Patterns of hip migration in non-ambulant children with cerebral palsy: A prospective cohort study.

BACKGROUND: In children with cerebral palsy (CP), we have little information on when hip migration (HM) starts, what causes hip displacement, how HM changes over time, and how to halt this migration to avoid surgery. OBJECTIVES: We aimed to estimate the prevalence of HM percentage (HMP)>40% in a homogeneous population of non-ambulant children with CP and model the changes in HMP over a 2.6-year mean follow-up. METHODS: From September 2009 to September 2015, this observational, prospective, multicenter cohort study recruited 235 children from 51 centers who were 3 to 10 years old and had levels IV and V of the Gross Motor Function Classification System for CP. The outcomes were yearly HMP measurements by the Reimers index. Only children with at least one hip with HMP≤40% at baseline were included in trajectory modeling. Comparisons of chidren's characteristics between trajectory groups were adjusted by the false discovery rate method. RESULTS: The prevalence of children with at least one hip with HMP>40% was estimated at 24.3% (95% confidence interval 18.6-30.0). Pelvic obliquity was observed in 51.4% and 24.4% of children with asymmetric and symmetric HMP (P=0.002). The trajectory modelling identified 3 types of MP changes over time. Many children (67.4% and 79.3% for the right and left hip) could be assigned to the "stable" trajectory group. CONCLUSIONS: In non-ambulant children with CP, the prevalence of HM requiring surgery is low and most hips remain practically stable over time.

Low level myelomeningoceles: do they need prenatal surgery?

BACKGROUND: Postnatal closure of a myelomeningocele remains the standard of care in many countries. The prenatal closure has given hope for decreasing the damage to the neural placode and has challenged classic management. However, this technique presents potential sources of complications. Patients with MMC with an anatomical level of L4 and below have a better functional prognosis than higher level malformations. Are they still candidates for prenatal surgery? OBJECTIVE: To evaluate outcome of MMC with an anatomical level of L4 and below and discuss, with support of the literature, the indications to perform prenatal closure in this particular group of patients. MATERIALS AND METHODS: Twenty-nine children were included in this observational study. The level of the vertebral malformation was sacral in 12 cases (41.4%) or lumbar (level ≤ L4) in 17 cases (58.6%). All the patients was operated postnatally for closure of the MMC with microsurgical technique as soon as possible after clinical evaluation (range 0-97 days). RESULTS: Only 11 out of 29 patients (37.9%) needed of a CSF diversion. A Chiari II malformation was present before MMC closure in 17 patients (58.6%) and only in 5 (17%) after. Twenty-six patients (89.7%) were able to walk. Seven (23%) and 16 (55%) of our patients have a normal bladder and bowel control, respectively. All school-aged children attend school. CONCLUSIONS: The functional outcome for low-level MMC is good when managed with modern microneurosurgical techniques with a low risk for the patient and the mother. Therefore, we do not suggest prenatal surgery for subgroup of infant with MM.

Postnatal Management of Myelomeningocele: Outcome with a Multidisciplinary Team Experience.

INTRODUCTION: Myelomeningocele (MMC) is a complex neural tube defect. Few studies report the results of modern postnatal management. The goal of this study was to report the long-term outcome of a multidisciplinary approach of patients with MMC. METHODS: Forty-six MMCs were included. Clinical status was evaluated prospectively. RESULTS: Mean follow-up was 8.1 years. The level of the malformation was sacral or lower lumbar (≤L4) in 27 cases, higher lumbar (between L1 and L3) in 5 cases, and thoracic in 14 cases. A Chiari II malformation was present at birth in 78.3% of the cases. Seventy-six percent of the patients were operated on within the first 24 hours of life. Sixty-one percent needed a cerebrospinal fluid diversion procedure. Seven patients underwent a second surgery for a retethering of the spine. Eighty percent presented with orthopedic problems. Sixty-five percent of our patients were able to walk. Only 13% of patients had a normal urinary elimination. Two groups of patients were identified: one group with a malformation at the level of L4 or below (group 1) and another group with a malformation strictly above L4 (group 2). Group 1 had significantly better outcome. CONCLUSIONS: This series proves that modern multidisciplinary postnatal management of MMC is effective. In the light of these results and of the results of prenatal management of MMC, prenatal surgery seems to be a highly valuable tool to improve the outcome of patients with high lesions (level ≥L3).