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The Denuded Sacrum

The problem of myelomeningocele is not new. As long ago as 1885 a subconunittee of the London Clinical Society reviewed the pathology of this condition. The basic principles of surgical treatment were laid down by Bayer of Prague in 1892 and even by today's standards his results are acceptable. There are, however, a number of definite advances in medicine in general which have made the management of myelomeningocele one of the most important problems of pediatric surgery today. First, antibiotics can cure or even prevent the development of ascending meningitis, a condition which was in former times a common cause of death in these infants. Secondly, the overall advances in neonatal surgery, and in neonatal antsthesia in particular, have lowered the operative mortality considerably. Thirdly, the introduction of ventriculoatrial drainage by Holter and Pudenz has provided a means of controlling hydrocephalus, an associated problem present in some 80% of all myelomeningocele patients. It is obvious that if hydrocephalus cannot be controlled then closure of the spinal defect is pointless. Finally, in 1962 Sharrard and his colleagues showed that neonatal closure gave better results, especially as far as leg movement was concerned, and since that time myelomeningocele has become recognized as an established emergency condition requiring surgery within the first twentyfour hours of life. However, at the same time, they unintentionally introduced a major problem in that assessment of the newborn infant with this abnormality is extremely difficult, so that selection for treatment can hardly be performed at this stage. The advantages of early closure of the spinal defect can be summarized as follows: