Spinal
dysraphism and spina bifida apply to a heterogeneous group which has defects of
closure affecting the spinal canal (which may encompass the meninges and spinal
cord itself in addition to bony vertebral elements). Myelodysplasia refers to
defects of spinal cord development, which commonly occurs with spina bifida;
however not necessarily associated with failure of fusion of the arches of the
vertebral spine, so this could include entities such as syringomyelia and
diastematomyelia. Spina bifida occulta is the simple failure of fusion of the
spinal arches (i.e., bony involvement only), such that the neural elements are
covered by skin and do not protrude above the level of the back. Occult spinal
dysraphism means that spina bifida occulta is present with overlying cutaneous
markers such as dimple, fistula, hair patch, and hemangioma. These markers may
indicate the presence of cord tethering with a lipoma or a dermoid cyst. Spina
bifida cystica is the commonest type of NTD which includes meningocele,
meningomyelocele/myelomeningocele, lipomyelomeningocele. A meningocele is a
lesion which does not involve neural elements in the cystic outpouching of the
meninges. Meningomyelocele or myelomeningocele means that dysplastic neural
elements protrude through the unfused vertebral arches. It can be completely
covered with meninges and skin (closed meningomyelocele) or there may be a
connection of spinal fluid to outside (open meningomyelocele). Lipomeningocele
and lipomyelomeningocele are closed meningomyelocele with overgrowth of fatty
tissue involving the meninges alone or including the spinal cord. The term
spina bifida is ambiguous in that it is often used to describe conditions from
spina bifida occulta to spina bifida with myelomeningocele.
The
manifestations of the spina bifida depend on the level of the spinal cord
involvement at which neural tube closure was incomplete. The lesion is located
in lumbosacral area in more than 80% of the cases (3).
Children
with the less common thoracic lesions, have flaccid paralysis of lower
extremities with variable weakness in abdominal and trunk musculature. These
defects are frequently associated with serious complications (e.g., respiratory
compromise). Children with high lumbar lesions (L1, L2) have flaccid paralysis
of knees and ankles and may walk with extensive braces and crutches. Children
with midlumbar lesions (L3) have paralyzed ankles and toes. These children can
accomplish independent ambulation with braces. Children with low lumbar lesions
(L4, L5) often have weak ankle and toe mobility. They are particularly prone to
ankle or foot deformities and often need orthosis for independent ambulation.
Bladder
and bowel problems are present in more than 90% of children with
meningomyelocele regardless of the level of lesion (1). Some children may have
problems with bladder emptying, while others may have problems with storing the
urine adequately. Despite the type of neurogenic bladder, it is crucial to prevent
urinary tract infections and protect the upper urinary tract since renal
failure is one of the important causes of death among these children. Bowel
continence requires normal external sphincter control, internal sphincter
reflex relaxation, rectal sensation and colonic motility. Lack of sensation and
inability to control external sphincters makes these children unable to sense
or control stool passage. Bowel management programs with regularly scheduled
toileting, use of stool softeners, and dietary measures (i.e., additional
fiber) are important to avoid constipation and soiling.
Spina
bifida is often not only an isolated birth defect of the spinal cord and spine,
but there commonly are associated congenital malformations of the brain.
Hydrocephalus is a major complication of meningomyelocele and is present at
birth in 85-95% of cases as shown by ultrasonography (3,4). These children with
hydrocephalus require ventriculoperitoneal shunt (VP shunt) placement. Shunt
malfunction and infection are frequent complications and most children
eventually require shunt revision (30-40% within one year of insertion of the
shunt). Lethargy, vomiting, irritability, bulging and tense fontanelle, and
headache, are common symptoms of shunt malfunction. Seizures also occur in up
to 17% of the children with meningomyelocele and almost always occur in those
with hydrocephalus (5).
Arnold-Chiari
II malformation (the cause of the hydrocephalus) is present in the majority of
children with meningomyelocele. The cerebellum and medulla oblongata are
shifted caudally, so this resultant packing into the cervical spinal canal
results in deformation. The symptoms are due to progressive hydrocephalus (if
untreated) and dysfunction of the lower cranial nerves, respiration and
swallowing. Hydrocephalus occurs in most children secondary to aqueductal
stenosis or obstruction to CSF flow around the medulla.
Any
clinical changes in children with meningomyelocele should prompt a search for
an underlying cause. By far, the most common cause of deterioration is shunt
malfunction. Another important cause is tethering of the spinal cord. Up to one
third of children with myelodysplasia may experience spinal cord tethering. A
tethered spinal cord results from traction on the conus medullaris and cauda
equina, which causes spinal cord stretching and ischemia with subsequent loss
of neurological function. Symptoms of a tethered spinal cord include
spasticity, weakness, decreased sensation in the lower extremities, changes in
urinary and bowel functions, or back pain, progressive scoliosis and foot
deformity. Some children with occult spinal dysraphism (i.e., no overlying
meningomyelocele) are asymptomatic and truly have an occult spinal cord
condition. An MRI scan will identify the spinal abnormality. Surgery is
indicated in symptomatic patients. Prophylactic intervention among asymptomatic
children can prevent the long-term disabilities associated with this condition.
