Meningomyelocele with Laminectomy

Meningomyelocele laminectomy

Meningomyelocele (myelomeningocele) This is a very rare, severe form of spina bifida in which the spinal cord, nerves and meninges are literally hanging out of a hole in the spine, usually at birth. A surgical correction should be performed sufficiently early to prevent infection and further nerve injury. 

Meningomyelocele Laminectomy: Introduction

One of the surgical repair surgeries is a meningomyelocele laminectomy which is performed to:

• Lying bare the affected spinal segment.
• Move neural tissue without risking damaging it.
• Close the soft tissues and spinal defect.
• The practice is performed more often during the first 24-72 hours of birth.

Laminectomy Indications

• Neural tissue bony compression is severe.
• Poor space to re-position spinal cord.
• Spinal canal pathological anomalies.

Myelomeningocele repair laminectomy

Myelomeningocele repair is a neonatal neurosurgical surgery used to seal an open defect of the spinal cords and protect the bare neural tissue. Only in case of the need to securely reposition the spinal cord and nerves, a laminectomy can be carried out during the repair.

Indication of Lamaminectomy in Myelomeningocele Repair

Laminectomy is the partially removed malformed vertebral bone to:

• Decrease the bony neural tissue compression.
• Establish sufficient space on which neural placode can be repositioned.
• Facilitate a watertight tension-free dural closure.

Indications

• Stenosed or pathologic spinal canal.
• Tethered or entrapment placode of the nerves.
• Vertebral dysraphism severe such that it cannot be safely closed.

Preoperative Preparation

• Ideally surgery in 24-72 hours of birth.
• Broad-spectrum antibiotics
• General anaesthetic positioning on the prone.

Exposure

• Incision of the circumference around the sac.
• Skin, subcutaneous tissue and dysplastic muscle dissection.

Neural Placode Management

• Detecting functional neural tissue.
• The close isolation of adjacent membranes.

Laminectomy (Selective)

• Part of malformed laminae resected.
• Do not damage spinal cord and nerve roots.
• Gives space and decompression to reduce.

Dural Repair

• Neural placode developed tubularity.
• Dura matter hermetically sealed to avoid leakage of CSF.

Soft Tissue & Skin Closure

• Stratified muscle and fascial closure.
• Skin closure; rotational/advancement flap where necessary.

Postoperative Care

• NICU monitoring
• Prone or lateral positioning.
• Continued antibiotics

Monitoring for:

• CSF leak
• Wound infection
• Hydrocephalus (in most cases, VP shunt is needed)

Pediatric meningomyelocele laminectomy

A neurological condition, pediatric meningomyelocele (myelomeningocele), is a neural tube defect where the spinal cord, nerves and meninges push through a vertebral defect. In children, laminectomy is not a routine standalone procedure but a selective procedure performed in the course of surgery to enable neural tissue reduction to be done safely and ensure the closure.

Guidelines to Laminectomy in Children

Laminectomy is only carried out when it is required; e.g.:

• Markedly deformed or tapered laminae.
• Small spinal canal that does not allow reduction of placode.
• Tethered or entrapment of the neural elements.
• Bony kyphosis that is associated and causes compression.
• The least bone cutting is desired to prevent instability in the postoperative period.

Timing of Surgery

• Neonates: Preferably 24-72 hours of birth.
• Late presenters/older children: Surgery immediately possible after assessment and infection control.

Meningomyelocele laminectomy recovery

The process of recovery following meningomyelocele (myelomeningocele) repair using laminectomy is a multidisciplinary, gradual one, occurring in the first stages of life, during the neonatal stage, and extending to childhood.

First 48-72 Hours After Surgery

Monitoring

• NICU/PICU care

Continuous monitoring of:

• Vital signs
• Neurological status
• Wound and dressing
• Leakage of cerebral spinal fluid (CSF).

Positioning

• Lateral or prone position in order to protect the surgical site.
• Do not start with supine position.

Medications

• IV antibiotics (prevention of infection)
• Pain control based on the pediatric guidelines.

Early Recovery Phase (1-2 weeks) 

Wound Care

Daily inspection for:

• Redness
• Swelling
• Discharge or CSF leak
• Stitches are normally removed approximately 10-14 days.

Feeding & Activity

• Early resumed breastfeeding or enteral feeding.
• Painless, no back pressure.

Hydrocephalus Surveillance

• Frequent measurement of head circumference.
• Cranial ultrasound/MRI
• VP shunt in case of the occurrence of hydrocephalus.

Hospitals Release Standards 

• Stable vitals
• Dry, healed wound
• No bleeding and/or infection of CSF.

Parents trained in:

• Positioning
• Wound care
• Warning signs

Long-Term Recovery & Aftercare

Neurological Treatment 

• Follow up with neurosurgery regularly.

Monitoring for:

• Tethered cord syndrome
• Progression of neuronal damage

Mobility & Rehabilitation 

Early physiotherapy to:

• Prevent contractures
• For firming up the muscles and the body.
• Use of assistive devices or braces as needed.

Bladder & Bowel Management 

• Urological evaluation
• Only when necessary: Clean intermittent catheterization.
• Continence bowel programs.

Orthopedic Follow-Up

Monitoring for:

• Scoliosis
• Kyphosis
• Hip and foot deformities

Meningomyelocele laminectomy complications

Early or late complications due to meningomyelocele (myelomeningocele) repair with laminectomy are based on the level of the lesion, neural involvement, the time of surgery, and the postoperative treatment.

Early Complications (Days–Weeks)

• Cerebrospinal Fluid Leak
• Wound Complications
• Meningitis / Sepsis
• Decline in Neurological Functioning 
• Hemorrhage

Intermediate Complications (Weeks–Months)

• Hydrocephalus
• Shunt-Related Complications

Late Complications (Months–Years)

• Tethered Cord Syndrome
• Spinal Deformities
• Bladder and Bowel Dysfunction
• Orthopedic Complications

Best hospital for meningomyelocele laminectomy India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Meningomyelocele laminectomy is not a standard treatment but a preventive and helpful measure used in the treatment of myelomeningocele when there is bony decompression that is required. Its main aim is to enable safe replacement of the neural tissue and a watertight closure with no tension that may cause the infection and additional neurological harm. Even though the procedure itself does not eliminate the pre-existing neurological deficits, early surgery along with a careful technique does minimise several complications like CSF leak and meningitis. The outcome will be dependent on the severity of the lesion, the neural characteristics and other related disorders such as hydrocephalus in the long term. To achieve optimal survival, function, and quality of life in the affected children, the management of the disease has to be early, with minimal bone removal, careful postoperative attention, and life-long multidisciplinary follow-up.

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FAQ

1. Is laminectomy necessary in all cases of repair of meningomyelocele?

• No. Laminectomy is not done selectively unless the malformed vertebrae are compressing the neural tissue or making the closure unsafe.

2. When should surgery be done?

• The operation should be performed 24 to 72 hours after birth to minimize the risk of infection and further nerve damage.

3. Does laminectomy improve neurologic outcome?

• No The therapy halts the advancing degeneration, but does not recover neurological damage that already took place.

4. Can children with meningomyelocele walk like normal children? 

• The ability to walk is based on the spinal defect level and nerve damage. Other children might require assistive devices or braces.

5. Is there prevention of meningomyelocele?

• Proper folic acid supplementation prenatal and in early pregnancy stage is an important risk-reducing measure.