EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011
Hassan & Elsawy
DIFFERENT MODALITIES FOR RECONSTRUCTION OF LARGE
MYELOMENINGOCELE DEFECTS
By
Khaled Mohamed Hassan* and Medhat Momtaz Elsawy**
Departments of *Plastic & Reconstructive Surgery and **Neurosurgery
Minia Faculty of Medicine
ABSTRACT:
Background: Closure of large myelomeningocele defects presents a challenging
problem to both the neuro-surgeons and the plastic surgeons. Direct closure is nearly
impossible and if done, it will be associated with problems of wound breakdown, skin
necrosis, and infection. Many efforts were done to overcome these problems and
variety of reconstructive procedures has been described over time.
Materials and methods: We present different techniques for the closure of wide
defect low thoracolumbar and lumbo-sacral myelomeningoceles. 20 neonates and
infants with wide defect myelomeningocele defects admitted to the neurosurgery
department of Minia university and Minia health insurance hospitals through the years
2007-2010. Techniques used for repair are rotational flaps, transposition flap and skin
graft, bilateral rotational fasciocutaneous flaps, skin graft only and sometimes wide
undermining and direct closure. Follow up period was 1-2 years.
Results: 20 neonates and infants were included in the study. The age of the patients
ranged from 3 days to 2 months with a mean of 13.2 days. The diameter of the defect
ranged between 8x7 and 14x11 cm with a mean of 10.2x7.7 cm. The surface area of
the defect ranged between 35.4 and 159 cm2. Techniques used rotational flaps (N =
5), transposition flap and skin graft (N = 5), bilateral rotational fasciocutaneous flaps
(N = 5), skin graft only (N = 2) and sometimes wide undermining and direct closure
(N = 3). During the follow up period, we did not encounter any major wound
complications or cerebrospinal fluid leakage in any of our patients. Superficial wound
dehiscence occurred in two patients (10%) and was managed conservatively. Longterm follow-up showed stable, durable soft tissue coverage with no recurrence of the
dural sac herniation.
Conclusion: These rather simple reconstructive solutions for such a major problem
offer a shorter operation time, less bleeding, no suture line over the area of dural
repair and is simple to learn and practice. They also do not prevent alternative
techniques in case of insufficiency.
KEY WORDS:
Myelomeningocele
Reconstruction
Rotational flap
Skin graft.
rate of one case per a thousand births
although its incidence shows regional
variance1. Precautions against folic
acid deficiency that is thought as the
etiologic factor and termination of
pregnancies with the advance of
intrauterine diagnosis have decreased
this incidence.
INTRODUCTION:
Myelomeningocele can be
described as posterior pouching of the
spinal canal, posterior fusion defect of
the vertebral column, and accompanying cutaneous defects. It is the
most common congenital abnormality
of the central nervous system with a
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EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011
Treatment of myelomeningocele is immediate closure of the
neural tube and dura, and closure of the
defect without tension with sufficient
cutaneous and subcutaneous tissue. To
prevent rate of complications surgical
treatment in first 24 h is strongly
suggested2. In small defects, treatment
is readily achieved by primary closing
the defects and undermining of
surrounding tissue. However, Patterson
& Till estimated that 25% of
myelomeningocele defects can not be
repaired by simple direct closure and
require more elaborate closure
techniques3. A variety of reconstructive procedures have been
described for the closure of broadbased myelomeningocele defects4-6.
Ozveren et al.7, classified meningoceles and myelomeningoceles in
terms of defect area as a percentage of
the thoraco-lumbar region to make it
possible to select the closure technique.
Any defect smaller than 8% of the
thoraco-lumbar region was classified
as grade 1 and can be closed primarily,
while those occupying more than 8%
are classified as grade 2 and were not
amenable to direct closure. In the
present study, based on the above
study, all myelomeningocele defects
included were of grade 2, requiring
some sort of reconstruction.
Hassan & Elsawy
MATERIALS AND METHODS:
This retrospective clinical study
was conducted at plastic and
reconstructive surgery department and
neurosurgery
department,
Minya
university hospital and health insurance hospital between April 2007 and
November 2010. A total of 20 newborns admitted with myelomeningocele to Minia university hospital and
Minia health insurance hospital.
Patients underwent repair of
low thoraco-lumbar, lumbo-sacral
myelomeningocele. The total area of
the thoraco-lumbar region was
calculated according to the “rule of
nines”. The thoraco-lumbar region
constitutes 18% of the total body
surface area. The percentage of the
defect to the thoraco-lumbar region
was calculated.
Patients with defects covering
less than 8% of the thoraco-lumbar
region in whom direct primary closure
could be accomplished were excluded.
All cases were evaluated by the
neurosurgery and plastic surgery teams
for treatment planning. Flap repair was
performed exclusively by the plastic
surgery team in all patients.
