41 wks]; p=0.001) and experienced more complications (chorioamnionitis, premature rupture of the amniotic membranes, oligohydramnios, and infant respiratory distress syndrome necessitating intermittent positive-pressure ventilation). Neurological function was better preserved after fSBA than after nSBA (median motor and sensory gain of two segments; better preserved knee-jerk [p=0.006] and anal [p=0.032] reflexes). The dMUD was smaller in fSBA than in nSBA infants (mean difference 24, 95% confidence interval [CI] 15-33; p<0.05), which was associated with better preserved segmental muscle function.
  
  
  CONCLUSIONS
  Fetal endoscopic surgery is associated with spinal segmental neuroprotection, but it results in more complications. Before considering clinical implementation of fetal endoscopic myelomeningocele closure as standard care, the frequency of complications should be appropriately reduced and results assessed in larger groups over a longer period of time.
authors: Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.  
authors: Renate J
authors: RJ
authors: Verbeek
authors: Axel
authors: A
authors: Heep
authors: Natalia M
authors: NM
authors: Maurits
authors: Reinhold
authors: R
authors: Cremer
authors: Eelco W
authors: EW
authors: Hoving
authors: Oebele F
authors: OF
authors: Brouwer
authors: Johannes H
authors: JH
authors: van der Hoeven
authors: Deborah A
authors: DA
authors: Sival
mesh_terms: D001139:Arnold-Chiari Malformation / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery; D015897:Comorbidity; D004185:Disability Evaluation; D005260:Female; D005332:Fetoscopy / Q000379:methods*; D005500:Follow-Up Studies; D005865:Gestational Age; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007431:Intraoperative Complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery; D008297:Male; D008591:Meningomyelocele / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology* / Q000601:surgery*; D018482:Muscle, Skeletal / Q000000981:diagnostic imaging / Q000503:physiopathology; D009460:Neurologic Examination; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology; D011379:Prognosis; D012307:Risk Factors; D016137:Spina Bifida Cystica / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome; D016216:Ultrasonography, Prenatal