Spina bifida is a group of congenital defects of the spine developed during fetal stage. During the first month after conception, the embryonic structure called neural tube is formed which eventually develops into the baby's brain, spinal cord and the surrounding bony structure. In case of spina bifida, the lower part of the neural tube does not develop or fuse fully leading to abnormalities in brain or spinal cord. When the spinal column does not close properly around the baby's spinal cord the nerves start to protrude through the opening causing spina bifida.
Spina bifida is a broader term used for various conditions of the spine. The defect may range from very mild form which may not present itself with any symptoms to a severe one causing disability and disrupting the patient's normal life. There are broadly three types of spina bifida which are discussed below.
Spina bifida occulta
It is a very mild and most common form of spina bifida in which one or two vertebrae are left unfused. The portion of the spinal cord that is not enclosed by vertebrae is covered by skin. Occulta means 'hidden' and since the opening is hidden under the skin, the condition is referred as spina bifida occulta. However, in such cases, nerve roots and the spinal cord are not affected and hence, the person remains asymptotic.
In meningocele, the meninges (membranes that surround and protect the spinal cord) protrude through the spinal opening without affecting the spinal cord. Sometimes a layer of skin is formed over the opening. In few cases of meningocele, when the membranes push through the opening, they get filled with the spinal fluid forming a cyst. With this type of spina bifida, one may experience only mild symptoms or in few cases the damage may be very severe.
Myelomeningocele is the most severe form of spina bifida. Myelomeningocele, almost certainly leads to mental and physical disabilities. The severity of the damage depends upon the site of the opening on the spine as the portion that is below the opening becomes dysfunctional. The higher the location of the opening, the greater will be the impact on the functioning of the body.
The symptoms vary depending upon the type of the spina bifida. In case of spina bifida occulta, the child remains largely asymptotic and there may be a birthmark, a patch, a dimple or hair growth on the skin under which the vertebrae is not joined properly. This condition is usually diagnosed during an ultrasound performed for some other purpose.
Meningocele may or may not show any symptoms. Partial paralysis with urinary and bowel problems are usually associated with meningocele. This condition is diagnosed before birth through fetal ultrasound and other tests. This condition is diagnosed when a test called maternal serum alpha-fetoprotein is performed on pregnant woman.
Spina bifida occulta doesn't require any treatment; however other two conditions are always treated surgically. In case of meningocele, surgery involves pushing back the membranes into the place and closing the vertebrates. Babies born with Myelomeningocele are operated within 24 to 48 hours of their birth. The surgery is mainly performed to prevent infection and further damage to the spinal cord. If the baby develops too much cerebrospinal fluid which is known as hydrocephalus, a shunt will be placed as part of the treatment. In recent times spina bifida is also treated through fetal surgery, wherein the uterus is surgically opened to correct the spine defect and immediately closed back. Spina bifida, particularly Myelomeningocele type, requires lifelong medical support as children with such a condition continue to suffer from neurological, orthopaedic and bladder and bowel related problems.
Fetal surgery refers to the surgical treatment of the developing baby in the womb to rectify congenital defects. Surgery of the fetus is performed to fix the prenatally diagnosed anomalies. However fetal surgery is a complicated procedure and comes with lot of risks to both mother and the baby. Yet, doctors recommend fetal surgery, if the risks associated with continuing the pregnancy, without surgical intervention, outweighs the risks that come with fetal surgery. Certain abnormalities, if left to progress in the womb, may turn fatal and infant may die soon after the birth. However fetal intervention is initiated only after taking the safety of the mother into consideration. The common risks that are associated with fetal surgery are premature delivery, infection of the uterus, leaking of amniotic fluid through the membrane, potential infertility and the risk of anesthesia.
There are various techniques followed to diagnose fetal anomalies. The diagnostic method can be non invasive such as ultrasound, fetal echocardiography, MRI, Radiography, Measuring MSAFP (maternal serum alpha-fetoprotein) and Measuring maternal serum beta-human chorionic gonadotropin (HCG) or invasive procedure such as amniocentesis, Chorionic villus sampling and Percutaneous umbilical blood sampling (PUBS) are used to detect the birth defects.
Types of Fetal Surgery
Depending on the incision level, fetal surgery is classified into three types.
Open Fetal Surgery
Open fetal surgery is almost similar to cesarean section and involves a total opening of the uterus. In this type of surgery, a long incision is made in the mother's abdomen and then on the uterus to reach the fetes. Once the surgical correction is performed on the fetus to treat the birth defect, the uterus and abdominal is closed back leaving the fetus intact. Open fetal surgery is performed under general anesthesia. Surgery is performed using special instruments containing staples to prevent bleeding from uterus. During the operation, warm saline water is infused to maintain the position of placenta and umbilical cord and surgeon will keep a vigil on the pulse and heart rate of the baby with the help of the oximeter. After the surgery, the mother is hospitalized for close to a week to facilitate close monitoring. One should remember that, with open fetal surgery, mother will forgo the option of vaginal delivery for the present and future deliveries. She can deliver the baby only through C-section. She may be given some medication to avoid pre term labor. Open fetal surgery is followed for the conditions like chest mass, neck mass, spinbifida, myelomeningocele and Sacrococcygeal teratoma (SCT) (a tumor at the base of the child's tail bone).
There is one more variation to the open fetal surgery called the EXIT (Ex Utero Intrapartum Treatment) Procedure. EXIT surgery is performed at the end of the full term and just before the delivery. In this method the baby is partially delivered by bringing out only a part of the fetes from uterus and keeping rest of the fetes attached to placenta and umbilical cord to allow blood circulation. Once the defect is rectified, the baby is delivered fully. Exit procedure is essentially followed to correct the airway blockage in the baby.
