LATE REPAIR OF MYELOMENINGOCOELE: DOES TIMING OF PRESENTATION AFFECT OPERATIVE OUTCOME?

Abstract

Background: Myelomeningocele (MMC) is the most severe form of spina bifida. While delayed surgical closure is not associated with a higher prevalence of long-term morbidity, early closure is known to reduce the risk of meningitis and ventriculitis. However, most of the patients in our practice setting either presented late or presented under septic condition both precluding the possibility of early repair. This later subset had the benefit of antibiotic treatment and wound care prior to operative repair. Aim of the study: To compare those that prsented early with those that presented late. Patients and Methods: This is a prospective cohort study involving patients with myelomenigocoele managed operatively at the Regional Centre for Neurosurgery, Sokoto between September, 2015 and November, 2016. Demographic and post-operative clinical outcomes during in-patient admission and six months follow-up period including superficial wound infection, deep wound infection, cerebrospinal fluid leaks, hydrocephalus and timing of VP shunt insertion were studied and analysed. Results: A total of 90 patients were studied with 45 recruited for each arm of the study (early presenters versus late presenters) respectively. The overall mean age at presentation was 101.86 days with male to female ratio of 1:1. The mean time from birth to first VP shunt was 2.7±1.4 months for the early presenters and 6.0±2.2 months for the late presenters with p < 0.001). Sixteen of the patients (35.6%) who presented early had superficial wound infection compared to 12 (26.7%) of those late presented late with p = 0.362. Six patients. Eight of the patients (17.8%) who presented early had CSF leaks while 10 (22.2%) of patients that presented late had CSF leaks with p = 0.598. Eighteen (40.0%) of patients that presented early developed hydrocephalus while 20 (44.4%) of patients that presented late developed hydrocephalus with p = 0.03. Twenty seven (60.0%) of the patients who presented late had poor gross motor development compared to 16 (35.6%) of patients that presented early with p = 0.020. Six (13.3%) of patients that presented early died compared to 1 (2.2%) patient that presented late. Conclusion: The mean time from birth to first ventriculo-peritoneal shunt insertion for those who presented early was 2.7+1.4 months compared to 6.0+2.2 months for patients that presented late This association had strong statistical correlations with P < 0.001. Superficial wound infection was commoner among those that presented early. Conversely, cerebrospinal fluid leak and hydrocephalus were more common among patients that presented late.