TY - JOUR
T1 - Neurosurgeons' opinions on the prenatal management of myelomeningocele
AU - Gadjradj, Pravesh S.
AU - Spoor, Jochem K.H.
AU - Eggink, Alex J.
AU - Wijnen, René
AU - Miller, Jena L.
AU - Rosner, Mara
AU - Groves, Mari L.
AU - DeKoninck, Philip L.J.
AU - Harhangi, Biswadjiet S.
AU - Baschat, Ahmet
AU - van Veelen, Marie Lise
AU - de Jong, Tjeerd H.R.
N1 - Funding Information:
We would like to thank all respondents for sharing their opinions and clinical management with us. These include Frank Van Calenbergh, Vaverka Miroslav, Salvatore Chibbaro, Micyn Micunovic, Erwin Cornips, Bernt Due-T?nnessen, Bruno Louren?o Costa, Horia Ples, Jos? Hinojosa, John Goodden, Tony Magana, Seraj S. Ajaj, Olufemi Idowu, Abubakr Darrag Salim Ahmed, Patrick McDonald, Jose Javier Cuellar Hernandez, Edgar Fernando Acosta G?mez, Rolando Jimenez-Guerra, Marco Enrique Munoz Lopez, Robin Bowman, Jay Wellons, P. Langham Gleason, Amos Stoll, Erik C. Brown, David Cech, Richard P. Moser, J. Paul Muizelaar, Curtis J. Rozzelle, Jesse Winer, Jodi L. Smith, William E. Whitehead, Christopher Bonfield, Arnett Klugh III, Alejandro Carlo Cardona Gonzales, Jose Aloysio da Costa Val Filho, Reynaldo Andre Brandt, Hamilton Matushita, Ricardo Santos de Oliveira, Eduardo Juc?, Artur Henrique Galvao Bruno Da Cunha, Alexandre Mau?s da Costa, J. Francisco Salom?o, Enrico Ghizoni, Felipe Otayza, William Cort?s Lozano, R. Andrew Danks, Juliet Clayton, Rakshith Shetty, Santosh Mohan Rao Kanangi, Prakash Singh, Sharath Kumar Maila, Vijay Parihar, Sri Maliawan, Julius July, Nobuhito Mopota, Ryo Ando, Azmi Alias, Jafri Malin Abdullah, Wisam Issawi, and Mustafa Altennari.
Publisher Copyright:
© AANS 2019.
PY - 2019
Y1 - 2019
N2 - OBJECTIVE Improvements in imaging and surgical technological innovations have led to the increasing implementation of fetal surgical techniques. Open fetal surgery has demonstrated more favorable clinical outcomes in children born with open myelomeningocele (MMC) than those following postnatal repair. However, primarily because of maternal risks but also because of fetal risks, fetal surgery for MMC remains controversial. Here, the authors evaluated the contemporary management of MMC in the hope of identifying barriers and facilitators for neurosurgeons in providing fetal surgery for MMC. METHODS An online survey was emailed to members of the Congress of Neurological Surgeons (CNS) and the International Society for Pediatric Neurosurgery (ISPN) in March 2019. The survey focused on 1) characteristics of the respondents, 2) the practice of counseling on and managing prenatally diagnosed MMC, and 3) barriers, facilitators, and expectations of fetal surgery for MMC. Reminders were sent to improve the response rate. RESULTS A total of 446 respondents filled out the survey, most (59.2%) of whom specialized in pediatric neurosurgery. The respondents repaired an average of 9.6 MMC defects per year, regardless of technique. Regardless of the departments in which respondents were employed, 91.0% provided postnatal repair of MMC, 13.0% open fetal repair, and 4.9% fetoscopic repair. According to the surgeons, the most important objections to performing open fetal surgery were a lack of cases available to become proficient in the technique (33.8%), the risk of maternal complications (23.6%), and concern for fetal complications (15.2%). The most important facilitators according to advocates of prenatal closure are a decreased rate of shunt dependency (37.8%), a decreased rate of hindbrain herniation (27.0%), and an improved rate of motor function (18.9%). Of the respondents, only 16.9% agreed that open fetal surgery should be the standard of care. CONCLUSIONS The survey results showed diversity in the management of patients with MMC. In addition, significant diversity remains regarding fetal surgery for MMC closure. Despite the apparent benefits of open fetal surgery in selected pregnancies, only a minority of centers and providers offer this technique. As a more technically demanding technique that requires multidisciplinary effort with less well-established long-term outcomes, fetoscopic surgery may face similar limited implementation, although the surgery may pose fewer maternal risks than open fetal surgery. Centralization of prenatal treatment to tertiary care referral centers, as well as the use of sophisticated training models, may help to augment the most commonly cited objection to the implementation of prenatal closure, which is the overall limited caseload.
AB - OBJECTIVE Improvements in imaging and surgical technological innovations have led to the increasing implementation of fetal surgical techniques. Open fetal surgery has demonstrated more favorable clinical outcomes in children born with open myelomeningocele (MMC) than those following postnatal repair. However, primarily because of maternal risks but also because of fetal risks, fetal surgery for MMC remains controversial. Here, the authors evaluated the contemporary management of MMC in the hope of identifying barriers and facilitators for neurosurgeons in providing fetal surgery for MMC. METHODS An online survey was emailed to members of the Congress of Neurological Surgeons (CNS) and the International Society for Pediatric Neurosurgery (ISPN) in March 2019. The survey focused on 1) characteristics of the respondents, 2) the practice of counseling on and managing prenatally diagnosed MMC, and 3) barriers, facilitators, and expectations of fetal surgery for MMC. Reminders were sent to improve the response rate. RESULTS A total of 446 respondents filled out the survey, most (59.2%) of whom specialized in pediatric neurosurgery. The respondents repaired an average of 9.6 MMC defects per year, regardless of technique. Regardless of the departments in which respondents were employed, 91.0% provided postnatal repair of MMC, 13.0% open fetal repair, and 4.9% fetoscopic repair. According to the surgeons, the most important objections to performing open fetal surgery were a lack of cases available to become proficient in the technique (33.8%), the risk of maternal complications (23.6%), and concern for fetal complications (15.2%). The most important facilitators according to advocates of prenatal closure are a decreased rate of shunt dependency (37.8%), a decreased rate of hindbrain herniation (27.0%), and an improved rate of motor function (18.9%). Of the respondents, only 16.9% agreed that open fetal surgery should be the standard of care. CONCLUSIONS The survey results showed diversity in the management of patients with MMC. In addition, significant diversity remains regarding fetal surgery for MMC closure. Despite the apparent benefits of open fetal surgery in selected pregnancies, only a minority of centers and providers offer this technique. As a more technically demanding technique that requires multidisciplinary effort with less well-established long-term outcomes, fetoscopic surgery may face similar limited implementation, although the surgery may pose fewer maternal risks than open fetal surgery. Centralization of prenatal treatment to tertiary care referral centers, as well as the use of sophisticated training models, may help to augment the most commonly cited objection to the implementation of prenatal closure, which is the overall limited caseload.
KW - Fetal surgery
KW - Meningomyelocele
KW - Spina bifida
KW - Survey
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U2 - 10.3171/2019.7.FOCUS19362
DO - 10.3171/2019.7.FOCUS19362
M3 - Article
C2 - 31574464
AN - SCOPUS:85072847798
SN - 1092-0684
VL - 47
JO - Neurosurgical Focus
JF - Neurosurgical Focus
IS - 4
M1 - E10
ER -