Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Myelomeningocele Repair (Open Neural Tube Defect Closure)

Case / Approach Snapshot

One-Liner

[Newborn / __ -day-old] [M/F] neonate with a [lumbar/lumbosacral/thoracic] myelomeningocele planned for [postnatal] microsurgical repair and multilayer closure [within 48-72 hours of birth] [or note prior fetal repair].

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

Neurosurgical Atlas · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Myelomeningocele Repair — Figure 1 Figure 1. Classification of cervical myelomeningocele and meningocele. (a) Fibrovascular or neuroglial tissue protruding from the posterior surface of the spinal cord attached to the sac wall. (b)… Source: Prenatal Diagnosis and Outcomes of Cervical Meningocele and Myelomeningocele — Journal of Medical Ultrasound 2024; CC BY-NC-SA.

Myelomeningocele Repair — Figure 3 Figure 3. Expression and distribution of bladder cleaved caspase-3 at E22. (A) The distribution of cleaved caspase-3 at E22. (B) The expression of cleaved caspase-3 in the bladder muscle layer was… Source: The Mechanism of Bladder Injury in Fetal Rats With Myelomeningocele — Frontiers in Neurology 2022; CC BY.

Myelomeningocele Repair — Fig. 1 Fig. 1. Identification of DEGs in the GSE101141 GEO dataset. A Normalization of the GSE101141 dataset was performed using Log2 transformation: N, Control; C, myelomeningocele; B UMAP plot; C… Source: Identification of potential key ferroptosis- and autophagy-related genes in myelomeningocele through bioinformatics analysis — Heliyon 2024; CC BY-NC.

Myelomeningocele Repair — Fig. 2 Fig. 2. Functional enrichment analysis of ferroptosis-related DEGs. A GO enrichment analysis of ferroptosis-related DEGs using SRplot: BP, biological process; CC, cellular component; MF,… Source: Identification of potential key ferroptosis- and autophagy-related genes in myelomeningocele through bioinformatics analysis — Heliyon 2024; CC BY-NC.

Myelomeningocele Repair — Fig. 3 Fig. 3. Functional enrichment analysis of autophagy-related DEGs. A GO enrichment analysis of autophagy-related DEGs using DAVID and SRplot: BP, biological process; CC, cellular component; MF,… Source: Identification of potential key ferroptosis- and autophagy-related genes in myelomeningocele through bioinformatics analysis — Heliyon 2024; CC BY-NC.

Myelomeningocele Repair — Fig. 4 Fig. 4. PPI analysis of ferroptosis- and autophagy-related DEGs. A and B PPI analysis of ferroptosis- and autophagy-related DEGs: orange, upregulated genes; blue, downregulated genes; C and D… Source: Identification of potential key ferroptosis- and autophagy-related genes in myelomeningocele through bioinformatics analysis — Heliyon 2024; CC BY-NC.

Myelomeningocele Repair — Fig. 5 Fig. 5. Expression and function enrichment of candidate genes. A Expression of candidate genes from GSE101141; B and C GO and KEGG enrichment analyses of candidate genes using DAVID and SRplot:… Source: Identification of potential key ferroptosis- and autophagy-related genes in myelomeningocele through bioinformatics analysis — Heliyon 2024; CC BY-NC.

Myelomeningocele Repair — Fig. 6 Fig. 6. Interaction network among miRNAs, TFs, and candidate genes. A Interaction network between candidate genes and targeted miRNAs: red, candidate genes; blue, miRNA; B Interaction network of… Source: Identification of potential key ferroptosis- and autophagy-related genes in myelomeningocele through bioinformatics analysis — Heliyon 2024; CC BY-NC.

History of Present Illness

Past Medical History / Birth

Imaging Review

MRI brain and spine

Labs

Neurological Examination

Surgical Planning

Case Logistics, OR Needs & Orders

Goals & Timing

Position

Key Surgical Steps

  1. Examine the defect: central neural placode, surrounding arachnoid/dura, then epithelialized skin junction
  2. Dissect the placode free circumferentially at the junction of neural tissue and the surrounding membrane/skin (the zona epitheliosa) — release tethering, excise non-neural epithelial tissue (prevents inclusion dermoid)
  3. Reconstitute the placode — “neurulate” by approximating the pia/placode edges into a tube (pial reapproximation) to reduce retethering
  4. Place the neural tube back into the spinal canal
  5. Dural closure — dissect dura from surrounding fascia, close in a watertight layer over the placode
  6. Fascial/myofascial layer — mobilize paraspinal fascia, close as additional watertight layer
  7. Skin closure — undermine skin, close (may need relaxing incisions or plastics flaps for large defects)
  8. Avoid tight closure/tension; ensure no CSF leak

Critical Anatomy & Structures at Risk

  1. Neural placode / functional neural tissue — preserve all functional tissue (handle gently, stimulate to identify)
  2. Nerve roots from the placode
  3. Watertight dura (CSF leak/meningitis), skin viability (large defects)
  4. Avoid leaving epithelial elements (dermoid/retethering)

Equipment

Monitoring

Anesthesia

Potential Complications

  1. CSF leak / wound breakdown / meningitis (closure integrity)
  2. Hydrocephalus (progressive — many need shunt/ETV after closure; monitor head circumference/ventricles)
  3. Symptomatic Chiari II (stridor, apnea, swallowing — may need decompression)
  4. Retethering (later), skin necrosis, infection
  5. Neurological function fixed by lesion level (closure preserves, rarely improves)

Operative Note Template

Preoperative Diagnosis: [Lumbosacral] myelomeningocele (open neural tube defect)

Postoperative Diagnosis: Same

Procedure: Microsurgical repair of [lumbosacral] myelomeningocele with neurulation and multilayer (dural, fascial, skin) closure

Surgeon / Assistant: Anesthesia: Neonatal general endotracheal, latex-free, thermoregulation EBL / Fluids: Adjuncts: Microscope, nerve stimulator, [plastics for large defects] Implants: [Dural substitute if needed] Complications: None

Indications: Newborn with a [lumbosacral] myelomeningocele [not repaired in utero], repaired within 48–72h to prevent infection/ventriculitis and preserve function. Latex precautions from birth. Risks (CSF leak, hydrocephalus, Chiari II) discussed with family.

Description of Procedure: After consent and time-out, neonatal general anesthesia was induced (latex-free, warming) and the infant positioned prone with the placode protected. Under the microscope, the neural placode was dissected circumferentially free at the junction with the surrounding membrane/skin (zona epitheliosa), and non-neural epithelial tissue excised (to prevent inclusion dermoid). The placode was reconstituted by pial reapproximation (neurulation) and returned into the spinal canal.

The dura was dissected and closed in a watertight layer, followed by a myofascial layer, and the skin closed [with relaxing incisions/flaps for the large defect], avoiding tension. No CSF leak was evident.

The infant was transferred to the NICU prone/side-lying with serial head-circumference/US monitoring (hydrocephalus) and a multidisciplinary spina bifida plan.

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Myelomeningocele Repair (Open Neural Tube Defect Closure):

Common Pimp Questions

Use these to pressure-test preparation for Myelomeningocele Repair (Open Neural Tube Defect Closure):

  1. What age-specific anatomy, blood volume, temperature, and positioning issue changes the plan?
  2. What is the neurologic, developmental, or syndromic baseline?
  3. What skin, wound, CSF, or infection risk is highest in this child?
  4. What family-facing expectation should be clarified before surgery?
  5. What postop bed, feeding, pain, imaging, and activity plan is safest?

Attending Preference Variables

Items that commonly vary by surgeon or institution: