Re: Prenatal ultrasound evaluation of segmental level of neurological lesion in fetuses with myelomeningocele: development of a new technique. E.Carreras, A. Maroto, T. Illescas, M. Meléndez, S. Arévalo, J. L. Peiró, C. G. García-Fontecha, M. Belfort and A. Cuxart. Ultrasound Obstet Gynecol 2016; 47: 162-167.

Abstract

Linked Comment: Ultrasound Obstet Gynecol 2016; 47: 162–167 Following the results of the MOMS trial (Management of Myelomeningocele Study), the option of fetal treatment has gained acceptance, particularly in cases in which termination of pregnancy is not considered to be an option. As with other revolutionary techniques and treatments, prenatal surgical treatment of meningocele is still controversial and poses interesting clinical and ethical dilemmas. Currently, more than 10 centers in the Americas and Europe are working in the field and, although incomplete, the published results appear promising. The Barcelona Vall d'Hebron group describe in the present study their novel experience in ultrasound assessment of the segmental level of insult in 18 fetuses with open neural tube defect (ONTD) that subsequently underwent surgery. The segmental neurological level was assigned according to the most distal active muscles present, as demonstrated by systematic observation of the lower-limb movements. The correlation between the quality of movement observed following fetal surgery and after delivery was good, but there was no improvement in the level of function when comparing pre- and post-surgery results. Interestingly, the number of patients opting for prenatal repair was an impressive 21 out of their initial population of 71 (30%) pregnant women carrying fetuses with myelomeningocele. If these results can be reproduced in a large cohort and, more importantly, if the post-surgery and postnatal results can be shown to be better than those obtained at the preoperative examination, this technique will provide further reassurance regarding the benefits of in-utero meningocele repair. As mentioned, the numbers are low, but promising. An important limitation of the study that will need to be addressed in future studies concerns the reproducibility and possibility of interobserver variability; these issues were not addressed in the current study. The Barcelona group performed for the first time a prospective evaluation of the segmental level of damage and were able to compare their results with the results of motor activity tests performed after delivery. They showed that, following surgery, there was no worsening in the level of damage and that the operation was likely to have stopped progression of damage. It is expected that they and other groups working in this field will continue to improve the method. I believe that now, as many centers have reached a good level of performance in fetal ONTD repair, it is time to create an international database that will ultimately include repeat motor assessments of fetuses before and after fetal surgery.