Meningomyelocele

In this condition the normally developed spinal cord or cauda equina may be protruded along with the meninges and these structures may be adherent to the posterior aspect of the sac.

Clinical Features

1. Though myelocele is the most common type of spina bifida (many cases are still born), yet meningomyelocele is the commonest variety of spina bifida in the living children.
2. The bony defect may usually extend over 3 or more segments.
3. At the summit of the swelling skin may be absent or atrophic, so here the meninges are exposed. That is why complications like infection and rupture are not uncommon.
4. In transillumination test the nerves may be seen within the sac (cf. meningocele), though it is a translucent swelling.
5. Neurological manifestations are almost always present. There may be sensory disturbances alongwith trophic changes in the lower extremities. There may be motor disturbances and in advanced cases one may find extensive paralysis of the legs. Bilateral talipes is quite common in this condition, as also urinary incontinence.
6. X-ray will show the bony defect. There may be other abnormalities of the vertebrae, like scoliosis or kyphosis or even haemivertebra.

Complications

1. Infection
2. Rupture
3. Urinary obstruction, hydronephrosis and urinary tract infection

Treatment

Operation must be performed as early as possible. Child’s condition should also be considered, as it should withstand operation.

Delay in operation may cause

1. Infection within the sac and postoperative problems.
2. The sac may rupture and will make operation extremely difficult with infection spreading throughout the subarachnoid space.
3. There will be more adhesion of nerves with the wall of the sac, which will be difficult to separate.
4. Gradually extensive paralysis of the legs and incontinence may occur, so that surgical intervention may become contraindicated.

Steps of Operation

1. The sac is opened and the redundant membrana is excised. Meticulous care must be taken to separate all the nerve fibres which are adherent to the posterior wall of the sac and then they are replaced into the vertebral canal.
2. The membranes are sutured in the midline deep to the bony defect.
3. Adjacent erector spinae muscles and the overlying fasciae are brought in the midline and sutured. Two lateral release incisions are made to minimize tension on the suture line of the muscles. The skin is closed without tension. If difficulty is encountered to bring the skin in the midline, a rotation flap may be used.
4. Further care of these children may be necessary. Repeated orthopaedic and urological surgery may be necessary to rectify orthopaedic defects and urinary incontinence. C.S.F. shunts may be necessary for hydrocephalus.

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4. Spina Bifida-An Overview
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