Neurosurgery notes/Procedures/Myelomeningiocele surgery/Postnatal repair of Open Myelomeningiocele

Postnatal repair of Open Myelomeningiocele

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Myelomeningiocele surgery

General

  • NICE: close within 48hrs
  • Multilayered closure need to be water tight

Pre-op

  • Nurse baby prone
  • prevent desiccation—keep the exposed neural tissue moist.
  • Wrap open leaking defect in sarin wrap
  • Examination
    • Measure the skin defect
      • if the skin defect with is larger than the height plastic will be needed
    • Examine to see any contraction when dorsiflexing the ankle
    • Check anal tone and wrinkling of the anal verge
  • Consent and book patient into theatre lists and inform plastics if required
  • Vancomycin infusion
  • Use latex-free environment
    • Reduces development of latex allergy, as well as attack by maternal antibodies that may have crossed through the placenta.
  • Do not allow scrub solutions or chemical antimicrobials to contact neural placode.
    • Betadine is neurotoxic
  • Do not use monopolar cautery.

Intra-op

  • Help with intubation of child when supine
  • Get neonatal set ready
  • Clean skin with saline
    • Betadine contact with neural tissue is toxic
  • Drape widely to allow for plastic skin mobilization
  • Using microscope or loops identify the neural placode and it's layers
Dealing with pathology
  • Begin by dividing the abnormal epithelial covering from the normal skin.
    • The pia-arachnoid may be separated from the neural tissue.
  • Define the pia layer (placode) and dissect it off the surrounding tissues suture the pia layer with 5.0 pds
    • place 3 tagging sutures to close the open chord before running a continuous suture
    • Avoid placing tension on the neural placode.
  • The dura
    • It often helps to start with normal dura above, and then work down.
    • The dura can then be isolated around the periphery and followed deep to the spinal canal superiorly.
    • The dura is then also formed into a tube and approximated in a water-tight closure.
    • If the dura cannot be closed, the placode may be judiciously trimmed.
    • Use 5.0 PDS to tag the Dura together to running suture to close the dual defect
    • Place tisseal glue on the sutured pseudo-dura
  • The filum terminale should be divided if it can be located.
  • The skin is then mobilized and closed.
    • Dermoid tumors may result from retained skin during the closure, but alternatively dermoids may also be present congenitally.
  • Kyphotic deformity,
    • Repaired at the same sitting as the MM defect closure.
    • The kyphotic bone is rongeured, and 2–0 Vicryl is used to suture the adjacent bones.
    • Post op bracing optional
  • Skin closure plastics involvement with 4.0 monocyrl
  • Multiple layer closure
    • 5 layers should be attempted if not 2
    • Benefit
      • If tethering occurs in the future can be easier to release with multilayerd closure
    • No evidence that multiple layer closure either improves neurologic function or prevents later tethering,
    • Silastic does not prevent adherence in series with long follow-up (>6 yrs), and may even render untethering procedures more difficult.

Post op

  • MRI Whole spine and brain
  • Keep patient off all incisions
  • Bladder catheterization regimen
  • Daily OFC measurements
  • Avoid narcotics
    • Midbrain malformation (associated chiari 2) renders these patients more sensitive to respiratory depression from narcotics
  • If not shunted
    • Regular head U/S (twice weekly to weekly)
    • Keep patient flat to ↓ CSF pressure on incision
  • If a kyphectomy was done, use of a brace is optional (surgeon preference)

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