Fetal endoscopic myelomeningocele closure preserves segmental neurological function

Abstract

Bonn, Germany) performed 19 fetal endoscopic procedures. Three procedures resulted in fetal death, three procedures were interrupted by iatrogenic hemorrhages and 13 procedures were successful. We matched each successfully treated fSBA infant with another nSBA infant of the same age and level of lesion, resulting in 13 matched pairs (mean age 14mo; SD 16mo; f ⁄ m=1.6; female-16, male-10). Matched fSBA and nSBA pairs were compared in terms of segmental neurological function and leg muscle ultrasound density (MUD). We also determined intraindividual difference in MUD (dMUD) between myotomes caudal and cranial to the myelomeningocele (reflecting neuromuscular damage by the myelomeningocele) and compared dMUD between fSBA and nSBA infants. Finally, we correlated dMUD with segmental neurological function. RESULTSWe found that, on average, the fSBA group were born at a lower gestational age than the nSBA group (median 32wks [range 25-34wks] vs 39wks [34-41wks]; p=0.001) and experienced more complications (chorioamnionitis, premature rupture of the amniotic membranes, oligohydramnios, and infant respiratory distress syndrome necessitating intermittent positive-pressure ventilation). Neurological function was better preserved after fSBA than after nSBA (median motor and sensory gain of two segments; better preserved knee-jerk [p=0.006] and anal [p=0.032] reflexes). The dMUD was smaller in fSBA than in nSBA infants (mean difference 24, 95% confidence interval [CI] 15-33; p<0.05), which was associated with better preserved segmental muscle function.INTERPRETATION Fetal endoscopic surgery is associated with spinal segmental neuroprotection, but it results in more complications. Before considering clinical implementation of fetal endoscopic myelomeningocele closure as standard care, the frequency of complications should be appropriately reduced and results assessed in larger groups over a longer period of time.

Comparison between two surgical techniques for prenatal correction of meningomyelocele in sheep

“…The study was not randomized and none of the hypotheses raised to explain this difference was acceptable, according to the authors. The two most recent studies (6,24) showed higher TSCS incidence in fetuses operated before birth. In the MOMS study, there were 6 cases of tethered spinal cord out of the 77 fetuses submitted to intrauterine operation, while there was only one case among the 80 cases operated after birth.…”

“…In the MOMS study, there were 6 cases of tethered spinal cord out of the 77 fetuses submitted to intrauterine operation, while there was only one case among the 80 cases operated after birth. Verbeek et al showed five TSCS cases out of 13 fetuses operated in utero and 2 cases among 13 operated after birth (24) . A possible explanation for these findings would be significant differences between fetal and neonatal healing.…”

“…Concerning tethered spinal cord, there are few studies published (6,21,24) comparing the outcome of human fetuses operated before and after birth. Danzer et al reported a significant difference in the postnatal outcome of fetuses submitted to intrauterine correction compared with those corrected after birth.…”

Anesthesia for In Utero Repair of Myelomeningocele

“…It was concluded by the authors that, "before considering clinical implementation of fetal endoscopic myelomeningocele closure as standard care, the frequency of complications should be appropriately reduced and results assessed in larger groups over a longer period of time. 77 " Ethical considerations regarding the principal concept of primum non nocere argues that until a procedure is appropriately tested in animals it is unethical to pursue in human trials. 78,79 As the prominence of fetal surgery increases, legal questions will arise.…”

Fetal endoscopic myelomeningocele repair

“…The interesting paper by Verbeek et al 1 describes two separate technological advances applied to myelomeningocele. The first, muscle ultrasound density, is not evident in either the title of the article or the conclusion.…”