Opciones quirúrgicas para la cobertura de defectos del cierre del tubo neural. Serie de casos / Surgical options for coverage of neural tube closure defects. Case series

Introducción. Los defectos del tubo neural (DNT) son la segunda causa más prevalente de malformaciones congénitas, solo detrás de las cardiopatías congénitas. Los DTN abiertos comprenden el 80% de estas malformaciones. El mielomeningocele es el defecto abierto más común del tubo neural. La mayoría de los defectos son lo suficientemente pequeños como para soportar un cierre por primera o por segunda intención, pero el cierre primario puede no ser posible en aproximadamente 25% de los casos, lo cual es evidente en defectos grandes. Pacientes y métodos. El trabajo a continuación tiene como objetivo mostrar la experiencia en el manejo quirúrgico posnatal a través de una serie de caso con 3 pacientes con diagnóstico de defectos de cierre del tubo neural en distintas localizaciones anatómicas sometidos a cirugía en forma conjunta entre el Servicio de Neurocirugía y Cirugía Plástica del Parque de la Salud en la ciudad de Posadas Misiones. Resultados. En nuestra serie los colgajos realizados para la cobertura de mielomeningoceles fueron eficaces, evolucionando en primera instancia con complicaciones menores. La resolución del caso de encefalocele occipital con un colgajo miocutáneo de trapecio diferido resultó ser una opción válida y confiable. Conclusión. El uso de colgajos regionales para la reconstrucción de este tipo de malformaciones congénitas es una opción válida y reproducible, con bajo porcentaje de complicaciones.

Introduction. Neural tube defects (NTD) are the second most prevalent cause of congenital malformations, only behind congenital heart defects. Open NTDs comprise 80% of these malformations. Myelomeningocele is the most common open neural tube defect. Most defects are small enough to support a first or second intention closure, but primary closure may not be possible in approximately 25% of cases, being evident in large defects. Patients and methods. The following work aims to show the experience in postnatal surgical management through a case series with 3 patients diagnosed with neural tube closure defects in different anatomical locations undergoing joint surgery between the Neurosurgery and Plastic Surgery Service of Parque de la Salud in the city of Posadas, Misiones. Results. In our series, the flaps made to cover myelomeningoceles were effective, evolving in the first instance with minor complications. Resolution of the occipital encephalocele case with a delayed trapezius myocutaneous flap proved to be a valid and reliable option. Conclusion. The use of regional flaps for the reconstruction of this type of congenital malformations is a valid and reproducible option, with a low percentage of complications.

Latex sensitization in patients with myelomeningocele: contribution of microarray technique.

Summary: Background. Microarray technique employing molecular allergens is pointed out as a new method to evaluate allergic patients. Objective. To evaluate if microarray technique (ImmunoCAP-ISAC®; I-ISAC®) is similar to fluorescence enzyme immunoassay (FEIA; ImmunoCAP®) in the diagnosis of latex allergy (specific IgE to latex plus symptoms) and latex sensitization (only antibody) in pediatric (9-mo to 14-yrs) patients with myelomeningocele undergone to surgical repair. Methods. Patients underwent skin prick testing (SPT) to latex and food (prick to prick), and dosage of serum specific IgE to latex and recombinant latex allergens (rHev b 1, rHev b 3, rHev b 5, rHev b 6.01, rHev b 6.02, rHev b 8, rHev b 9, and rHev b 11) by ImmunoCAP® and I-ISAC®. Results. The comparison between the two methods showed high level of concordance considering positive and negative results. A statistically significant correlation for rHev b 3 and rHev b 6.01 for the allergic patients, and for rHev b5 and rHev b6.01 for those sensitized to latex, was observed. I-ISAC® is limited to 5 recombinant latex allergens (rHev b 1, 3, 5, 6.01 and 8). Despite the presence of antibodies against pollens, LTP and profilins (I-ISAC®) in some patients, none of them reported symptoms related with intake of fruits and/or vegetables. Conclusion. Both methods are effective in assisting the diagnosis of latex allergy, but differ in the assessment of sensitized pediatric patients with myelomeningocele. The assessment of latex sensitized patients is more complete using the 8 recombinant latex fractions available for ImmunoCAP®, instead of I-ISAC®.

Congenital hemangioma in spondylocostal dysostosis: a novel association

Abstract Congenital hemangioma is a benign tumor caused by dysfunction in embryogenesis and vasculogenesis, which progresses during fetal life to manifest as fully developed at birth. Although hemangiomas are the most common tumor of infancy, rapidly involuting congenital hemangioma has not been described in spondylocostal dysostosis. I report the novel association of congenital hemangioma and spondylocostal dysostosis in a Mexican newborn female patient with neural tube defects. Given the embryological relationship between skin and nervous system, I surmise that this association is not coincidental. I also propose that these morphologic alterations be incorporated to the spondylocostal dysostosis phenotype and specifically looked for in other affected children, in order to provide appropriate medical management and genetic counseling.

Congenital hemangioma in spondylocostal dysostosis: a novel association.

Congenital hemangioma is a benign tumor caused by dysfunction in embryogenesis and vasculogenesis, which progresses during fetal life to manifest as fully developed at birth. Although hemangiomas are the most common tumor of infancy, rapidly involuting congenital hemangioma has not been described in spondylocostal dysostosis. I report the novel association of congenital hemangioma and spondylocostal dysostosis in a Mexican newborn female patient with neural tube defects. Given the embryological relationship between skin and nervous system, I surmise that this association is not coincidental. I also propose that these morphologic alterations be incorporated to the spondylocostal dysostosis phenotype and specifically looked for in other affected children, in order to provide appropriate medical management and genetic counseling.

Lipomyelocele with osseous dysraphic hamartoma in a child: a case report.

Lipomyelocele is a well-known vertebral malformation that affects intraspinal and extraspinal tissues and compartments. However, other tissues can be associated with the lipomatous component, such as well-developed bones in unusual sites. This association is consistent with dysraphic hamartoma, one of the rarest malformations of the vertebral canal closure. We describe an 8-year-old girl without neurological deficit with a voluminous lipomyelocele associated with a well-developed flat bone articulated to the left iliac wing. We reviewed the role of magnetic resonance and computed tomography with tridimensional reconstruction in this rare form of spinal dysraphism and described the imaging features.

Surgical treatment of myelomeningocele carried out at 'time zero' immediately after birth.

BACKGROUND/AIMS: To present a protocol of immediate surgical repair of myelomeningocele (MMC) after birth ('time zero') and compare this surgical outcome with the surgery performed after the newborn's admission to the nursery before the operation. METHODS: Data from the medical files of 31 patients with MMC that underwent surgery after birth and after admission at the nursery (group I) were compared with a group of 23 patients with MMC admitted and prospectively followed, who underwent surgery immediately after birth--'at time zero' (group II). RESULTS: The preoperative rupture of the MMC occurred more frequently in group I (67 vs. 39%, p < 0.05). The need for ventriculoperitoneal shunt was 84% in group I and 65% in group II and 4 of them were performed during the same anesthetic time as the immediate MMC repair, with no statistically significant difference. Group I had a higher incidence of small dehiscences when compared to group II (29 vs. 13%, p < 0.05); however, there was no statistically significant difference regarding infections. After 1 year of follow-up, 61% of group I showed neurodevelopmental delay, whereas only 35% of group II showed it. CONCLUSIONS: The surgical intervention carried out immediately after the birth showed benefits regarding a lower incidence of preoperative rupture of the MMC, postoperative dehiscences and lower incidence of neurodevelopmental delay 1 year after birth.

Intervenção fisioterapêutica na mielomeningocele / Physical therapy intervention in myelomeningocele

A mielomeningocele (MMC) é um defeito de fechamento do tubo neural, caracterizado pela falha na fusão dos arcos vertebrais, displasia medular e distensão cística das meninges, que contêm tecido nervoso em seu interior. O defeito acontece entre a terceira e quinta semana de vida intra-uterina e nem sempre é diagnosticada durante a gravidez, sendo responsável por 85 por cento dos casos de defeito do tubo neural (DFTN). A manifestação clínica mais óbvia da mielomeningocele (MMC) é a perda das funções sensoriais e motoras nos membros inferiores. O presente estudo demonstrou os resultados da fisioterapia em uma criança com MMC através da funcionalidade e da independência nas atividades de vida diária (AVDs), por meio de aquisições da capacidade de engatinhar e deambular com auxílio.

The myelomeningocele (MMC) is a failure on the neural tube closing, characterized by the flaw in the fusion of vertebral arches, medullary dysplasia and cystic distention of the meninges which contain nervous tissue in their interior. The defect occurs between the third and fifth week of intra-uterine life and not always is diagnosed during pregnancy. It is responsible for 85 percent of neural tube defect cases. The most obvious myelomeningocele clinical manifestations are: loss of sensory and motor functions of the lower limbs. The present study showed the results of physical therapy in a child with MMC through functionality and independence on daily life activities through acquisitions of the capacity of crawling and walking with assistance.

