Open Spina Bifida surgery [Neurosurgery Wiki]

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====== Open Spina Bifida surgery ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1xYNIuIh3tIGBZwAyq2jhuaVleIcKLqf1FT-K5HopPDEmq6s1H/?limit=15&utm_campaign=pubmed-2&fc=20250611025447}}

“[[Open spina bifida]]” is a broader term that encompasses all [[neural tube defect]]s where the [[spinal cord]] is exposed (without [[skin]] covering), including [[myelomeningocele]].

[[Myelomeningocele repair]] — either [[prenatal]] (fetal) or [[postnatal]] (after birth) — is often what people mean when they refer to “surgery for open spina bifida.”

⚠️ Key Distinctions (if precision is needed):
“Open spina bifida” technically includes other rare variants (e.g., [[myeloschisis]]) — though in practice, >95% of OSB cases are MMC.

MMC repair can be done via:

[[Open fetal surgery]] (via [[hysterotomy]])

Minimally invasive [[fetoscopy]] (hybrid or percutaneous)

Postnatal closure

🔍 Summary:

In clinical and surgical literature, “myelomeningocele repair” is effectively synonymous with “open spina bifida surgery,” unless the context requires distinguishing between different types of open neural tube defects.
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[[Open Spina Bifida surgery]] can be performed postnatally or prenatally, using different techniques with varying outcomes. Below is a comparative table of the main surgical options:

===== Surgical Technique Comparison =====

^ Feature / Outcome                              ^ Postnatal Repair                            ^ Open Fetal Surgery (MOMS Trial)                    ^ Fetoscopic Fetal Surgery (Hybrid / Percutaneous)         ^
| **Timing**                                     | < 48 hours after birth                      | 19–26 weeks of gestation                            | 19–26 weeks of gestation                                 |
| **Surgical Access**                            | Neonatal laminectomy & closure              | Maternal laparotomy + uterine hysterotomy           | Laparoscopy or percutaneous trocars into uterus          |
| **Neurosurgical Closure**                      | Standard microsurgical closure              | In utero placode reposition & duraplasty            | Same goals, more technically demanding                   |
| **Hydrocephalus (Shunt Required)**             | ~80%                                        | ↓ ~40%                                              | ~35–50% (varies by study)                                |
| **Chiari II Malformation**                     | Almost universal                            | ↓ incidence and severity                            | ↓ incidence, possibly similar to open fetal              |
| **Walking at 30 Months**                       | ~55–60%                                      | ↑ up to ~70%                                        | Similar or higher (limited data)                         |
| **Premature Birth (<32 weeks)**                | Low (term birth expected)                   | ↑ ~12–15%                                           | ↑↑ ~13–33% depending on technique                        |
| **Preterm Rupture of Membranes (PROM)**        | None                                        | ~30–35%                                             | ↑↑ Up to 80% in percutaneous fetoscopy                  |
| **Uterine Rupture (Next Pregnancy)**           | No risk                                     | ~9%                                                 | Unknown / likely lower than open                        |
| **Placenta Accreta (Next Pregnancy)**          | No increased risk                           | ~4%                                                 | Unknown                                                  |
| **Technical Complexity**                       | Familiar, standardized                      | Requires specialized multidisciplinary team         | Highly complex, steep learning curve                    |
| **Maternal Morbidity**                         | Minimal                                     | Moderate to high (surgical + obstetric risks)       | Variable; possibly lower than open fetal surgery         |
| **Global Availability**                        | Widely available                            | Only in fetal surgery centers                       | Very limited; still under development in many places     |
| **Long-term Follow-up Data**                   | Well established                            | 10–15 years follow-up (e.g. MOMS)                   | Sparse and heterogeneous                                |

===== Key Points for Neurosurgeons =====

  * Postnatal repair remains the **most widely available and safest standard**, especially in non-specialized centers.
  * Open fetal surgery shows **functional advantages** but at the cost of **maternal and obstetric risks**.
  * Fetoscopic surgery is **promising but still evolving**, and lacks robust long-term data.
  * Regardless of technique, patients require **lifelong multidisciplinary follow-up**, especially for:
    * Hydrocephalus and CSF diversion
    * Tethered cord syndrome
    * Neurogenic bladder and bowel management

===== Fetoscopic Myelomeningocele Repair =====

[[Fetoscopic Myelomeningocele Repair]].

===== Systematic review and proportional meta-analysis =====
In a systematic review and proportional meta-analysis Kunpalin et al.
((Kunpalin Y, Karadjole VS, Medeiros ESB, Dominguez Moreno M, Sichitiu J, Abbasi N, Ryan G, Shinar S, Snelgrove JW, Kulkarni AV, Van Mieghem T. Benefits and complications of fetal and postnatal surgery for open spina bifida: systematic review and proportional meta-analysis. Ultrasound Obstet Gynecol. 2025 Jun 10. doi: 10.1002/uog.29240. Epub ahead of print. PMID: 40492626.))
sets out to clarify a clinically murky field—prenatal and postnatal surgery for open spina bifida (OSB)—but ends up showcasing how data accumulation can masquerade as insight while offering little in terms of real-world guidance.

1. Mixing apples, oranges, and fetoscopies:
The authors lump together studies of wildly differing quality and surgical approaches (classic hysterotomy, mini-hysterotomy, hybrid fetoscopy, percutaneous fetoscopy), as if they were variations on the same technique. This methodological free-for-all undermines the validity of any comparative conclusions. Clinical and methodological heterogeneity is not acknowledged as a critical flaw, but instead paraded as statistical inclusiveness.

2. Misleading proportions, hollow outcomes:
The exclusive use of single-proportion meta-analyses to report outcomes and complications is, at best, naive. No direct comparisons, no adjustments for confounding factors—just raw percentages that invite false equivalencies. A reader might come away thinking that 80% PROM in percutaneous fetoscopy is comparable to 15% preterm birth in mini-hysterotomy. This is not just misleading—it’s dangerous.

3. White-coat selection bias:
By limiting inclusion to studies that mirror the MOMS trial criteria, the authors create an artificial homogeneity that favors prenatal surgery outcomes while ignoring broader real-world diversity. While they claim to assess risk of bias, no meaningful integration or critical discussion of bias is provided in the results or conclusions.

4. The illusion of functional benefit:
Ambiguous claims about toddlers walking at 30 months are presented without context: no survival bias correction, no clarity on assessment methods, and no accounting for socioeconomic, neurological, or rehabilitative variables. Crucially, maternal long-term quality of life, psychosocial impact, and economic cost are entirely omitted. What we’re left with is a sterile list of percentages with no human dimension.

5. Self-congratulatory conclusions:
The article ends by suggesting that its data should inform clinical decision-making. In reality, it offers a descriptive inventory of complications without analytical depth, cost-benefit appraisal, or any patient-centered perspective. A catalog of numbers is not a compass for care.

Final verdict:
This is not clarification—it is confusion dressed in statistics. Rather than advancing understanding, this paper reinforces a superficial narrative by aggregating inconsistent data without critical rigor. In a field that urgently needs nuanced clinical insight, this was a wasted opportunity.