Intrauterine Myelomeningocele Repair Research Articles

The 17 years of experience in intrauterine myelomeningocele repair in fetal surgery center bytom poland

The 17 years of experience in intrauterine myelomeningocele repair in fetal surgery center bytom poland

Administration of prosaposin-derived neurotrophic factor to neural tube defects facilitates regeneration and restores neurological functions.

Neural tube defects (NTDs) cause fetal and pediatric deaths or lifelong neurological disabilities. No effective treatment is currently available for NTDs. We attempted to elucidate the pathogenesis of NTDs and propose a therapeutic strategy. Intra-amniotic treatment with prosaposin-derived 18-mer peptide (PS18) protected the spinal cord from secondary damage and rescued neurological function in an established chicken model of spina bifida aperta (SBA), the severe type of NTDs. PS18 promoted the formation of a neuroectodermal covering over the defective neural tube within 24-h after treatment, enhanced the regeneration/restoration process, and decreased apoptotic activity in the developing spinal cord. PS18 reduced the SBA wound and almost completely formed the spinal cord. SBA chicks that received PS18 exhibited relatively normal walking and sensorimotor responses, and reduced pain-associated behavior in postnatal life. In conclusion, PS18 is a promising therapeutic agent for NTDs and may be useful for treating other types of spinal cord injuries.

Alternative technique of intrauterine myelomeningocele repair to decrease the incidence of unfavorable maternal and fetal outcomes.

The aim of the study was to determine the effectiveness of an alternative method of open fetal surgery to prevent severe unfavorable prenatal events, both for the mother and the fetus. In this study, the previously published results for a cohort of 46 patients, who had undergone intrauterine myelomeningocele repair (IUMR) at our Center by 2014, constituted the retrospective control group (CG). The MOMS protocol had been applied for hysterotomy, with an automatic uterine stapling device. The study group (SG) n = 57 was assembled during a prospective observation. IUMR was performed using an alternative method of hysterotomy, with the typical opening and closure of the uterus, without automatic stapling device, as described by Moron et al. Additionally, our single-center results were compared with the post-MOMS findings of other centers: CHOP (Children' S HOSPITAL OF PHILADELPHIA: ) and VUMC (Vanderbilt University Medical CENTER: ). No cases of delivery before 30 weeks of gestation (0%, 0/55) were observed in the study group, which is a statistically significant difference (p < 0.05) as compared to controls (15/44). Statistically significantly lower incidence of chorioamniotic separation (5.4% (3/55) vs CHOP 22.9% (22/96), p < 0.001) and contractile activity resulting in preterm labor (16.3% (9/55) vs CHOP 37.5% (36/96), p < 0.05) was found in the study group. Premature rupture of the membranes was statistically significantly less common in the study group as compared to controls, CHOP and VUMC (SG 12.7% (7/55) vs CG 52.2% (24/46), p < 0.001; vs CHOP 32.3% (31/96), p < 0.001; vs VUMC 22% (9/43), p < 0.01, respectively). The presented IUMR method is associated with improved perinatal outcomes, i.e., lower rates of preterm delivery at < 30 weeks of gestation, preterm premature rupture of membranes, and uterine contractility resulting in preterm delivery. That, in turn, results in lower prematurity rates and, consequently, more favorable neonatal outcomes.

A comparison of MRI appearance and surgical detethering rates between intrauterine and postnatal myelomeningocele closures: a single-center pilot matched cohort study.

Intrauterine myelomeningocele repair (IUMR) and postnatal myelomeningocele repair (PNMR) differ in terms of both setting and surgical technique. A simplified technique in IUMR, in which a dural onlay is used followed by skin closure, has been adopted at our institution. The goal of this study was to compare the rates of clinical tethering in IUMR and PNMR patients, as well as to evaluate the appearance on MRI. We conducted a retrospective review of 36 patients with MMC repaired at our institution, with 2:1 PNMR to IUMR matching based on lesion level. A pediatric neuroradiologist blinded to the clinical details reviewed the patients' lumbar spine MRIs for the distance from neural tissue to skin and the presence or absence of a syrinx. An EMR review was then done to evaluate for detethering procedures and need for CSF diversion. Mean age at MRI was 4.0years and mean age at last follow-up was 6.1years, with no significant difference between the PNMR and IUMR groups. There was no significant difference between groups in the distance from neural tissue to skin (PNMR 13.5mm vs IUMR 17.6mm; p = 0.5). There was no difference in need for detethering operations between groups (PNMR 12.5% vs IUMR 16.7%; RR 0.75; CI 0.1-5.1). There was no significant difference between postnatal- and intrauterine-repaired myelomeningocele on MRI or in need for detethering operations. These results imply that a more straightforward and time-efficient IUMR closure technique does not lead to an increased rate of tethering when compared to the multilayered PNMR.

