Follow-up for Myelomeningoceles in Children

Author

Richard Gepp, M.D.

Section Editors

Bermans Iskandar, M.D.

Graham Fieggen, M.D.

Senior Editor

Ann Ritter, M.D.

Editor in Chief

Rick Abbott, M.D.

Frequency of Office Visits

• Time of initial postoperative visit: Children are seen in the neurosurgery clinic 1-2 weeks after discharge to evaluate wound healing and follow head circumference and other external signs of hydrocephalus.
• Time of first follow-up visit and who should be seen: Subsequent follow-up is determined on the basis of appearance of the wound and the rate of change for head circumference.
• Frequency of subsequent visits and who should be seen: A 6-week multidisciplinary follow-up visit includes evaluations by neurosurgery, urology, orthopedics, PT/OT, and rehabilitation.
• Multidisciplinary team preferred: Patients with spina bifida should receive periodic evaluations by all the members of the multidisciplinary team. At some institutions, however, such teams are not available, which places the bulk of responsibility of thoroughly assessing the patient on the neurosurgeon. For this reason, it is of great importance that the neurosurgeon be familiar with the major clinical complications that can affect these patients and their quality of life.
• Complete history including developmental: The clinical history should include the child’s developmental progress since birth. The history and examination cover the physical and functional capabilities of the child, including cognition and schooling, independence, bowel and bladder habits and the frequency of urinary tract infections, respiratory issues and apnea, problems of swallowing and gastroesophageal reflux, as well as the social situation in general, and performance in school, work, and home in specific. As concerns arise, referral for more specific evaluations may be warranted, such as sleep studies or neuropsychological testing. More specific questions are directed as needed.
• Physical examination for skin anomalies, scoliosis: The physical examination should include full inspection of the perineal region, dependent regions at risk for skin ulcers, the back for spinal alignment and cutaneous anomalies such as hypertrichosis and dimples, which may indicate an underlying tandem spinal dysraphic lesion,.

Frequency of Imaging

• Baseline imaging: It is important to obtain baseline cranial imaging to evaluate ventricular size whether the child has a shunt, has had an ETV, or is shunt-free. In children with treated hydrocephalus, imaging is reasonable a few weeks after hydrocephalus treatment to ensure the ventricular size is stable. The initial perinatal image can serve as a baseline in a child with no signs or symptoms of hydrocephalus.
• Repeat imaging if signs of shunt malfunction: Developmental delay, rapid increase in head circumference, or new/recurrent neurological symptoms including apnea, bradycardia, and lower cranial nerve dysfunction should prompt cranial imaging to evaluate for progressive ventriculomegaly.
• MRI preferred: Quick-brain and quick-spine MRIs are useful ways to obtain non-sedated, radiation-free imaging (34).

Other Investigations Required

• Urological: Laboratory evaluation of kidney function (eGFR), a voiding cystourethrogram, renal ultrasound, and urodynamic evaluation are all used to assess urological function.
• Tethering assessment: Spine assessment for scoliosis and neurological assessment for signs of deterioration are done regularly to look for signs that may indicate clinically important tethering of the spinal cord.