Biosynthetic cellulose induces the formation of a neoduramater following pre-natal correction of meningomyelocele in fetal sheep.

PURPOSE: The aim of this study was to compare the effectiveness of two dura-mater substitutes, namely human acellular dermal matrix (HADM) and biosynthetic cellulose (BC), in repairing, in utero, surgically-induced meningomyelocele (MMC) in fetal sheep. METHODS: A neural tube defect was created at 74-77 days gestation in 36 fetal sheep. They were divided into 3 groups, the control group that did not receive pre-natal corrective surgery, and the other two groups that received corrective surgery using HADM (Group A) or BC (Group B). Both materials were used as a dura-mater substitutes between the neural tissue and the sutured skin. Correction was performed at gestation day 100 and the fetuses were maintained in utero until term. Sheep were sacrificed on gestation day 140. The fetal spine was submitted to macro and microscopic analysis. At microscopy, adherence of the material to the skin and neural tissue was analyzed. RESULTS: In the initial phase (pilot), experimentally-induced MMC was performed on 11 fetuses and 4 survived (37%). In the second phase (study), 25 fetuses received surgery and 17 survived (68%). In the study group, 6 fetuses did not undergo repair (control group), 11 cases were submitted to corrective surgery (experimental group) and one fetal loss occurred. Of the surviving cases in the experimental group, 4 constituted Group A and 6 in Group B. Macroscopically, skin and underlying tissues where easily displaced from the BC in all cases it was used; in contrast, HADM adhered to these tissues. To compare the adherence, 4 cases from Group A and 4 in Group B were studied. We observed adherence, host cell migration and vessel proliferation into the HADM all sections from Group A and this aspect was not present in any cases in Group B (p < 0.05). In Group B, we also observed that a new fibroblast layer formed around the BC thus protecting the medulla and constituting a "neoduramater". CONCLUSION: The use of BC seems to be more adequate as a dura-mater substitute to cover the damaged neural tissue than HADM. It seems promising for use in the in utero correction of MMC because to does not adhere to neural tissue of superficial and deep layers ("tethered spinal cord"). Thus, BC minimizes the mechanical and chemical intrauterine damage to the spinal medulla.

Biosynthetic cellulose induces the formation of a neoduramater following pre-natal correction of meningomyelocele in fetal sheep

PURPOSE: The aim of this study was to compare the effectiveness of two dura-mater substitutes, namely human acellular dermal matrix (HADM) and biosynthetic cellulose (BC), in repairing, in utero, surgically-induced meningomyelocele (MMC) in fetal sheep. METHODS: A neural tube defect was created at 74-77 days gestation in 36 fetal sheep. They were divided into 3 groups, the control group that did not receive pre-natal corrective surgery, and the other two groups that received corrective surgery using HADM (Group A) or BC (Group B). Both materials were used as a dura-mater substitutes between the neural tissue and the sutured skin. Correction was performed at gestation day 100 and the fetuses were maintained in utero until term. Sheep were sacrificed on gestation day 140. The fetal spine was submitted to macro and microscopic analysis. At microscopy, adherence of the material to the skin and neural tissue was analyzed. RESULTS: In the initial phase (pilot), experimentally-induced MMC was performed on 11 fetuses and 4 survived (37 percent). In the second phase (study), 25 fetuses received surgery and 17 survived (68 percent). In the study group, 6 fetuses did not undergo repair (control group), 11 cases were submitted to corrective surgery (experimental group) and one fetal loss occurred. Of the surviving cases in the experimental group, 4 constituted Group A and 6 in Group B. Macroscopically, skin and underlying tissues where easily displaced from the BC in all cases it was used; in contrast, HADM adhered to these tissues. To compare the adherence, 4 cases from Group A and 4 in Group B were studied. We observed adherence, host cell migration and vessel proliferation into the HADM all sections from Group A and this aspect was not present in any cases in Group B (p < 0.05). In Group B, we also observed that a new fibroblast layer formed around the BC thus protecting the medulla and constituting a "neoduramater". CONCLUSION: The use of BC...