Alternative Hysterotomy Technique for the Reduction of Prenatal Complications of Intrauterine Myelomeningocele Repair

Introduction: The main aim of the fetal surgery of myelomeningocele (MMC) is the improvement in prognosis for children with this defect and at the same time high safety of the procedure for mother and fetus. Objective: The aim of the study was to determine the effectiveness of alternative hysterotomy technique for fetal surgery of MMC in prevention of essential perinatal complications. Methods: Forty-nine pregnant women diagnosed with fetal MMC (fMMC) who underwent classic hysterotomy without the use of stapler formed the study cohort. Two cases of intrauterine fetal death or neonatal death in the immediate perioperative period in the study group (SG) were excluded from further analyses. In the historical control group (46 patients) from our center hysterotomy was performed according to Management of Myelomeningocele Study (MOMS) protocol. The study cohort’s outcomes were compared with the historical controls and with post-MOMS results in Children’s Hospital of Philadelphia (CHOP) and Vanderbilt University Medical Center (VUMC). Results: In the SG we did not observe delivery before 30 weeks of gestation (0/47; 0%) and the incidence of chorionamniotic membrane separation (CMS, 3/47; 6%) and preterm premature rupture of membranes (PPROM, 7/47; 15%) was lower compared to the other groups. Preterm delivery as a result of uterine contractions occurred significantly less frequently in the SG (8/47; 17%). Fetal surgery with classic hysterotomy resulted in rare use of magnesium sulfate (3/47; 6%). Conclusions: The alternative hysterotomy technique for fetal surgery of MMC results in low occurrences of CMS, PPROM, preterm delivery, and the rare use of tocolytics.

Letter to the Editor. The fallacy of sunk cost: decision-making after intrauterine myelomeningocele repair.

Letter to the Editor. The fallacy of sunk cost: decision-making after intrauterine myelomeningocele repair.

258: Characterization and time lapse experiments of fetal neuroprogenitor cells development derived from cerebral spinal fluid

Our objective was to capture and characterize the in vitro differentiation patterns of primary fetal neural progenitor cells (NPCs) isolated from fetal CSF obtained at the time of intrauterine myelomeningocele (MMC) repair. To optimize our differentiation of the MMC NPC cells, we developed a neonatal porcine model. We isolated NPCsfrom CSF as well as the sub ventricular zone (SVZ), which served as a positive control. Using fluorescent probes specific to progenitors (CDR3) and neurons (NeuO), we gated on porcine SVZ (“Brain”) and CSF populations during FACS. RT-qPCR and microscopy were employed in parallel as a means of molecular phenotyping aimed at confirmation of cellular phenotyping by FACS. We also performed a time lapse experiment over five days for observation of the differentiation pattern of these cells. Our fluorescence- activated cell sorting (FACS) results confirmed thatall of our neonatal piglet derivative cultures from SVZ differentiated into cells with NPC cellular phenotyping (CDR3+,NeuOlo/hi), but CSF from neonatal pigs retained a more heterogeneous population (Fig.1). Among human fetal MMC derived cells, we similarly derived NPCs with a minimum of 10% live cells which did not express markers of hematopoietic lineage cells (CDR3+/CD133+/CD45-). For both human and piglet derivatives, neurospheres were observed in culture on day 4, and persisted for at least 14 days (Fig.2) by time lapse microscopy. We have successfully demonstrated our capacity to isolate and differentiate NPCs from fetal human and neonatal piglet CSF. This is a key and novel in vitro model for future in vitro studies aimed at phenotyping neuronal single gene disorders and determining NPC susceptibility to congenital viral infections.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The Use of Indomethacin with Complete Amniotic Fluid Replacement and Classic Hysterotomy for the Reduction of Perinatal Complications of Intrauterine Myelomeningocele Repair