Fetoscopic surgery is minimally invasive and unlike open fetal surgery, fetes remains inside the uterus while operating. Surgeon uses special instruments such as laser and makes a small incision with the help of the fetoscope to correct the birth defects. Fetoscopic surgery has shown high success rate in conditions such as Twin-Twin Transfusion Syndrome (TTTS), Twin Reversed Arterial Perfusion (TRAP), Amniotic band syndrome, and Tracheal occlusion for CDH. Fetoscopic surgery does not pose a risk of pre term labor and also eliminates most of the risks associated with open fetal surgery. This is essentially why fetoscopic surgery is the preferred choice, yet one should note that few complicated birth defects can be corrected only through open fetal surgery.
Fetal image guided surgery
Fetal image guided surgery is the least invasive of all wherein surgery is performed with the guidance of images of fetus produced on the external screen by ultrasound. Very thin instruments are inserted through a small opening in the abdomen and the correction is made without any endoscopic view and the whole procedure is guided by the sonogram images.
Various congenital conditions treated through fetal intervention
Congenital diaphragmatic hernia (CDH): Congenital diaphragmatic hernia (CDH) refers to the opening in the diaphragm through which the contents of the abdomen enter the chest cavity leaving no space for the lungs to develop properly. This is a serious condition and may lead to respiratory failure after birth. This condition, depending upon its severity, is treated through fetal intervention.
Spina bifida: Spina bifida refers to a condition wherein spinal column of the baby does not close properly around the spinal cord and the nerves start to protrude through the opening. Spina bifida can range from mild to severe form, and the severe cases lead to serious neurological problems after the birth. Only the severe form of spina bifida like Meningocele and Myelomeningocele call for fetal intervention through open fetal surgery.
Neck masses: Neck masses are the tumors of the neck that may obstruct the airway and esophagus of the child and also increase the level of amniotic fluid surrounding the baby. Typically, tumors of any kind are treated after birth. In rare cases they grow very large and may even cause heart failure. In such cases fetal intervention becomes necessary to remove the tumors.
Lung lesions: Lung lesions refer to the abnormal growth of lung tissue and these lesions can be cystic (fluid filled) or solid. There are various types of lung lesions and treatment depends upon their size and location. During pregnancy, continuous monitoring is necessary to keep vigil on the size of the lesion. Most often lung lesions shrink and make way for normal development. Lesions of smaller and moderate size are best treated after delivery. But if the size of the lung tumor is abnormally huge and poses a risk of hydrops (excess accumulation of fluid in the fetus) fetal intervention is initiated. Cystic lesions are normally removed through needle aspiration under the constant guidance of ultrasound images, but solid lesions require more elaborate procedure such as EXIT.
Congenital heart diseases: Not all congenital heart defects call for fetal intervention. Sometimes the septum (wall separating the right and left side of the heart) of the heart develops a hole while in the womb. However septum defects are typically treated after the birth of the child and rarely require fetal surgery. But if the heart develops severe obstructive cardiac disorders such as aortic stenosis, pulmonary stenosis and coarctation of the aorta,a fetal image-guided procedure may be necessary to open or enlarge the narrowed valve. This procedure involves placing a balloon catheter by inserting it through the uterus and into the fetal’s heart.
Amniotic Band Syndrome: This is a condition where fetus is entrapped in fibrous amniotic bands in the womb, restricting blood flow to the affected portion of the fetes. It normally affects legs, arms, toes and fingers. In utero surgery may be performed to rectify the condition if there is risk of amputation of the limb after the birth.
Twin-to-twin transfusion syndrome (TTTS): TTTS is a condition that occurs in identical twins wherein unbalanced exchange of blood takes place between the twins. One receives higher amount of blood whereas the other receives less amount. The fetus with less blood supply may become anemic and the one with excess blood supply may suffer heart failure due to excess fluid. Fetal surgery through laser fetal intervention is the preferred option to correct the condition. This procedure involves inserting a laser along with small telescope into the uterus and separating the blood vessels on the placenta that are connected to both twins.
Congenital high airway obstruction syndrome (CHAOS): Congenital high airway obstruction syndrome (CHAOS) refers to the blocking of fetal airway resulting in enlarged lungs, windpipe and bronchial tube. A complete or near to complete blockage may lead to a heart failure. Though congenital high airway obstruction syndrome (CHAOS) is treated after birth, in severe cases where fetes is at high risk such as hydrops, fetal surgery is performed.
Spinal Cord Injury
Myelopathy or spinal cord injury is a problem in the spinal cord that causes numbness and loss of motor (muscular) control. Spinal cord injuries can be caused due to trauma such as accident and falls and Disease caused due to spina bifida, polio, tumors etc. The effect of spinal cord injuries be Complete (total function and sensation is lost below the injured point) or Incomplete (Sensation is not lost and only few functions of the part suffers malfunctioning).
Spinal cord injuries in general occur due to the following:
Symptoms of spinal cord injury include weakness, numbness and reduced synchronization from beneath the point of the injury. There is loss of feelings and tingling sensation. There may be excessive pain or loss of bladder or bowel control. Quadriplegia is an injury at the neck level of the spine and induces difficulty in breathing and paralyzes the arms, legs and trunk. Paraplegia is an injury to the lower spine and results in weakness and loss of mobility and feeling in the legs and the lower part of the body.
Prevention of spinal cord injuries
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Bibliography / Reference
Collection of Pages - Last revised Date: November 19, 2019