Meningomyelocele: the price of treatment.

Abstract

This study was originally carried out to compare the manage ment of patients with meningomyelocele at the London Hospital with that at Sheffield Children's Hospital (where a particular clinical interest in this problem exists) with a view to improving the arrangements at the former. It soon became apparent that to set up a service along the lines of that in Sheffield would be extremely expensive and would place immense demands on the diagnostic and therapeutic facilities of a hospital whose re sources were already stretched to the maximum. It was therefore decided to assess, if possible, the cost to the taxpayer of a nationwide service in England and Wales. Many of these calculations are nothing more than educated estimates, but they do serve to show at least the minimum cost. In the last decade of the nineteenth century 153 babies in every 1,000 live births died in the first year of life. In 1965 this figure had been reduced to 19 deaths per 1,000 live births.12 Of these 19 deaths 21% were due to congenital abnormalities, and 0*5 per 1,000 of these were meningomyeloceles. Until about 14 years ago 94% of infants with a meningomyelocele died early of meningitis, progressive hydrocephalus, or the complications of paraplegia. Of the remainuer 4% lived as permanent invalids in chairs and 2% managed some form of life after multiple opera tions.1 Thus absence of treatment brought with it the inheritance of survivors whose mental and physical abilities left much to be desired, but who represented only 6% of affected children. These figures were produced by a policy of treatment which would now be regarded as treatment by neglect. An ethically acceptable minimum of treatment now produces a 30% survival rate at three years.3 Many of these survivors will be severely disabled, and about half will need almost permanent institutional care. The remainder all need special educational facilities and a great deal of surgical treatment. The use of antibiotics, bypass procedures for the hydroce phalus (which occurs in about half of these patients), and closure of the spinal defect within the first 24 hours of life have greatly improved the expectation of life. At 2 years 70% of these patients will be alive and 40% will survive to adult life, a good proportion achieving some independence.1 Figures based on the experience of the Sheffield Children's Hospital serve to indicate the size of the resulting therapeutic problem.2 These figures are for all patients with spina bifida cystica, and are therefore optimistic. Nevertheless, as 86*5% of such patients in Sharrard's study3 had meningomyeloceles these figures are a reasonable parallel, though not totally accurate. For every 100 patients 30 die. Of the remainder 15 have no urinary complications, 25 require operation resulting in satisfactory urinary function, 25 have satisfactory urinary function with