Objective: This study presented outcomes of classical hysterotomy with modified antiprostaglandin therapy for intrauterine repair of foetal myelomeningocele (fMMC) performed in a single perinatal centre. Study Design: Forty-nine pregnant women diagnosed with fMMC underwent classic hysterotomy with anti-prostaglandin management, complete amniotic fluid replacement and high dose indomethacin application. Results: The average gestational age (GA) at delivery was 34.4 ± 3.4 weeks, with no births before 30 weeks GA. There were 2 foetal deaths. Complete reversal of hindbrain herniation (HH), assessed in magnetic resonance imaging at 30–31 weeks GA was found in 72% of foetuses (mostly with HH grade I prior to fMMC repair). Our protocol resulted in rare use of magnesium sulphate (6%), low incidence of chorioamniotic membrane separation – chorioamniotic membrane separation (6%), preterm premature rupture of membranes – preterm premature rupture of membranes (pPROM; 15%) and preterm labour – preterm labour (PTL; 17%). The postoperative wound continuity of the uterus was usually stable (in 72% of patients), with low frequency of scar thinning (23%). Conclusion: Our protocol results in rare use of tocolytics, and the low occurrences of CMS, pPROM and PTL in relation to other study cohorts: Management of Myelomeningocele Study, Children’s Hospital of Philadelphia, and Vanderbilt University Medical Centre.

Improvement of motor function and decreased need for postnatal shunting in children who had undergone intrauterine myelomeningocele repair

To compare neuromotor development between patients who did and those who did not undergo intrauterine myelomeningocele repair. Children with myelomeningocele aged between 3.5 and 6 years who did undergo intrauterine repair (Group A, n=6) or not (Group B; n=7) were assessed for neuromotor development at both anatomical and functional levels, need for orthoses, and cognitive function. Intrauterine myelomeningocele repair significantly improved motor function. The functional level was higher than the anatomical level by 2 or more spinal segments in all children in Group A and 2 children in Group B, with a significant statistical difference between groups (p<0.05). Five children in Group A and one in Group B were community ambulators. Despite the small sample, it was observed that an improvement of motor function and decreased need for postnatal shunting in the 6 children who had undergone intrauterine myelomeningocele repair.

Anesthesia for In Utero Repair of Myelomeningocele

Recently published results suggest that prenatal repair of fetal myelomeningocele is a potentially preferable alternative when compared to postnatal repair. In this article, the pathology of myelomeningocele, unique physiologic considerations, perioperative anesthetic management, and ethical considerations of open fetal surgery for prenatal myelomeningocele repair are discussed. Open fetal surgeries have many unique anesthetic issues such as inducing profound uterine relaxation, vigilance for maternal or fetal blood loss, fetal monitoring, and possible fetal resuscitation. Postoperative management, including the requirement for postoperative tocolysis and maternal analgesia, are also reviewed. The success of intrauterine myelomeningocele repair relies on a well-coordinated multidisciplinary approach. Fetal surgery is an important topic for anesthesiologists to understand, as the number of fetal procedures is likely to increase as new fetal treatment centers are opened across the United States.

Intrauterine myelomeningocele repair Postnatal results and follow-up at 3.5 years of age — initial experience from a single reference service in Brazil

Present the outcomes of six cases submitted to intrauterine myelomeningocele (MMC) repair. Descriptive observational study of six children submitted to antenatal surgical repair of MMC between 26 and 27 weeks gestation. All deliveries were through cesarean section. The following neonatal variables were assessed: gestational age at delivery, birth weight, Apgar scores, need for intubation, duration of hospital stay and need for postnatal shunt procedures. After 3.5 years, the children were evaluated using the Columbia Mental Maturity Scale or Denver II tests and the Hoffer Ambulation Scale. All deliveries were preterm at a mean gestational age of 32 + 4 weeks and mean birth weight was 1,942 g. Two infants had Apgar scores <7 at 1 min and 1 at 5 min. Ventricular-peritoneal shunts were placed in two cases. All six children are alive: five have normal cognitive development and one has a neuropsychomotor developmental delay. Two children had normal leg movements, a sacral functional level and are community ambulators. Three children had upper lumbar anatomical level lesions and one had a lower thoracic level lesion at the time of fetal surgery. One child, with an L1-L2 anatomical level lesion, in noambulatory and fully dependent on a wheelchair for mobility. Antenatal surgical repair of MMC reduced the need for postnatal shunt placements. Despite preterm delivery, the cognitive development of most children at 3.5 years was normal. Antenatal surgery seemed to improve lower limb motor function in these cases.

Congenital myelomeningocele - do we have to change our management?

