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  • Shaken Baby Syndrome

    Tuesday, 21 July 2015 16:28
  • Amniotic fluid problems

    Thursday, 14 May 2015 12:54
  • Choosing a pre-school

    Friday, 10 April 2015 17:50
  • Newborn reflexes

    Tuesday, 03 March 2015 15:49
  • Mastitis

    Tuesday, 03 March 2015 15:41
  • Pelvic floor exercises

    Wednesday, 11 February 2015 17:20
  • Colic

    Wednesday, 11 February 2015 17:11
  • Antenatal Classes

    Monday, 03 June 2013 09:34
  • Strap-in-the-Future

    Thursday, 30 June 2011 13:52

Spina Bifida

 "Unborn baby grabs the hand of the surgeon"

Fact or fiction, sensationalism or miracle; advances in surgery have allowed damage to the spinal cord and excessive fluid around the brain, to be repaired before birth in some cases of spina bifida.

What is Spina Bifida (Myelomeningocele)?

Spina bifida is a congenital defect consisting of an opening in the spinal column. Although most children with this defect survive, they can be left with severe disabilities, such as paralysis, problems with bowel and bladder control, a Chiari II malformation, excessive fluid in the brain (hydrocephalus), and mental retardation. The higher the opening on the spine, the greater the impairment. The most severe form of spina bifida is called myelomeningocele.

Spina bifida is one of the most common birth defects, affecting approximately 1 in every 1 000 live births. It occurs 5 times more often in females than males. In general, the cause of spina bifida is unknown, though it has been associated with maternal diabetes, certain medications, and certain genetic problems.

In the past, infants with myelomeningocele, underwent surgery shortly after birth, to close the normal tissues of the back and protect the spinal cord. A ventriculoperitoneal (VP) shunt was also placed to treat the excessive fluid on the brain. Since the success of the MOMS (Management of Myelomeningocele Study) Trial, in 2002, foetal intervention is now considered to be a treatment option for some cases of spina bifida.

Currently, spina bifida is the only non-fatal, foetal defect for which foetal intervention is performed. According to Dr. Harrison, at the UCSF Fetal Treatment Centre: "spina bifida is the only foetal problem that we've gone after, that is not life-threatening- because babies born with this problem, don't die- but it certainly has such a major impact on their life, that i think it is reasonable to go after it".

How is spina bifida detected?

Between the 15th and 20th week of pregnancy, a blood test called AFP or maternal serum fetoprotein, is offered to screen for spina bifida. If the levels of alpha fetoprotein are elevated, additional tests such as an ultrasound are performed, to confirm the diagnosis.

If spina bifida has been identified, a series of ultrasounds are performed throughout the pregnancy, to monitor the baby's progress. A chromosomal analysis may be recommended to identify chromosomal abnormalities. If other abnormalities are suspected, a foetal MRI or echocardiogram may be required. These prenatal tests will be evaluated by a neurosurgeon.

In a postnatal spinal examination, spina bifida can be felt as 2 separate vertebral body prominences.

Evaluating the severity of spina bifida:

The range of outcomes for spina bifida, depend on the level of the defect. If the defect is higher than L2 (lumbar vertebrae), it carries a very high risk that the child will need a wheelchair for life, due to lower limb paralysis with urinary and fecal incontinence. If it is lower than L2, there is a good chance for at least partial independent ambulation. Lesions below S2 (sacral vertebrae), have a very good chance for independent walking.

There are several other complications, besides motor functions or the ability to walk, associated with neural tube defects. The most important one is an associated complication in the brain, namely a Chiari II malformation. This occurs when the base of the brain is positioned too low, so that it extends into the top of the spinal cord. This can result in hydrocephalus or too much fluid accumulation in parts of the brain. Hydrocephalus is a fairly common complication and if it is severe enough, it requires a VP shunt, to drain the excess fluid into the abdominal cavity. Progressive hydrocephalus is associated with mental retardation and other central neurological deficits. 

The MOMS study:

For the first time in the history of mankind, a randomized clinical trial was conducted to compare prenatal versus postnatal repair of myelomeningocele. It was found that prenatal intervention, significantly reduced the need to divert or shunt fluid away from the brain, caused improvements in mental development and motor functioning, and increased the child's chances of walking unassisted, later in life. The study showed that some of the causative factors, responsible for problems like Chiari II malformation and hydrocephalus, only develop during the second half of pregnancy. Surgery during early pregnancy, to close the foetus' back, may restore some nerve functioning in pregnancy and reverse the development of this serious condition. Prenatal surgery was found to reduce the need for shunting and improved motor outcomes. However, it did increase the risks for preterm delivery and uterine dehiscence (splitting open, as in a surgical wound) at delivery.


