Article

Our aim was to compare the effect of prenatal endoscopic with postnatal
myelomeningocele closure (fetally operated spina bifida aperta [fSBA]) versus
neonatally operated spina bifida aperta [nSBA]) on segmental neurological leg
condition. METHOD: Between 2003 and 2009, the fetal surgical team (Department of
Obstetrics, University of 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 14 mo; SD
16 mo; 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. RESULTS: We found that,
on average, the fSBA group were born at a lower gestational age than the nSBA
group (median 32 wks [range 25-34 wks] vs 39 wks [34-41 wks]; 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.
CI - (c) The Authors. Developmental Medicine & Child Neurology (c) 2011 Mac Keith
Press.

Langue : ANGLAIS