BackgroundEagerly awaiting the results of the Management of Myelomeningocele Study (MOMS) and with an increasing interest in setting up intrauterine myelomeningocele repair (IUMR), the optimal management of patients suffering from congenital myelomeningocele (MMC) has become a matter of debate again. We performed a cross-sectional study at our referral-center for MMC to determine the outcome for our expectantly managed patients.Materials and methodsA computed chart review at our institution revealed 70 patients suffering from MMC. Forty-three patients were eligible for the study and analyzed further. A retrospective analysis was performed only in patients that underwent MMC repair within the first two days of life and were seen at our outpatient clinic between 2008 and 2009 for a regular multidisciplinary follow-up. Data were collected on: gestational age (GA) and weight at birth, age at shunt placement and shunt status after the first year of life, radiological evidence for Arnold-Chiari malformation (ACM) and tethered cord (TC), need for surgery for TC, bladder function, lower leg function and educational level. Data were compared to published results for IUMR and to studies of historical controls.ResultsPatients were born with MMC between 1979 and 2009 and are now 13.3 ± 8.9 (mean ± SD) years of age. At birth, mean GA was 37.8 ± 2.3 weeks and mean weight was 2921.3 ± 760.3 g, both significantly higher than in IUMR patients. Shunt placement in our cohort was required in 69.8% at a mean age of 16.0 ± 10.7 days, which was less frequent than for historical controls. Amongst our cohort, radiological observations showed 57.1% had ACM II and 41.9% had TC. Only two of our patients underwent a surgical correction for TC. Clean intermittent catheterization was performed in 69.7% of our patients, 56.4% were (assisted) walkers and 64.1% attended regular classes, both comparable to historical controls.ConclusionsWith a close and interdisciplinary management by pediatric surgeons, neurologists and urologists, the long-term outcome of patients suffering from MMC can currently be considered satisfactory. With respect to the known drawbacks of fetal interventions for mother and child, especially preterm delivery, the results of the MOMS trial should be awaited with caution before proceeding with a complex intervention like IUMR.

Successful developmental outcome in intrauterine myelomeningocele repair

Myelomeningocele (MM) is one of the forms of dysraphism. Hydrocephalus secondary to Arnold-Chiari (AC) malformation is responsible for the morbidity and mortality of the disease. The intrauterine repair of MM may reverse AC and limit hydrocephalus progression. The aim of this work is to report the successful outcome of a case of intrauterine correction of MM, with favorable evolution and birth at 36 weeks of pregnancy. KCMC, 19 years old, was submitted to intrauterine repair of MM at 24 weeks of gestational age after approval by the family and the Research Ethics Committee of the School of Medical Sciences-UNICAMP. Although it is not the standard option for surgical correction, selected MM cases with early fetal diagnosis may be eligible for intrauterine repair, when there is consensus with the Research Ethics Committees and family members.

The Timing of Primary Neurosurgical Repair Significantly Affects Neurogenic Bladder Prognosis in Children With Myelomeningocele

The correlation between timing of the primary neurosurgical repair and urological prognosis in infants with open spinal dysraphism remains unknown. We investigated the impact of primary repair timing on neurogenic bladder prognosis in children with myelomeningocele. We retrospectively reviewed the records of 401 children with myelomeningocele followed at our multidisciplinary clinic between 1996 and 2005. Among these patients 129 were included in the study based on the availability of urological followup data at age 3 years, which was chosen as an ideal point for the standardization of urological findings. Children were assigned to 1 of 2 groups-those who underwent primary neurosurgical repair within 72 hours of delivery (group 1) and those undergoing repair after 72 hours (group 2). We compared the incidence of febrile urinary tract infections, hydronephrosis, vesicoureteral reflux and secondary tethering of the spinal cord at age 3 years, as well as cystometric bladder capacity and detrusor leak point pressure between the 2 groups. Urological followup data at age 3 years revealed significantly increased incidence of febrile urinary tract infections, vesicoureteral reflux, hydronephrosis and secondary tethering of the spinal cord in children in group 2 compared to group 1 (chi-square, p < or =0.05 for all comparisons). Urodynamic assessment also showed a significantly lower bladder capacity and a substantially higher detrusor leak point pressure in children who received primary repair at later than 72 hours (t test, p <0.05). A subgroup analysis of group 1 comparing children who underwent repair before and after 24 hours following delivery failed to demonstrate any significant difference in terms of febrile urinary tract infections, vesicoureteral reflux, hydronephrosis and secondary tethering (chi-square, p >0.05 for all comparisons), whereas mean bladder capacity was significantly higher (t test, p <0.05) and mean detrusor leak point pressure was lower (t test, p = 0.08) in children undergoing repair within 24 hours of delivery. The timing of primary neurosurgical repair has a significant impact on neurogenic bladder prognosis in children with myelomeningocele. Closure of the spinal lesion on the first day of life seems to provide the best chance for favorable lower urinary tract function.