Fetal surgery for myelomeningocele:

As Dr. Adzick, the Chief surgeon at the Children's Hospital of Philadelphia points out: "Foetal intervention for spina bifida is not a cure, but there are clearly benefits…All that is very gratifying because you begin with a concept and you land up with hope- hope for families, hope for mothers who are carrying babies with myelomeningocele, hope for those babies themselves, of course".

Prenatal repair of myelomeningocele is a similar procedure to a caesarian section, but the foetus is not removed and the umbilical cord is not touched. An incision is made in the mother's abdomen and uterus just large enough for the spinal defect to be operated upon. A neurosurgeon closes the neural tube and layers of the fetus's back. The mother's incisions are then closed.

After the procedure, the patients will be required to stay in hospital for 4-5 days for recovery. They will be cared for by skilled nurses who have experience in foetal surgical care and the foetus will be monitored via ultrasound.

Delivery recommendations for spina bifida:

Delivery by caesarian section is not necessarily required if your baby has spina bifida, but it may be recommended in certain cases. Discuss delivery plans with your obstetrician to determine the best options for you and your baby. Babies with spina bifida should be delivered in a hospital that is equipped to handle their intensive care and surgical needs. Unless foetal intervention is recommended to address the serious complications of the worst cases of spina bifida, there is usually no reason why a mother should be intentionally induced for early delivery. Mothers can usually carry the child to term.

What will happen after delivery?

Immediately following delivery, your baby will be carefully evaluated to assess their treatment needs. After being stabilized in the neonatal care unit, surgery will be performed by a pediatric neurosurgeon, to repair the spinal malformation. This typically occurs within the first 48 hours following delivery. Your doctors will treat any other complications resulting from the spina bifida and help your family establish a long-term care plan and follow-up.

Long term outcomes and considerations:

There are 2 major problems with spins bifida:

1) The spinal cord opening- this causes problems with the way in which the spinal cord functions.
2) When part of the nervous system is open, it is particularly vulnerable to infection. If this is not repaired, the child has a high risk of developing meningitis, which can be fatal.

The primary goal of surgery after delivery, is to reconstitute the spinal cord, return it to a normal position and close as many layers of the body over it, to prevent further infection.

In general, the muscles and other parts of the lower extremities that are supplied by the spinal cord, do not function. This complication can range from mild to severe.

In almost all children with spina bifida, the involuntary muscles that control bowel and bladder functioning, are severely affected.

Failure of the spinal cord to form properly, also has major effects on brain functioning, most commonly in the form of Chiari II malformations and hydrocephalus.

Some children will require intensive treatment throughout their lives, due to the range of problems associated with spina bifida. The level of the spinal defect is a partial predictor of the severity and extent of the neurological problems. However, the severity of the problems will only be determined over time.

Coping and support:

Although it may be devastating as a parent to learn that your child has a condition, such as spina bifida, there is reason to hope- because most people with spina bifida can go on to lead active, productive lives.

In terms of motor functioning, although children with severe spina bifida, may require a wheelchair; others are able to walk short distances with the assistance of braces, canes or crutches. These devices give them a certain measure of independence and control over their condition.

Many children with spina bifida have normal intelligence but need early educational intervention for learning problems, and can benefit from the assistance of teachers and counsellors to adapt to school. Due to the emotional and social problems that often accompany a disability, children with spina bifida require encouragement to participate in peer related activities and to lead independent lives, within the confines of their physical disability and capabilities.

It may be helpful for parents who are dealing with the condition, to join a support group and talk to others who understand the challenges and rewards of living with spina bifida.


Environmental causes of spina bifida are not yet well understood, but a diet deficient in certain vitamins may play a contributory role. Studies have shown that folic acid consumption prior to and soon after conception, as well as throughout the first trimester of pregnancy, can help prevent some cases of spina bifida.

Coovadia, H.M. & Wittenberg, D.F. (1998). Paediatrics & Child Health: A manual for health professionals in the third world. Oxford University Press: Cape Town.