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ASPECTS OF THE SURGICAL MANAGEMENT OF MYELOMENINGOCELE: A REVIEW

Before 1960 there was little sense of urgency in referring an infant born with a myelomeningocele for definitive treatment. Keiller (1922) had advocated excising the exposed neural placode (which she regarded as functionless) immediately after birth and closing the spinal theca, so as to avoid what was then the inevitably fatal complication of bacterial meningoventriculitis; but her ideas do not seem to have been put into practice. Rather, immediate operation was rarely advised unless rupture of the sac threatened or had actually occurred. Otherwise the consensus was that of infants born with severe neurological deficit, only those should be treated who survived to the age of 18 months (Ingraham and Hamlin 1943, Ingraham and Matson 1954). Chambers (1950) reported five cases of elective closure of a myelomeningocele within two days of birth, in which he had preserved and replaced the exposed placode within the reconstituted theca, and during the next few years several other surgeons operated on a few cases in this way. But three factors in particular militated against success: delay in referring the infants for surgery, a high incidence of postoperative infection and, most importantly, the fact that when hydrocephalus developed after the operation it could not be controlled. Moreover, only a few dedicated surgeons, such as Nash (1956), were prepared to deal with the long-term care of the few severely crippled and often hydrocephalic patients who survived into childhood. Between 1949 and 1960 Guthkelch (1 962) tried closing myelomeningoceles at various intervals ranging from a few hours to several weeks after birth. Among these patients, most of whom were operated upon in the preshunt era, the best results were obtained when the exposed placode was first allowed to epithelialize completely, and a secondary repair was later performed through mature scar-tissue, once there seemed to be no immediate danger of infection spreading from the myelomeningocele through the nervous system, or of the child developing symptomatic hydrocephalus. Since this policy entailed having the infants in hospital for periods of several weeks, we were able to study their neurological function in detail. At the c 9 4 e