Impact of maternal-fetal surgery for myelomeningocele on the progression of ventriculomegaly in utero

Intrauterine myelomeningocele (MMC) repair decreases hindbrain herniation and the need for postnatal ventriculoperitoneal shunting. We examined the impact of intrauterine repair on the progression of ventriculomegaly in utero. Fetuses with MMC were identified through computerized databases from June 1988 to April 2003. A retrospective cohort design was used to evaluate the impact of intrauterine repair on ventricular progression with a multivariate linear regression model that included baseline ventricle measurement, gestational age, level of lesion, and gender. Fourteen fetuses with intrauterine repair and 39 fetuses with postnatal repair were identified. The natural history of progression of ventricular diameter increased in a linear fashion throughout gestation (0.57 mm/week). After adjusting for confounding variables, no transient or sustained difference was observed in the rate progression of ventriculomegaly between intrauterine and postnatal repair (0.27 +/- 0.35 mm/week; P=.45). Intrauterine MMC repair does not impact the progression of ventriculomegaly.

Intrauterine closure of myelomeningocele: an update.

Preliminary evidence suggests that intrauterine myelomeningocele repair may benefit patients by reducing the both incidence of hydrocephalus and the severity of the Chiari malformation; however, this benefit remains unproved. Furthermore, the procedure entails substantial risks not associated with conventional therapy. A randomized controlled trial of intrauterine and conventional therapies is underway. This study should definitively establish the procedure related risks and benefits. Regardless of the outcome, it is clear that the risks of intrauterine intervention need to be reduced before myelomeningocele, or other congenital malformations, can be effectively treated prior to birth. To that end, studies are being conducted to assess the potential advantages of applying state-of-the-art endoscopic techniques to intrauterine therapy. If benefit can be proven and risks reduced, intrauterine myelomeningocele repair has the potential to become the preferred therapy for patients suffering from this debilitating disease.

Intrauterine surgery for myelomeningocele and MOMS

Ms. Worcestor of the Tallahassee Bureau reported in October 2003 that Dr. Joseph Bruner told a world conference in Lisbon that intrauterine myelomeningocele repair (IUMR) results in fewer urinary tract infections, less gastrointestinal reflux, improved leg function and cognitive development and less need for a cerebrospinal fluid shunt. Our experience has been with only 22 cases. The authors of articles from Children's Hospital of Philadelphia (CHOP) and Vanderbilt admit to premature births causing death (5 or 0.03%), infection, development of demoid tumours causing paralysis and maternal morbidity (N Engl J Med 2002). And their latest scientific article stated their CSF shunt rate is only 54.8 % (Pediat Neurosurg 2003). Our data are from five centres with experience in following patients referred for IUMR to CHOP, Vanderbilt or San Francisco. 20 of 22 mother/patients pairs (91%) are known to have significant complications as follows: 18/22 (82%) have CSF shunts one of whom had cardiac arrest due to high CSF pressure (2 were lost to follow up because their local centre recommended a shunt but the IUMR centre did not), 4 (17%) had the IUMR site dehisce, 4 (17%) developed sepsis – 3 meningitis and 1 sepsis and intracranial bleed due to prematurity, 7 had symptoms of Chiari II (30%) of which 3 (14%) were decompressed and 1 has required both gastrostomy and tracheotomy with ventilation, 8 patients (36%) were born prematurely and spent prolonged time in the neonatal intensive care nursery, 2 patients had hydromyelia, and one patient each developed mental retardation, tethered cord, broken femur, scoliosis or kyphosis as young infants. Five mothers developed significant complications as follows: one each rupture of the uterus, abruption of the placenta, intrauterine haemorrhage, dehiscence of her abdominal wound and oligohydramnios. These percentages add up to greater than the 91% because some individual pairs had more than one complication. Conclusion The Management of Myelomeningocele Study (MOMS) being funded by the U S Government in the 3 centres mentioned above is critically important from 48th Annual Meeting of the Society for Research into Hydrocephalus and Spina Bifida Dublin, Ireland, 23–26 June 2004 Published: 23 December 2004

Intrauterine Myelomeningocele Repair: Effect on Short-Term Complications of Prematurity

