Erratum. Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement

John C. Wellons IIIVanderbilt University Medical Center, Nashville, TN

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TO THE READERSHIP: An error appeared in the article by Tulipan et al. (Tulipan N, Wellons JC III, Thom EA, et al. Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement. J Neurosurg Pediatr. 2015;16[6]:613-620).

Credit for copyrighted text was not included in the footnotes of Tables 2 and 3 for material previously published in The New England Journal of Medicine. The tables appear on the following pages with the proper credit given in the footnotes.

TABLE 2.

Primary outcome and related outcomes*

VariablePrenatal Surgery (n = 91)Postnatal Surgery (n = 92)Relative Risk (CI)p Value
Primary outcome66 (72.5)90 (97.8)0.74 (96.2% CI 0.65–0.85)<0.0001
 Death before shunt criteria could be evaluated2 (2.2)0 (0.0)
 Met criteria, shunt placed40 (44.0)73 (79.3)
 Did not meet criteria, shunt placed0 (0.0)4 (4.3)
 Met criteria, no shunt placed24 (26.4)13 (14.1)
 Did not meet criteria, no shunt placed25 (27.5)2 (2.2)
Specific criteria met<0.0001
 None27 (29.7)6 (6.5)
 Criterion 1a, c, or d only36 (39.6)20 (21.7)
 Criterion 1b & one or more of 1a, 1c, 1d only21 (23.1)35 (38.0)
 Criterion 2 (w/ or w/o Criterion 1)0 (0.0)2 (2.2)
 Criterion 3 (w/ or w/o Criterion 1 or 2)6 (6.6)6 (6.5)
 Criterion 4 (w/ or w/o Criteria 1–3)1 (1.1)23 (25.0)
Revised composite outcome45 (49.5)80 (87.0)<0.0001
 Death before shunt criteria could be evaluated2 (2.2)0 (0.0)
 Met criteria, shunt placed25 (27.5)63 (68.5)
 Shunt placed w/o meeting criteria15 (16.5)14 (15.2)
 Met criteria, no shunt placed3 (3.3)3 (3.3)
 Did not meet criteria, no shunt placed46 (50.5)12 (13.0)
Shunt & revision14 (15.4)37 (40.2)0.38 (95% CI 0.22–0.66)<0.001
No. of revisions
 026 (65.0)40 (52.0)
 17 (17.5)21 (27.3)
 ≥27 (17.5)16 (20.8)

Data presented as number (%).

Criterion 1: at least 2 of the following:

  • a) an increase in the greatest occipital-frontal circumference adjusted for gestational age defined as crossing percentiles (if a plateau was reached this did not qualify);

  • b) bulging fontanelle or split sutures or sunsetting sign;

  • c) increasing hydrocephalus on consecutive imaging studies determined by increase in ratio of biventricular diameter to biparietal diameter according to the method of O’Hayon et al.; or

  • d) head circumference > 95th percentile for gestational age.

Criterion 2: presence of marked syringomyelia with ventriculomegaly.

Criterion 3: ventriculomegaly with symptoms of Chiari malformation (stridor, swallowing difficulties, apnea, bradycardia).

Criterion 4: persistent CSF leakage from the myelomeningocele wound or bulging at the repair site.

From The New England Journal of Medicine, Adzick NS, Thom EA, Spong CY, et al. A randomized trial of prenatal versus postnatal repair of myelomeningocele, Volume 364, pp 993-1004. © 2011 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

Of those who had shunts placed.

TABLE 3.

Subgroup analyses for shunt placement and outcome with revised criteria

VariableShunt PlacementRevised Composite Outcome*
Prenatal Surgery (n = 91)Postnatal Surgery (n = 92)p ValuePrenatal Surgery (n = 91)Postnatal Surgery (n = 92)p Value
Lesion level0.190.30
 T1–L211/29 (37.9)15/16 (93.8)15/29 (51.7)16/16 (100)
 L3–S129/62 (46.8)62/76 (81.6)30/62 (48.4)64/76 (84.2)
Gestational age at randomization in wks0.030.01
  ≤2316/51 (31.4)37/43 (86.1)18/51 (35.3)39/43 (90.7)
  ≥2424/40 (60.0)40/49 (81.6)27/40 (67.5)41/49 (83.7)
Ventricle size in mm0.010.007
 <106/30 (20.0)27/34 (79.4)6/30 (20.0)28/34 (82.4)
 10 up to 1519/42 (45.2)43/50 (86.0)22/42 (52.4)45/50 (90.0)
 ≥1515/19 (79.0)7/8 (87.5)17/19 (89.5)7/8 (87.5)
Hindbrain herniation0.530.49
 Mild/moderate27/64 (42.2)56/69 (81.2)28/64 (43.8)58/69 (84.1)
 Severe13/27 (48.2)21/23 (91.3)17/27 (63.0)22/23 (95.7)

Revised composite outcome is defined as follows:

Shunt placement or death or meeting revised criteria as follows:

Criterion 1: bulging fontanelle or split sutures or sunsetting sign with at least 1 of the following:

  • a) increase in the greatest occipital-frontal circumference adjusted for gestational age defined as crossing percentiles (if a plateau was reached this did not qualify);

  • c) increasing hydrocephalus on consecutive imaging studies determined by increase in ratio of biventricular diameter to biparietal diameter according to the method of O’Hayon et al.; or

  • d) head circumference > 95th percentile for gestational age.

Criterion 2: presence of marked syringomyelia with ventriculomegaly.

Criterion 3: ventriculomegaly with symptoms of Chiari malformation (stridor, swallowing difficulties, apnea, bradycardia).

Criterion 4: persistent CSF leakage from the myelomeningocele wound or bulging at the repair site.

From The New England Journal of Medicine, Adzick NS, Thom EA, Spong CY, et al. A randomized trial of prenatal versus postnatal repair of myelomeningocele, Volume 364, pp 993-1004. © 2011 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

p value for interaction between factor and surgery group by logistic regression adjusting for sex and lesion level.

Ventricle size and gestational age are included as continuous variables in the model.

The article has been corrected online as of November 4, 2022.

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Figure from Candela-Cantó et al. (pp 61–70).

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