Complete neurological assessment and local examination involved
the site and dimensions of the defect,
its lie (vertical or transverse) are
necessary preoperatively.
In this article, we present our
patients repaired with rather traditional
plastic reconstruction procedures as
rotational flaps, transposition flap and
skin graft, bilateral rotational fasciocutaneous flaps, skin graft only and
sometimes wide undermining and
direct closure. These techniques have
the advantages of shorter operation
time, less bleeding, and no suture line
over the area of dural repair, and are
simple to learn and practice. Also
alternative techniques still can be done
in case of insufficiency.
All
relevant
laboratory
investigations and X-ray of dorsolumbar spine have been done. CT brain
and MRI spine were done only when
hydrocephalus. An informed consent
was obtained from parents.
Methods of repair included
rotational flaps, transposition flap and
skin graft, bilateral rotational fasciocu-
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EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011
taneous flaps, skin graft only and wide
undermining and direct closure.
Hassan & Elsawy
Placement of small subcutaneous
drains bilaterally along the flank is
optional and helps prevent seromas
that might be confused with cerebrospinal fluid leakage from the spinal
column (1 to 2 days of drainage is
adequate).
Surgical technique:
General anaesthesia is needed
to all patients. Endotracheal tube is
checked after the establishment of
prone position. Avoid hypothermia
which is common in newborn by warm
air
conditioner,
warming
the
intravenous fluids and wrapping the
extremities. A watertight closure of
dura by the neuro-surgeon is essential
and can be verified by the
anesthesiologist performing a Valsalva
maneuver on the patient. To reinforce
the dural suture line, the paravertebral
muscles and fascia are mobilized to
close in the midline, if possible, and to
reestablish their proper dorsal position
relative to the vertebral elements.
RESULTS:
The study included 20 neonates
and infants with large myelomeningocele defects admitted to the
neurosurgery department of the Minia
university hospital through the years
2007-2010. The age of the patients
ranged from 3 days to 2 months with a
mean age of 13.2 days. Fifteen boys
and five girls. Eighteen patients
presented as elective cases, while two
patients presented with ruptured
myelomeningocele.
Definitive reconstruction technique was chosen according to the size
and orientation of the defect and was
performed as usual.
Four patients had low thoracolumbar;
while
sixteen
had
lumbosacral
myelomeningoceles
(Table 1).
Table 1: Location of defects
Location of defect
Thoracolumbar
Lumbosacral
Total
Males
10(67%)
5(33%)
15 (75%)
Females
3(60%)
2 (40%)
5 (25%)
The myelomeningocele defect
was elliptical in 3 patients and rounded
in 17 patients. The diameter of the
defect ranged between 8x7 and 14x11
cm with a mean of 10x7.3. The surface
area of the defect ranged between 39.4
and 165cm2. The percentage of the
defect to that of the thoracolumbar
region ranged between 9.1 and 26%
with a mean of 13.83%. All cases were
seen by both the neurosurgery and
plastic surgery teams for treatment
Total
13 (65%)
7(35%)
20 (100%)
planning. Flap repair was performed
exclusively by the plastic surgery team
in all patients.
Methods of repair included
rotational flaps (N = 5) (Fig. I),
transposition flap and skin graft (N =
5), bilateral rotational fasciocutaneous
flaps (N = 5), skin graft only (N = 2)
and wide undermining and direct
closure (N = 3) (Fig. II) and (Table 2).
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Hassan & Elsawy
Figure I: 20 days old boy with large (10×8 cm) lumbosacral myelomeningocele
defect. Above, preoperative view. Middle, rotational flap elevation. Below, immediate
postoperative, not closure without tension.
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Hassan & Elsawy
Figure II: 1.5 months old boy with 2 myelomeningocele defects (large lumbosacral
and small thoracic). Above, preoperative view. Below, immediate postoperative. Note
repair by wide undermining and direct closue.
Table 2: Treatment modalities used for coverage of defects
Procedure
Rotational flap
Transposition flap
Bilateral rotation flap
Split thickness skin grafting
Primary closure
Number of patients
5
5
5
2
3
Patients who developed hydrocephalus were treated with ventriculoperitoneal shunt insersion either at
the same time or in a separate
operative session after the myelomeningocele repair.
%
25
25
25
10
15
We did not have major
complications like major wound complications or cerebrospinal fluid leakage in
any of our patients. Superficial wound
dehiscence occurred in two patients
(1%) and was managed conservatively
(Fig. III) and (Table 3).
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EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011
Hassan & Elsawy
Figure III: 25 days old girl showing superficial wound dehiscence following repair of
large lumbosacral myelomeningocele defect using bilateral rotational flaps.
Table 3: Complications
Complications
Wound infection
Superficial Wound dehiscence
Total
Number of patients
1
1
2
%
5
5
10
Long-term follow-up period ranged from 1-2 years and showed durability of the
repair and the absence of late skin breakdown or ulceration.
salvage by preventing both infection
and neural desiccation10,11. In the
present study, all cases were operated
upon as soon as the patient arrives to
the hospital and after proper
preoperative
consultation
and
preparation. This usually takes 1-2
days.