Objective: To determine whether short-term complications of prematurity are affected by intrauterine myelomeningocele repair. Methods: Medical records of the first 100 infants undergoing intrauterine myelomeningocele repair (IUMR) at the Vanderbilt University Medical Center were reviewed. Infants born at <34 weeks’ gestation were identified. Two controls were identified for each IUMR infant. Controls were matched for gestational age, sex, birth weight, antenatal steroids, and mode and month of delivery. Development of respiratory distress syndrome, intraventricular hemorrhage, and chronic lung disease and days on ventilator and length of hospital stay were recorded. The results are expressed as mean values and ranges. Comparison of data between groups was performed using the Mann-Whitney U test. Categorical data were compared using the chi-square test and Fisher’s exact test. p ≤ 0.05 was considered statistically significant. Results: One hundred infants underwent IUMR. Forty-four infants were born at <34 weeks of gestation. Complete data were available on 37 infants. Seventy-four matched controls were studied. Eleven infants from the IUMR group and 23 infants from the control group developed respiratory distress syndrome (29.7 vs. 31.1%; p = 0.8). Six infants from the IUMR group and 13 infants from the control group developed chronic lung disease (16.2 vs. 17.5%; p = 0.9). The length of stay was 28 (range 2–82) days for the IUMR group and 24 (range 1–99) days (p = 0.09) for the control group. There was also no significant difference between groups with regard to intraventricular hemorrhage and days on ventilators. Conclusion: There is no difference between short-term complications of prematurity following IUMR and those associated with prematurity resulting from other causes.

Myelomeningocele: Prenatal Evaluation—Comparison between Transabdominal US and MR Imaging

To compare transabdominal ultrasonography (US) with fetal magnetic resonance (MR) imaging in the prenatal evaluation of myelomeningocele lesion level. Prenatal US images, pre- and postnatal MR images, and postnatal spinal radiographs obtained in the first 100 fetuses who underwent intrauterine myelomeningocele repair were the basis for this study. Each image was used to assign a lesion level. The assigned levels were compared by means of the kappa statistic, as an index of agreement. All fetuses underwent prenatal US. Sixty-one fetuses underwent prenatal MR imaging. Fifty fetuses underwent both postnatal spinal radiography and postnatal MR imaging, and an additional 34 fetuses underwent one postnatal study but not the other. When findings on prenatal US images were compared with those on postnatal radiographs, the findings agreed within one spinal level in 79% (55 of 70, kappa = 0.60) of cases. When findings on prenatal MR images were compared with those on postnatal radiographs, the findings agreed in 82% (31 of 38, kappa = 0.63) of cases. Findings on postnatal MR images and those on postnatal spinal radiographs agreed within one spinal level in 100% (50 of 50, kappa = 1.0) of cases. Findings at prenatal MR imaging and prenatal US are equally accurate for the assignment of a lesion level in a fetus with myelomeningocele. Given that findings with both modalities will lead to misdiagnosis of the spinal level by two or more segments in at least 20% of cases, care should be exercised when neurologic outcome is predicted on the basis of these studies alone.

Late Gestational Intrauterine Myelomeningocele Repair Does Not Improve Lower Extremity Function

Objective: To determine whether intrauterine myelomeningocele repair performed at between 20 and 28 weeks gestation improves lower extremity function (LEF). Methods: Thirty-seven consecutive patients who had undergone intrauterine repair of their myelomeningocele at Vanderbilt University Medical Center had their lower extremity function and radiographic level (first defective vertebral level) compared to these same parameters in 40 controls who had undergone traditional postgestational repair of their myelomeningocele at the Children’s Hospital in Birmingham, Ala., USA. Results: Of all 77 patients (controls and study group), 13 had a LEF that matched their radiographic level, 27 had a LEF that was rostral to their radiographic level, and 37 had a LEF that was caudal to their radiographic level. Further stratification revealed that for the intrauterine repaired myelomeningoceles, 11% had no difference between LEF and radiographic level, 43% had a LEF that was rostral to their radiographic level, and 46% had a LEF that was caudal to their radiographic level. For those closed in a traditional manner, LEF matched their radiographic level, was rostral to their radiographic level, and was caudal to their radiographic level in 22.5%, 27.5%, and 50% respectively. However, the overall mean differences between institutions produced a p-value of 0.2026 (paired t-test). Conclusions: Although the current timing of intrauterine myelomeningocele repair has been found to lessen the degree of herniation of the rhombencephalon and reduce the incidence of shunt-dependent hydrocephalus, it does not statistically improve LEF. Parents should be advised of these findings prior to surgical intervention so as to focus their expectations.