The Use of External Ventricular Drainage to Reduce the Frequency of Wound Complications in Myelomeningocele Closure

Abstract

Introduction: Myelomeningocele (MMC) is an open neural tube defect routinely surgically closed within 48 h of birth to prevent secondary infection. Up to 18% of patients experience wound complications, and 85% require shunting for hydrocephalus. We hypothesized that wound complications could be reduced by cerebrospinal fluid (CSF) diversion at the time of closure. Methods: Institutional review board approval was obtained to review records of the 88 patients who underwent MMC closure between January 2005 and June 2016 at the Children's Hospital of Pittsburgh. Twenty-three patients (26%) had an external ventricular drain (EVD) placed at the time of MMC closure and underwent 7-11 days of CSF drainage. Fourteen patients (16%) had a shunt placed at the time of MMC closure, and 51 (58%) had no form of CSF diversion at the time of MMC closure. Results: Patients with an EVD or shunt placed at the time of closure had no wound complications. In contrast, 8 patients (16%) without CSF diversion at closure developed wound complications (p = 0.048). Seven of the 8 wound complications occurred in the 71 patients with evidence of hydrocephalus at birth (p = 0.98). Of patients with evidence of hydrocephalus at the time of MMC closure, wound complications had a higher rate of occurrence among patients who did not receive a shunt or EVD at closure (p = 0.01). When comparing only patients with evidence of hydrocephalus at birth, the EVD group alone had a lower rate of wound complications than patients who did not receive CSF diversion at the time of closure (p = 0.031). Conclusions: These results suggest that addressing hydrocephalus at the time of MMC closure significantly reduces the likelihood of wound complications and may justify temporary CSF diversion at birth, at least in those patients manifesting hydrocephalus.

Twenty years’ experience with myelomeningocele management at a single institution: lessons learned

“…Our surgical technique and complications of myelomeningocele closures, including wound infections and CSF leaks, have been published previously. 16…”

“…All patients underwent standard neurosurgical closure within 24 hours of birth; our technique has been described elsewhere. 16 Data collection points included Apgar scores, birth weight, anatomical level of defect (shown by radiograph, CT scan, or MR image), functional level of defect (lowest level of purposeful movement in either leg at the age of 24 months, as demonstrated by neurological examination), presence of shunt-treated hydrocephalus, symptomatic Chiari malformation type II (CM-II), and ambulatory ability. Patients were followed for a period ranging from 2 years to 20 years, with a mean of 9.9 years.…”

“…The anatomical level of defect was determined by identifying the lowest intact vertebral level on plain radiograph, CT scan, or MR image. The age of 24 months was chosen as the time to assess functional level for several reasons: It was believed to be the best time to evaluate neurological lower-extremity function-i.e., allowing for the resolution of in utero contractures and myelination of the corticospinal tracts, yet being at a stage before a child is likely to become symptomatic from a tethered spinal cord and prior to most orthopedic procedures; 14,16 this age has been used in previous studies 13,18 and standardization of methodology was thought to be important. Functional level was defined as the lowest level of purposeful lowerextremity movement at 24 months of age as determined by standard neurosurgical physical examination.…”

Shunt infection and malfunction in patients with myelomeningocele

“…A previous study investigated temporary CSF diversion with EVD or VP shunt placement at the time of MMC closure in patients with evidence of hydrocephalus at birth and found that this procedure reduces the rate of wound complications in MMC closure. 28 Given the relatively high risk of developing shunt failure and infection in MMC patients, it is important to explore any potential correlation between early CSF diversion at the time of closure and the presence of shunt infection. The present study shows that CSF diversion with either an EVD or a VP shunt at closure was not significantly associated with the first revision resulting from infection.…”

Management of Neural Tube Defect: A Single-Center Experience

“…In addition, neural malformations are often associated with abnormalities in other organ systems [2,3,[11][12][13][14]. NTD is accompanied by hydrocephalus in 90%, Chiari malformation type II in 70%, scoliosis in >50%, and kyphosis in about 20% of patients [12,15]. This study presents our clinical experiences regarding the development and comorbidities of infants with NTD and compares them with the literature.…”