SPINA BIFIDA

Spina bifida
Failure of fusion of the vertebral arches
producing a defect in the posterior midline with
or without mal-development of the spinal cord
and membranes

Two types
o Spina bifida occulta
o Spina bifida aperta (cystica)
 Meningocele
 Myelomeningocele
 TYPES
• SPINA BIFIDA • SPINA BIFIDA CYSTICA
– MENINGOCELE
OCCULTA
– MENINGOMYELOCELE
– OPEN
MYELOMENIGOCELE
 Spina bifida
Spina bifida occulta
o Seen in 50% of the normal
o Small defect in lumbo-sacral region
o Spinal cord & meninges are normal
& thus un-noticed
o Incidental finding on X-rays
Presentation
o Cutaneous lesion seen
 Tuft of hair
 Naevus
 Sacral pit
 Haemangioma
 Lipoma
 SPINA BIFIDA OCCULTA
• Mildest form
• Midline defect between laminae and nothing more
• Usually l5 LEVEL
• OFTEN ENCOUNTERED ACCIDENTLY

• Occasionaly several vertebrae involved

• Dimpling, pit, tuft of hair, pigmentation if present
signify some something serious
• Associated intraspinal abnormality like tethering of
conus medularis, diastematomyelia(splitting of cord)
 Spina bifida
Spina bifida occulta
Investigations
o X-rays
o Myelogram
o CT scan
o Magnetic resonance imaging
 Spina bifida
Spina bifida occulta
o No neurological abnormality
o Myelogram show no obstructive pathology
o Non-progressive neurological deficit
No active treatment required

o When neurological deficit is

present,progressive and myelogram is
abnormal
Surgical intervention needed
 SPINA BIFIDA CYSTICA
• Severe form
• Contents of canal prolapse through defect

• MENINGOCELE
– 5% of spina bifida
– Duramater is open posteriorly but meninges intact
– Cord and root remain inside the canal
• MYELOMENIGOCELE
– MOST COMMON TYPE
– PART OF CORD and nerve root prolapse into meningeal sac
– In a more primitive form the unfolded neural tube is open out to
environment and there is no sac OPEN MYELOMENINGOCELE

– Almost always there is some neurological deficit

– Sacular lesion over lumbar spine
– Deformities associated
 Equinovarus or calcanevalgus of feet
 Recurvatum of knee
 Hip dislocation
• LMN PLASY
• LOSS OF SENSATION BELOW AFFTECTED LEVEL
• LOSS OF SPINCTER CONTROL

• HYDROCEPHALOUS MAY BE PRESENT

• IN OLDER CHILDREN (TETHERED CORD SYNDROME)

– CLAWING OF TOES
– CHANGE IN GAIT
– INCONTINENCE
 SCREENING AND
INVESTIGATIONS
• Elevated Serum Alpha feto protein level
• Elevated Amniotic alpha feto protein

These are usually done in second trimester

• Midterm USG can detect 95% of cases of spina bifida

– Lemon sign
– Banana sign
These signs are intracranial findings which are associate with
neural tube defects
• PLAIN XRAYS
• MRI
• GADOLINIUM ENHANCED MRI

PRECONCEPTIONAL 400 MCG FOLLIC ACID

TAKEN UPTO 12 WEEKS OF GESTATION
REDUCES THE INCIDENCE
 TREATMENT
• IN RECENT YEAR INTRAUTERINE SURGERYS

• Care must be taken to dress the wound and prevent infectiom

• Formal neurosurgical closure should be done in 48 hours

• All neural tissue should be preserved and covered with dura

• Some center avoid urgent operation if neurological level is

above L1, if there is hydrocephalous, if there is severe spinal
deformities
 Spina bifida
Spina bifida cystica
Orthopaedic management : Principles
Optimise locomotor function
o Correction of limb deformities
 To facilitate bracing of the limb
o Restoration of muscle power
 Prevent recurrence of deformity
o Bracing of the paralysed limb
 To facilitate walking
 Spina bifida
Spina bifida cystica
Orthopaedic management : Principles
Correction of limb deformities
o Recurrence rate of deformities is high as muscle
imbalance is not corrected
o Procedures like manipulation & cast application are
avoided
 No sensation & hence risk of ulceration is high
o Surgery preferred
 Tendon lengthening
 Bony procedures : excision of bone
 Spina bifida
Spina bifida cystica
Orthopaedic management : Principles
Restoration of muscle power
 Tendon lengthening / tenotomy
 Tendon transfer
Bracing with orthosis
 Prevent deformity
 Following surgery
 prevent recurrence & facilitate walking
 Spina bifida
Spina bifida cystica
Orthopaedic management : Principles
Prevent neuropathic ulcers
 Care of the anesthetic feet
 Use of soft lined footwear
 Correction of limb deformities
 Plantigrade foot
• Surface area of contact increased
• Minimizes risk of ulceration
 Spina bifida
Spina bifida cystica
Orthopaedic management : Principles
Associated problems
 Has to be evaluated by the neurosurgeons &
the urologists for status of hydrocephalus &
kidneys
 Every visit to hospital requires review by the
entire team including the physiotherapist