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BarrowNeurologicalInstitute

BarrowQuarterlyVolume16,No4,2000
MyelomeningoceleRepair
W.BruceCherny,MD
DivisionofNeurologicalSurgery,BarrowNeurologicalInstitute,St.JosephsHospitalandMedicalCenter,Phoenix,Arizona
Abstract
Thetechniqueforrepairingmyelomeningocelesisreviewed.
KeyWords:myelomeningocele,spinabifida

Spinabifidamaybeassociatedwithawide
rangeofmeningealandneuralherniations
thatvariesfromasmalloutpouchingofthe
meningestocompleterachischisis.
Meningocelesandmyelomeningoceles(Fig.
1)presentwithagreatvarietyoflocations,
forms,sizes,andcoverings.Neurological
functionvariesfromcompleteparalysis
belowthelevelofthelesiontopatients
beingneurologicallyintact.Themost
commonlocationforthesecongenital
anomaliesisoverthelumbosacralregion.
Thesechildrenmayalsohavemanyother
congenitalabnormalities.
Inmostinstances,myelodysplasiashouldbe
treatedsurgicallyassoonafterbirthas
possible,irrespectiveofwhetherthe
meningocelehasruptured.Thegoalsof
surgeryaretoprotecttheneuralelements,
toremoveexcessskintissue,andtoobtain
awatertightduralclosuretoprevent
infectionwithoutexacerbatingneurological
deficits.

Figure1.(A)Midsagittalsection(B)crosssectionofalumbar
myelomeningocele.

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Figure2.Operativepositionofthepatient.Thelumbarareaiselevatedwithrespecttotheheadtoreducethe
lossofcerebrospinalfluid.Thecircumferentialincisionpreservesasmuchhealthyskinaspossible.
Technique
Aftergeneralanesthesiahasbeeninduced,thebabyisplacedproneontheoperatingtablewiththeheadslightlylowerthanthe
backsothatthecerebrospinalfluidwillnotbereplacedbyair(Fig.2).Theoperativesiteiscleanedappropriately.The
myelomeningoceleisirrigatedwellwithwarmsterilesaline,andthesurroundingskiniscleansedwithBetadine(Purdue
FrederickCo.,Norwalk,CT)orHibiclens(ZenecaPharmaceuticals,Wilmington,DE).BetadineandHibiclensareneurotoxicand
shouldnotbeplaceddirectlyontheexposedneuralplacode.Theanusissealedofffromtheoperativefieldbyproperdraping.
Thedrapesareappliedwithagenerousareaexposedsothatextensiveskinflapscanbemobilized.
Theskinincisionissketchedonthebabysback.Verticalextensionsareplannedtounderminetheskinandtoachieveamidline
closure,ifpossible.Theskinisincisedimmediatelyadjacenttotheexposedmeninges(Fig.3).Eveniftheskinextendswellon
tothedomeofthelesion,itshouldbepreserved.Redundantskinisexcisedlater.Theincisioniscarrieddownandoftenintothe
meningealsac,initiallyinanareafreeofneuralelements.Theskinedgesareretractedlaterally.Inthewallofthesac,nerve
rootsthatcoursebackintothespinalcanalaremobilized.Someneuralelementsareatreticandterminateinthesacitselfand
maybesacrificed.Theedgesoftheneuralplacodearethenfoldedandsuturedwithinterrupted60monofilamentnylon(Fig.4)
toreanimate(restore)theconfigurationofthespinalcord.Withinthespinalcanal,thefilumterminalecanoftenbeidentified.It
shouldbecutsharplytoreleasetheassociatedtetheringofthespinalcord.

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Figure3.Operativefieldasviewedbythesurgeon.Dashedlinesindicatecircumferentialincisionattheedgeof
theplacodeanditsrostralandcaudalextensions.Dottedlinesindicatetheextentoftheunderminedskinneeded
toaccomplishclosure.

Figure4.(A)Surgeonsviewoftheneuralplacodeduringclosure.Dashedlinesindicateduralincision.Figure4.(B)Cross
sectionoftheplacodesuturedclosed.Theduraisincisedandmobilized.Theskinflapisdissectedsubcutaneouslyfromthe
fascia,beginningattheedgeofthebonydefect.
Theduraisthendissectedfromthesubcutaneoustissueandlumbosacralfascia(Fig.4).Awatertightclosureisessentialand
canbeverifiedbytheanesthesiologistperformingaValsalvamaneuveronthepatient.Toreinforcetheduralsutureline,the
paravertebralmusclesandfasciaaremobilizedtocloseinthemidline,ifpossible,andtoreestablishtheirproperdorsalposition
relativetothevertebralelements(Fig.5).Alternatively,semilunarflapsoflumbosacralfasciacanbeswungacrossthemidline
andsuturedtothebaseoftheoppositeside(Fig.6).Theskinmarginsareunderminedtotheextentthatthewoundcanbe
reapproximatedwithouttension,oftenfarouttothelateralflankareasbilaterally.Placementofsmallsubcutaneousdrains
bilaterallyalongtheflankisoptionalandhelpspreventseromasthatmightbeconfusedwithcerebrospinalfluidleakagefromthe
spinalcolumn(1to2daysofdrainageisadequate).Alayerofabsorbable,undyedsutureisusedtoclosethesubcutaneous
dissection.

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Figure5.(A)Duralclosureandfascialincision(dashedlines).(B)Closureofthefasciaandparavertebralmusclesalongthe
midline.Thebonydefectisghostedbelowtheclosure.

Figure6.(A)Alternatefascialclosureusingsemilunarflaps.Thedashedlinesindicatethefascialincision.(B)Eachsemilunar
flapissuturedacrossthemidlinetotheotherfascialflap.

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Figure7.(A)Theskinisapproximatedandtrimmed.Thesubcutaneousunderminingisindicatedbytheshadedarea.(B)The
skinisclosedwithacontinuoussuture.Optionalsubcutaneousepifascialdrainsareshown.
Nylonisusedtosuturetheskinandisleftinplaceabout10days(Fig.7B).Thedressingmustremaindryandthewound
isolatedfromfeces.Thechildisnurturedproneorlateral3to4daysaftersurgerytoavoidunduepressureonthefreshsurgical
woundandtoallowdependentdrainageofurineandfeces.

2014DignityHealth

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