DISCUSSION:
There are various causes
identified
for
myelomeningocele
including, genetic, deficiency of
essential vitamins and minerals like
folate and zinc, use of teratogenic
drugs,
antiepileptic
drugs
like
carbamazepine or valproic acid,
obesity and diabetes mellitus type I8.
Much debate regarding patients with
myelomeningoceles has focused on the
long-term sequelae and survival, but
the focal point of controversy is the
decision when to operate and how to
close the defect9.
Primary closure in cases of
meningocele and myelomeningoceles
has been reported at rates of 75-95%.
This primary wound healing can be
attained in small myelomeningocele
defects with wide undermining of the
wound edges and direct closure of the
wound12,13.
Currently, because a consensus
cannot be established on the ultimate
quality of life of the myelomeningocele patient, most neurosurgeons will probably elect to treat the
condition within the first 24-48 hours
of the postnatal period. The urgent
closure maximizes the neurological
The closure of large defect
myelomeningoceles presents a challenging problem. Attempts at direct
closure are associated with problems of
wound breakdown, partial skin
necrosis, and wound infection.
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EL-MINIA MED. BULL. VOL. 22, NO. 1, JAN., 2011
Patterson and Till3, in a series
of 130 infants with myelomeningoceles
observed that only 25% of cases
required more elaborate closure
techniques than primary closure.
Hassan & Elsawy
for coverage but care should be taken
to keep the suture line away from dural
repair line to avoid dehiscence21.
Clark et al.22 and Scheflan and
co-workers23 reported on the use of
“reversed” or distally based latissimus
dorsi muscle flaps, employing the deep
paraspinous perforators for their blood
supply.
Ozveren et al.7, classified
meningoceles and myelomeningoceles
in terms of defect area as a percentage
of the thoraco-lumbar region to make it
possible to select the closure technique.
Any defect smaller than 8% of the
thoraco-lumbar region was classified
as grade 1 and can be closed primarily,
while those occupying more than 8%
are classified as grade 2 and were not
amenable to direct closure. In the
present study, all myelomeningocele
defects were of grade 2, requiring
some sort of reconstruction.
The procedure is associated
with the major disadvantage of
destroying the insertion of the
latissimus dorsi muscle which is
valuable in the paraplegic patient,
especially in transferring24. In the
present study, we did not use or
sacrifice any of the valuable back
muscles.
Several variations of skin flaps
have been described to close larger
myelomeningocele defects.
We did not encounter any
major wound complications or
cerebrospinal fluid leakage in any of
our patients. Superficial wound
dehiscence occurred in two patients
(1%) and was managed conservatively.
Long-term follow-up showed
stable, persistant soft tissue coverage
with no recurrence of the dural sac
herniation.
Advancement flaps14, bipedicle flaps15
local transposition flaps16, rotation
flaps17, and Limberg type flaps18 have
all been utilized successfully in
achieving
closure
of
large
myelomeningocele defects.
Luce and Walsh 19 reported
satisfactory results with the use of split
thickness skin grafts with low
morbidity and mortality. However, a
long-term follow-up by the same
authors revealed a 23% incidence of
chronic and/or severe skin ulceration
requiring secondary surgery20. In the
present study, we had no mortalities
and no skin breakdown.
The procedures used provide a
relatively simple and reliable option
for reconstruction of a relatively major
problem namely low thoracolumbar
and
lumbosacral
large
myelomeningocele defects.
CONCLUSION:
Skin grafting is a good option
for coverage of wounds where the
defect size is large because there is
little morbidity associated with this
procedure. Local flaps are good choice
for coverage but care should be taken
to keep the suture line away from dural
repair line to avoid dehiscence.
Skin grafting is an excellent
choice for treatment of wounds where
the defect size is huge because there is
diminutive morbidity associated with
this method, local flaps are fine option
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Hassan & Elsawy
11. McLone DG: Results of
treatment of children born with a
myelomeningocele. N Engl J Med.
1985; 312:1590-4.
12. De Chalain TM, Cohen SR,
Burstein FD, Hudgins RJ, Boydston
WR, O’Brien MS: Decision making in
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35:272-8.
13. Thomas CV: Closure of large
spina bifida defects: A simple
technique based on anatomical details.
Ann Plast Surg. 1993; 31:522-7.
14. Zook E.G., Dzenitis A.J.,
Bennett J.E.: Repair of large myelomeningoceles.Arch Surg.1969;98:41-5.
15. Habal M.B., Vries J.K.:
Tension free closure of large
meningomyelocele
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Surg
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16. Bajaj P.S., Welsh P.S., Shadid
F.A.: Versatility of lumbar transposition flaps in the closure of
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