Care management and contemporary challenges in spina bifida: a practice preference survey of the American Society of Pediatric Neurosurgeons

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OBJECTIVE

Neurosurgical management preferences related to myelomeningocele (MMC) care demonstrate significant variability. The authors sought to evaluate variability in practice patterns across a group of senior pediatric neurosurgeons. The purpose of this study was to identify the extent of variability and of consensus with regard to neurosurgical management of MMC and associated hydrocephalus, Chiari II malformation, and tethered spinal cord.

METHODS

A 43-question survey was distributed electronically to the members of the American Society of Pediatric Neurosurgeons (ASPN). The survey covered domains such as clinic case volume, newborn management, hydrocephalus management, transition to adulthood, clinical indications for shunt revision, Chiari II malformation decompression (C2MD), and tethered cord release (TCR). Ninety responses were received from 200 active ASPN members, for an overall response rate of 45%.

RESULTS

The majority (58%) of respondents closed 5–15 new cases of open MMC per year. Nearly all (98%) respondents perform back closure within 48 hours of birth, with the majority imbricating the placode and striving for a 3- to 4-layer closure. The most consistent indications for surgical intervention in early hydrocephalus were CSF leak from the back (92%), progressive ventricular enlargement (89%), and brainstem symptoms, including apnea/bradycardia (81%), stridor (81%), and dysphagia (81%). Eighty percent of respondents indicated that spina bifida care is delivered through multidisciplinary clinics, with neurosurgery, orthopedic surgery, urology, physical therapy, and social work as the most common disciplines included. One-third of clinics see both pediatric and adult patients, one-third offer a formal transition program to adult care, and one-third have no transition program. The vast majority of respondents offer prenatal counseling (95%), referral for in utero closure (66%), and endoscopic third ventriculostomy/choroid plexus cauterization (72%). Respondents were more willing to perform shunt revision for symptoms alone than for image changes alone. An asymptomatic broken shunt without ventricular enlargement produced responses evenly divided between observation, intervention, and further investigation. Operative shunt exploration was always performed before C2MD by 56% of respondents and performed sometimes by 40% of respondents. Symptoms of brainstem dysfunction were the strongest clinical triggers reported for C2MD, while declines in urinary continence, leg strength or sensation, or ambulation were the most consistent thresholds for TCR.

CONCLUSIONS

Significant disparities exist surrounding key areas of decision making regarding treatment for patients with MMC, though there are central areas of agreement among ASPN members. Additionally, there is significant variation in the clinical management of chronic hydrocephalus, C2MD, and TCR, underscoring the need for further research into these specific areas.

ABBREVIATIONS ASPN = American Society of Pediatric Neurosurgeons; CDC = Centers for Disease Control and Prevention; C2MD = Chiari II malformation decompression; ETV/CPC = endoscopic third ventriculostomy with choroid plexus cauterization; EVD = external ventricular drain; IUMC = intrauterine MMC closure; MMC = myelomeningocele; MOMS = Management of Myelomeningocele Study; TCR = tethered cord release.

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Article Information

Correspondence Jeffrey P. Blount: University of Alabama at Birmingham, Birmingham, AL. jeffrey.blount@childrensal.org.

INCLUDE WHEN CITING Published online August 30, 2019; DOI: 10.3171/2019.5.PEDS18738.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Volume of postnatal MMC closure. Histogram demonstrating reported annual volume of postnatal MMC closure. The majority of respondents (> 60%) close 5–15 MMCs each year. Figure is available in color online only.

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    Theoretical hydrocephalus scenarios: Would you surgically intervene for hydrocephalus in the following clinical scenarios?

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    Preferences for temporizing hydrocephalus. Figure is available in color online only.

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    Histogram demonstrating the reported distribution of shunt revisions performed for clinical symptoms alone or imaging changes alone. Figure is available in color online only.

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    Theoretical Chiari II malformation scenarios: What would you do if this were a newborn with myelomeningocele and progressively worsening stridor? If it was an older child with sleep apnea and an existing shunt?

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