Thoracolumbar myelocele repair: how I do it

TL;DR

This paper describes a surgical technique for repairing thoracolumbar myelocele in infants to prevent infections and stabilize neurological function.

Contribution

The paper presents a detailed surgical approach for thoracolumbar myelocele repair, emphasizing anatomical precision and prevention of complications.

Findings

Surgical repair of myelocele stabilizes neurological status and prevents infections.

Anatomical understanding is crucial for preserving healthy tissue and restoring normal anatomy.

Watertight dural closure and meticulous soft tissue handling are essential to avoid complications.

Abstract

Myelocele is a rare form of open spina bifida. Surgical repair is recommended prenatally or in the first 48 h. In some cases, the repair may be delayed, and specific surgical factors need to be considered.

We give a brief overview of the surgical anatomy, followed by a description of the surgical repair of a thoracolumbar Myelocele in an 11-month-old child.

Surgical repair of the Myelocele stabilizes the neurological status, prevents local and central nervous system infections. The understanding of Myelocele anatomy enables its removal while preserving as much healthy tissue as possible and restoring normal anatomy.

The online version contains supplementary material available at 10.1007/s00701-024-06163-2.

1. In the absence of life-threatening condition, any spinal dysraphism repair should be undertaken as soon as possible, ideally within the first 48 hours of life. However, circumstances may lead to a delayed repair, as in our case.

2. Each child should undergo a preoperative MRI of the spinal cord and imaging of the brain to look for signs of hydrocephalus (present in approximately 90% of cases).

3. A good anatomical understanding is fundamental.

4. The aim of the surgery is to restore the normal anatomical pattern, stabilize the neurological and clinical status of the child and prevent complications such as local infection or meningitis.

5. Microscopic magnification is crucial for identification of structures such as the opening of the normal dura into the skin, fusion of the spinal cord into the placode and the emergence of roots in epidural space.

6. Removal of the epithelium covering the placode is mandatory to prevent the formation of inclusion dermoid cysts.

7. Watertight closure of the dura mater is imperative to prevent CSF leakage.

8. Maximum effort should be made to facilitate primary closure of the soft tissue. Incision at the border of the dystrophic skin covering the MC and horizontal incision allows efficient skin transposition and closure.

9. Blunt dissection between the subcutaneous fat and the thoracolumbar fascia allows for the preservation of the perforating arteries.

10. Early signs of complications such as wound dehiscence, CSF leakage and infection of the operative site should be carefully monitored.

The online version contains supplementary material available at 10.1007/s00701-024-06163-2.

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