Meningomyelocele Repair: An Algorithmic Approach based on 5-year Review and Systematic Review of the Literature

Abstract

PURPOSE: We propose a reconstructive algorithm based on retrospective review of meningomyelocele (MM) repairs at our institution and systematic review of the literature. METHODS: A retrospective review of human infants undergoing MM repair over 5 years at a single children’s hospital. Location and size of defect, major wound complications (MWC) (return to the operating room), minor wound complications (mWC) (any wound breakdown treated without return to operating room, superficial infection, or CSF leak), and follow up were recorded. Interviews of neurosurgeons and plastic surgeons were performed on approach MMC repairs. A systematic review of the literature was performed to evaluate all reconstructions for MM. Inclusion criteria included articles that discussed reconstructive technique, age, defect location and size, and complications (MWC and mWC). Exclusion criteria included age greater than 1 year, articles published prior to 1984, and non-English language. Additionally, articles missing individual patient data, reconstructions using greater than two flaps, or use of alloplastic/xenograft were excluded. Flaps were categorized by reconstructive method: primary closure with and without fascial flaps (PC), random pattern flap (based on unnamed vessels) (RP), VY advancement flap (VY), perforator flap (based on unnamed vessels) (PF), myocutaneous flap (defined muscle flap or perforators off named muscle), and keystone island perforator flap (islanded fasciocutaneous flap based on random regional musculocutaneous perforators) (KIPF). RESULTS: In our cohort, there were 39 patients who underwent repair with three MWC (8%). An estimated 79% of cases (n = 31) were performed by neurosurgery with PC. Two (5%) had an MWC. Plastic surgery was consulted for 20% of the cases (n = 8), with 1 patient (13%) having an MWC. Of the three total MWC for MM repair, two were located in the lumbosacral area and one in the lumbar area. All complications occurred with defects greater than 50 cm2. On interviews of neurosurgeons, plastic surgery consultation occurs when there is a paucity of soft tissue (lack of adequate skin or redundant tissue) or subsequent wound breakdown. Upon systematic review, 551 articles were screened with 95 articles assessed for eligibility. Twenty-seven articles were further reviewed and included for qualitative synthesis. Two hundred fifty-six patients underwent MM repair: 41 PC (16%), 71 RP (28%), 25 VY (10%), 61 PF (24%), 26 myocutaneous flap (10%), and 32 KIPF (13%). MM were located at thoracic (n = 6), thoracolumbar (n = 84), lumbar (n = 15), lumbrosacral/sacral (n = 151). Lowest MWC were associated with KIPF (6%), RP (7%), myocutaneous flap (11%), VY (13%), PC (15%), and PF (17%), respectively. A majority of MWC were in the lumbrosacral/sacral region (90% of MWC). In this region, PC was used for average defect [9.7 cm2 (3–28.3 cm2) with 16% MWC]. The only reconstructions for sacral MM were PF (n = 2) and KIPF (n = 7). PF average defect was 6.8 cm2 (3.5–10 cm2) with no MWC and 1 mWC. KIPF average defect was 43.7 cm2 (8–100 cm2) with 1 MWC and 3 mWC (3% and 9%, respectively). CONCLUSIONS: Plastic surgery consultation should be strongly considered for MM with defects in the lumbosacral/sacral region. KIPF and PF should be considered for sacral defects.