Neurosurgeons' opinions on the prenatal management of myelomeningocele

Pravesh S. Gadjradj, Jochem K.H. Spoor, Alex J. Eggink, René Wijnen, Jena L. Miller, Mara Rosner, Mari L. Groves, Philip L.J. DeKoninck, Biswadjiet S. Harhangi, Ahmet Baschat, Marie Lise van Veelen, Tjeerd H.R. de Jong

Research output: Contribution to journalArticle

Abstract

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.

Original languageEnglish (US)
Pages (from-to)E10
JournalNeurosurgical focus
Volume47
Issue number4
DOIs
StatePublished - Oct 1 2019

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Meningomyelocele
Mothers
Tertiary Care Centers
Hope
Fetoscopy
Neurosurgeons
Inventions
Surveys and Questionnaires
Rhombencephalon
Neurosurgery
Standard of Care
Counseling
Pediatrics

Keywords

  • CNS = Congress of Neurological Surgeons
  • fetal surgery
  • ISPN = International Society for Pediatric Neurosurgery
  • meningomyelocele
  • MMC = myelomeningocele
  • MOMS = Management of Myelomeningocele Study
  • spina bifida
  • survey

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Gadjradj, P. S., Spoor, J. K. H., Eggink, A. J., Wijnen, R., Miller, J. L., Rosner, M., ... de Jong, T. H. R. (2019). Neurosurgeons' opinions on the prenatal management of myelomeningocele. Neurosurgical focus, 47(4), E10. https://doi.org/10.3171/2019.7.FOCUS19362

Neurosurgeons' opinions on the prenatal management of myelomeningocele. / Gadjradj, Pravesh S.; Spoor, Jochem K.H.; Eggink, Alex J.; Wijnen, René; Miller, Jena L.; Rosner, Mara; Groves, Mari L.; DeKoninck, Philip L.J.; Harhangi, Biswadjiet S.; Baschat, Ahmet; van Veelen, Marie Lise; de Jong, Tjeerd H.R.

In: Neurosurgical focus, Vol. 47, No. 4, 01.10.2019, p. E10.

Research output: Contribution to journalArticle

Gadjradj, PS, Spoor, JKH, Eggink, AJ, Wijnen, R, Miller, JL, Rosner, M, Groves, ML, DeKoninck, PLJ, Harhangi, BS, Baschat, A, van Veelen, ML & de Jong, THR 2019, 'Neurosurgeons' opinions on the prenatal management of myelomeningocele', Neurosurgical focus, vol. 47, no. 4, pp. E10. https://doi.org/10.3171/2019.7.FOCUS19362
Gadjradj, Pravesh S. ; Spoor, Jochem K.H. ; Eggink, Alex J. ; Wijnen, René ; Miller, Jena L. ; Rosner, Mara ; Groves, Mari L. ; DeKoninck, Philip L.J. ; Harhangi, Biswadjiet S. ; Baschat, Ahmet ; van Veelen, Marie Lise ; de Jong, Tjeerd H.R. / Neurosurgeons' opinions on the prenatal management of myelomeningocele. In: Neurosurgical focus. 2019 ; Vol. 47, No. 4. pp. E10.
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title = "Neurosurgeons' opinions on the prenatal management of myelomeningocele",
abstract = "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.",
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author = "Gadjradj, {Pravesh S.} and Spoor, {Jochem K.H.} and Eggink, {Alex J.} and Ren{\'e} Wijnen and Miller, {Jena L.} and Mara Rosner and Groves, {Mari L.} and DeKoninck, {Philip L.J.} and Harhangi, {Biswadjiet S.} and Ahmet Baschat and {van Veelen}, {Marie Lise} and {de Jong}, {Tjeerd H.R.}",
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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.

PY - 2019/10/1

Y1 - 2019/10/1

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.

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KW - ISPN = International Society for Pediatric Neurosurgery

KW - meningomyelocele

KW - MMC = myelomeningocele

KW - MOMS = Management of Myelomeningocele Study

KW - spina bifida

KW - survey

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