OBJETIVO: Estudar os efeitos do emprego de dois materiais consideravelmente diferentes quanto à origem e custo na correção intra-uterina da meningomielocele criada experimentalmente em feto de ovino. MÉTODOS: Em 36 fetos de ovinos foi criado um defeito aberto de tubo neural, com 75 de dias de gestação. Os casos foram divididos em três grupos: o controle onde o defeito não foi corrigido, grupo corrigido A onde o material utilizado para cobrir a medula exposta foi a matriz dérmica humana acelular (MDHA) e o grupo corrigido B onde o material foi a celulose biossintética (CB). Após a correção realizada com 100 dias, os fetos eram mantidos intra-útero até o termo da gestação. Os sacrifícios foram realizados com 140 dias e a coluna fetal era submetida à análise macro e microscópica onde foi observada a aderência dos materiais à pele, medula ou tecido nervoso remanescente. RESULTADOS: Na fase inicial (piloto), 11 fetos foram operados e 4 sobreviveram (37 por cento). Na segunda fase (estudo) 25 fetos foram operados e 17 sobreviveram (68 por cento). No grupo de estudo, 6 fetos não foram submetidos à correção (grupo controle), 11 casos foram corrigidos e ocorreu 1 perda fetal. Do total de 10 casos, 4 constituíram o grupo A e 6, o grupo B. A macroscopia observou-se deslizamento da pele e tecidos subjacentes sobre a CB em todos os casos onde ela foi empregada e isto não ocorreu em nenhum dos casos onde a MDHA foi utilizada. Para comparar a aderência, foram considerados 4 casos do grupo A e 4 do grupo B. A aderência, caracterizada pela migração de células do hospedeiro e proliferação de vasos para dentro da MDHA, foi observada em 100 por cento dos casos do grupo A e em nenhum caso no grupo B (p < 0,05). No grupo B observou-se formação de uma camada de fibroblastos ao redor do material, protegendo a medula, caracterizando a formação de uma "neoduramater". CONCLUSÃO: A utilização da película de celulose biossintética parece ser mais adequada como substituto...

Intraoperative acute tissue expansion for the closure of large myelomeningoceles.

OBJECT: Skin closure has always been the main challenge in treating myelomeningoceles (MMCs). Most cutaneous defects can be treated with the simple undermining and primary suture of the wound edges. This is the ideal treatment, but it is not adequate in cases in which the lesions are greater than 5 cm in diameter. Numerous reconstructive procedures have been described and the results have been satisfactory. The need to mobilize large skin areas and the fact of excessive blood loss, however, are major problems in newborns. Moreover, the tissue undermining destroys most of the skin's vascularization and can harm the adaptation of the skin flaps. The authors describe a technique for primary closure of large MMC skin defects in which they use acute skin expansion during the surgical procedure. METHODS: Skin expansion was achieved by traction of the wound edges with U-shaped sutures and without the need of skin flaps. Sixteen patients with MMCs greater than 5 cm in diameter were evaluated. RESULTS: The MMC areas ranged from 30 to 64 cm2 (mean 45 cm2). Two suture systems were developed based on the quality of the skin edge and the size of the skin defect. Wound edge traction was performed in 10-minute periods. The edges were gradually approximated and this allowed the primary closure of the wound without undermining the tissue in all patients. In one patient skin necrosis developed, which was associated with compression of the malformed underlying vertebrae. CONCLUSIONS: Simplicity, low cost, and satisfactory results were the main advantages of the method and an increase in operative time was a disadvantage. The goal of this technique is not to replace the other methods, but the technique constitutes an effective option in the treatment of large MMCs.

Description of endoscopic ventricular anatomy in myelomeningocele.

OBJECTIVE: The purpose of this work is to present our endoscopic neuroanatomical findings of a series of myelomeningocele and hydrocephalus patients, treated with endoscopic third ventricular cisternostomy (ETVC), in order to describe ventricular configuration abnormalities in this group of patients, in which this neurosurgical procedure has limited performance. METHOD: We checked the videos of 10 endoscopic third ventricular cisternostomies of myelomeningocele patients taken during 24 months as from December 1998. A previous guideline is designed to record anatomic variables in the lateral ventricles, IIIrd ventricle, and basal cisterns. The topic is analyzed in view of the necropsy and imaging background data. RESULTS: The ETVC of lateral ventricles showed: absence of septum (9/10); absence of anteroseptal vein (8/10); absence of choroid plexus and thalamostriate vein (0/10); absence of fornix (1/10): small foramen of Monro (4/10). The ETVC of the IIIrd ventricle showed: impossibility of recognizing any mammillary bodies (4/10); presence of septations (5/10); presence of atypical veins in the floor (6/10); translucent floor (5/10); floor umbilications (5/10); absence of infundibulum (4/10); arachnoid adherences (7/10); and visual contact of basilar artery (4/10). CONCLUSION: There are categorical structural alterations in the ventricular system of myelomeningocele patients that are well correlated with previous necropsy and imaging reports. The ventricular system of dysraphic children presents severe anatomic alterations, which alter the reference points of the classical endoscopic third ventricular cisternostomy.

Cystic spinal dysraphism of the cervical and upper thoracic region.

BACKGROUND: Cystic dysraphic lesions of the cervical and upper thoracic region are rare and only a few series have been published about the topic. These malformations can be divided into categories that include both myelocystoceles and the so-called cervical meningoceles or myelomeningoceles. METHODS: A retrospective study of 18 patients was conducted. RESULTS: In 17 patients a squamous or a cicatricial epithelium of variable thickness covered the dome of the lesions, while the base was covered with full-thickness skin. In one case the skin was entirely normal. Four patients displayed associated CNS malformations and three more had systemic congenital anomalies. All patients underwent surgical exploration and the length of time between birth and surgery ranged from 6 h to 9 months. The most frequent surgical finding, seen in 14 patients, was a stalk connecting the dorsal surface of the spinal cord to the cyst. In three patients the findings were consistent with myelocystocele. Only in one case was a true meningocele found. Hydrocephalus and Chiari II malformation were not as consistently associated as in myelomeningoceles. Neurological signs and symptoms were not so marked as in myelomeningoceles and were found in the follow-up of four patients. In two of them there was a non-progressive deficit, probably expressing an imperceptible involvement of the nervous system in the first year of life. The histopathological findings were of three types: neuroglial stalks, fibrovascular stalks and myelocystoceles. CONCLUSIONS: Cystic dysraphisms of the cervical and upper thoracic region differ clinically and structurally from meningomyelocele and have a more favorable outcome. We believe that these malformations have not been properly labeled and propose a classification based on the structures found inside the cyst.

Arnold-Chiari in a fetal rat model of dysraphism.

UNLABELLED: Dysraphism is a defect in neural tube development, leading to dysplastic growth of the spinal cord and meninges. Myelomeningocele (MM) is just one of its forms. Hydrocephalus is among the most important alterations in MM and occurs as a consequence of Arnold-Chiari malformation (AC). Experimental models have been developed in sheep, rabbits and rats to study MM physiopathology, allowing a more detailed evaluation of clinical parameters involved in this anomaly. OBJECTIVE: Using the experimental model of dysraphism in fetal rats, the aim of this study was to evaluate the relevance of AC malformations, clinical parameters and grade of histological lesions. MATERIALS AND METHODS: Three groups with 16 fetuses in each were compared, MM, Control and Sham, after intrauterine surgical creation of MM on day 18.5 of gestation (term = 22 days). AC was evaluated by photographic comparison of sagittal cuts of fetal heads. Clinical and histological evaluations were also made. RESULTS: 88% of AC (14/16) in MM fetuses were obtained, besides 100% of clinical alterations. Necrosis and erosion of the spinal cord exposed to amniotic fluid were verified in histology. CONCLUSION: The presence of AC in the dysraphism rat model was high. These results allowed the use of this model to study alterations and intrauterine evolution of MM in a fashion similar to those observed in humans.

Successful fetal surgery for the repair of a 'myelomeningocele-like' defect created in the fetal rabbit.

OBJECTIVE: To study the correction of a 'myelomeningocele-like' defect in fetal rabbits. METHODS: Twelve pregnant rabbits had a spinal defect surgically created in 40 of their fetuses at 23 days of gestation. Immediate repair was performed in 30 fetuses (group I), and 10 remained uncorrected (group II). After 30 days, the fetuses were harvested and the anatomopathological aspects where compared using Fisher's exact test. RESULTS: Three different techniques to apply a cellulose graft were used for correction in 8 (technique A), 7 (technique B), and 15 animals (technique C), but only one (technique C) was successful. The survival rate at 30 days was 66.7% (10/15) in group I and 80% (8/10) in group II. A 'myelomeningocele-like' defect was present in all fetuses in group II, while in group I the defect was successfully repaired in 80% of the surviving fetuses (p < 0.01). CONCLUSION: The surgically created spinal defect was successfully repaired, and also the fetal rabbit could be established as a model for the study of intrauterine correction of a myelomeningocele-like defect.