Mastery
of bowel and bladder continence is crucial to optimal functioning and is of the
major importance for social acceptance. The voiding program may include
medications, intermittent catheterization, and possibly operative
reconstruction. Clean intermittent catheterization is the most commonly used
method to help urinary continence. It is used to remove residual urine, improve
urinary drainage, and provide decompression. The goal is to have this task
accomplished by early school age. A child's physical abilities and
psychological readiness for toileting should be assessed and continued assistance
may be necessary for some children.
Children
with physical disabilities are often described by their disabilities, and not
by their strengths or abilities, which are also important. Children with spina
bifida are often automatically placed in regular classes or classes for
children with orthopedic problems. Although this is frequently the best
placement, there are children whose orthopedic problems are secondary and their
learning disability associated with spina bifida may be the major disability.
Children with spina bifida and hydrocephalus may have problems with motor
skills, attention, memory and organization. These issues should be understood
and addressed in the Individualized Education Program (IEP).
Latex
allergy has been common among children with spina bifida (about 20-70%) (6).
Although the cause of latex allergy in children with spina bifida is not known,
it may be due to the early, intense, constant exposure to rubber products among
these children. Latex comes from the sap of the rubber tree Hevea brasiliensis.
After the commercial purification process there are small amount of residual
proteins that could cause allergy symptoms ranging from mild skin rashes or
sneezing to hives, respiratory distress and anaphylactic shock.
Many products
contain rubber components of which we are unaware and environmental exposure to
rubber products in both the community and hospital is widespread (e.g., rubber
bands, erasers, gym mats, certain paints and glues, elastic waist or leg bands
in clothing and disposable diapers). There are some food items (e.g., bananas,
avocado, chestnuts) which can also cause cross-reactions. Prevention is the
best approach. This allergic condition should be documented on medical and
school records, communication devices such as medical alert bracelet should be
provided as well as auto-injectable epinephrine as a part of the emergency plan
for these children. In fact, it is commonly recommended that all children with
spina bifida and/or myelodysplasia be kept latex free even if allergy has not
yet been demonstrated.
The
initial treatment for spina bifida is early surgical closure of the defect.
Because of the multisystem involvement of this condition as stated above,
management of this condition requires a comprehensive, multidisciplinary team
approach. This team may include pediatricians, nurses, specialists
(neurologists, neurosurgeons, urologists, orthopedists,
developmental-behavioral pediatricians), physical therapists, occupational
therapists, social workers, and special education teachers.
Alpha-fetoprotein
(AFP) is elevated in maternal serum (MSAFP) and amniotic fluid (AFAFP) in open
NTDs such as encephalocele, meningomyelocele and anencephaly. It is also
increased in other conditions such as abdominal wall defects (gastroschisis and
omphalocele). AFP becomes measurable in maternal serum at the end of first
trimester. Maternal blood sample measurements are collected between 16-18 weeks
of gestation to provide enough time for more definitive testing as necessary
and to allow sufficient time for decision making regarding continuation or
termination of an affected pregnancy. The MSAFP level is affected by
gestational age and the number of fetuses. Elevated AFP level in amniotic fluid
is more definitive than MSAFP, identifying 90-95% of affected fetuses with open
NTDs. Acetylcholinesterase assay is more specific for neural tissue with a 99%
accuracy rate. Ultrasonography also has been increasingly accurate in prenatal
diagnosis of fetal anomalies.
Folic
acid is a synthetic compound used in dietary supplements and fortified foods.
The term folate includes all compounds that have the vitamin properties of
folic acid (folic acid and naturally occurring compounds in food). The average
diet in the United States contains 200 microgram of naturally occurring folate,
which is less bioavailable than folic acid. Studies have demonstrated that 50%
or more NTDs can be prevented if women consume a folic acid supplement before
and during the early weeks of pregnancy. The American Academy of Pediatrics
endorses the US Public Health Service recommendation that all women capable of
becoming of pregnant consume 400 microgram of folic acid to prevent NTDs.
Studies
have shown improved long term outcome regarding ambulation, urinary continence,
and social continence of stool. One of the studies also showed that about 60%
of children with spina bifida attended regular school programs. These outcomes
depend on the level of lesion and the severity of complications.
Department of Pediatrics, University of Hawaii
John A. Burns School
of Medicine.
Mari Uehara, MD
October 2002
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