Surgeons repair spina bifida before birth

BMJ 1998; 317 doi: (Published 28 November 1998) Cite this as: BMJ 1998;317:1474
  1. Scott Gottlieb
  1. New York

    Surgeons have achieved the first correction of spina bifida in a 23 week old fetus, allowing the baby to be born with normal leg movements a few weeks later.

    The doctors who performed the surgery reported that by repairing the condition before birth, it was possible to prevent the nerve damage that frequently accompanies the condition (Lancet1998;352:1675-6). The doctors were from the Children's Hospital in Philadelphia and the University of Pennsylvania. Similar procedures have been performed in utero to correct other conditions, particularly life threatening fetal heart abnormalities.

    Dr Scott Adzick, the lead surgeon who carried out the procedure, and his colleagues were first alerted to the fetus's condition during the 20th week of gestation after an ultrasound scan was performed because of raised maternal serum * fetoprotein. After ascertaining that the fetus's leg movements were still good, the surgeons operated through the mother's uterus, using general anaesthesia. Tocolysis was maintained postoperatively with magnesium sulphate and indomethacin. Seven weeks after surgery, at 30 weeks' gestation, the mother went into early labour and a 1.3 kg boy was delivered by caesarean section.

    The infant's leg movements were normal at birth. “We believe that covering the exposed spinal cord in utero protects the nerves from damage,” said Dr Adzick. “Amniotic fluid progressively damages the exposed spinal nerves, and if we intervene early enough, prior to 24 weeks' gestation, we can thwart neurologic devastation by covering the nerves.” Although performing the repair carries its own potential consequences--particularly early delivery and the medical issues of premature birth--it seems to provide the fetus with the best possible chance of having little or no permanent nerve damage, according to Dr Adzick.

    The results look good so far: the baby's left leg has full function. “The baby's right leg works well from the hip to the knee, and overall his mobility and strength are pretty incredible considering that without intervention this child would have been born paralysed from the navel down,” Dr Adzick concluded.

    Lewis Spitz, professor of paediatric surgery at Great Ormond Street Institute of Child Health, commented: ‘This is pioneering work that needs to be done, but it is still at an experimental stage.” He suggested that the technique would have to be evaluated in a series of patients before its use could be considered more widely.

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