A different technique to create a 'myelomeningocele-like' defect in the fetal rabbit.

OBJECTIVE: To evaluate the fetal survival rate using a modified technique to surgically create a 'myelomeningocele-like' defect in a rabbit model. METHODS: Six white New Zealand rabbits had a spinal defect created in their fetuses at 23 days of gestation. At 30 days of gestation, the fetuses were harvested for anatomo-pathologic evaluation. RESULTS: The defect was created in 19 fetuses and an attempt to correct it was made in 15 cases (group I), and 4 fetuses where left without correction (group II). At 30 days, a 'myelomeningocele-like' defect was present in all surviving fetuses. The total survival rate was 73.68% (14/19); 11 fetus survived in group I and 3 in group II. CONCLUSION: The technical modifications, including fetal positioning and exposure of its back prior to the incision of the lamina, associated with a different technique for myometrium closure, offer an alternative and probably safer method to surgically create a spinal defect in the fetal rabbit.

Diseases of the spine in South American mummies.

OBJECTIVE: The skulls and spinal columns of people from ancient civilizations, which frequently are found in a preserved state at archeological sites, can provide a large amount of information about these individuals' physical condition through paleopathological investigation. METHODS: This study represents the examination of more than 700 human remains dating back more than 8000 years that were recovered from archaeological excavations in the Andean region of southern Peru and northern Chile. RESULTS: Examples of congenital malformations, degenerative processes, infectious diseases, neoplasias, and traumatic diseases were discovered. Congenital anomalies such as spina bifida occulta were relatively common in these populations. No cases of meningomyelocele were discovered. The most common pathological findings were degenerative changes of the vertebral bodies. Large cervical and lumbar osteophytes were identified in some remains. Several cases of cervical spondylosis were determined to be the result of an occupational disease resulting from carrying heavy loads on the back. These heavy loads were supported by wearing around the forehead a tumpline, known as a capacho. The most common infectious disease process in the spine was due to tuberculosis. The diagnosis was made by radiological and histopathological studies, and in several cases the organism Mycobacterium tuberculosis was identified in the soft tissues. Metastatic lesions on the vertebral bodies were identified in a single case. Examples of traumatic spinal injury were rare. Compression fractures were noted infrequently. CONCLUSION: Diseases of the spinal column in the ancient inhabitants of the Andean region of South America were similar to those that affect the present-day population of that area.

Current considerations for myelomeningocele repair.

Important advances have been made in the reconstruction of myelomeningocele during the last few years. Techniques of closure that use diverse tissues available in the back range from very simple to very complex. Most of them have become essential to the plastic surgeon. To facilitate a more efficient interdisciplinary approach, recent advances in knowledge of the vascular anatomy of the skin and specific clinical surgical considerations concerning skin grafts, cutaneous flaps, and musculocutaneous flaps are reviewed. A topographical division of the lesion that will permit a methodologically adequate treatment plan for congenital defects in the back, specifically in the thoracic, thoracolumbar, and lumbosacral regions is suggested.

Mielomeningocele / Meningomyelocele

Por tanto concluimos que formando un equipo multidisciplinario que se haga cargo del tratamiento del paciente con mielomeningocele y su familia en una clínica de asistencia integral, encontraríamos mayor espectro de atención, el cual permitiría no solo ver el sistema afectado, sino también atender al niño en su totalidad. Este equipo compuesto por neurocirujanos, urólogos, ortopedistas, terapistas físicos, ortesistas y pediatras que coordinen al mismo, además de consultores de otras especialidades logra plantear el acompañamiento de la familia desde el diagnóstico precoz intrauterino donde podrían disfrutar de su bebe, pudiendo entender que: "tenían un problema con un niño y no un niño con problemas". Y de esta manera poderlos acompañar en este largo camino que implica la circunstancia que significa tener un niño con una discapacidad, en donde la misma muestra cuan compleja es, que este ser humano pueda ser protagonista y no solo pasar por la vida, necesitamos por lo tanto apoyar, contener, informar y dar el espacio necesario para que los padres no tengan que peregrinar de profesional a profesional sin poder encontrar respuestas claras y concretas. Así, de esta manera, logramos en gran mayoría tener niños que concurran a la escolaridad común, movilizandose con o sin ortesis pero manteniendo su independencia para deambular y mantener seco por período prolongados para realizar sus actividades integrándose a la sociedad