A meningomyelocele is an opening in the spine where the covering layers and skin failed to close before birth, leaving the spinal cord exposed. It is closed urgently, and the plastic surgical part of that operation is providing durable skin and muscle cover over the repair.
Meningomyelocele reconstruction is the soft tissue closure of an open spinal defect in a newborn. A neurosurgeon frees and returns the neural tissue and closes the covering layers; the plastic surgeon then provides skin and muscle cover, using local flaps where the defect is too wide to close directly. It is usually done within the first 48 to 72 hours of life to reduce infection risk.
The spine forms early in pregnancy by folding into a tube. Where that folding is incomplete, the bones, the muscles and the skin over that segment all fail to close, and the spinal cord sits exposed on the back.
Two problems follow immediately. The first is infection: an open route to the spinal fluid risks meningitis within days. The second is mechanical: exposed neural tissue dries and is easily damaged. Both make this an urgent operation rather than a planned one, and closure is usually done within the first 48 to 72 hours.
The neurosurgical part frees the neural placode, returns it into the canal and closes the dura around it. The reconstructive part is what follows: providing cover that will not break down. A small defect closes directly. A wide one cannot, and pulling the skin edges together under tension guarantees breakdown over a repair that must stay watertight. In that situation flaps of skin, fat and sometimes the back muscles are moved in from either side to close the gap without tension.
Closure does not reverse the neurological damage. The nerve function that is absent at birth is generally absent for life, and children need lifelong follow up for bladder, bowel, mobility and hydrocephalus. What closure does is prevent infection, protect what function exists, and allow the child to lie, sit and be handled normally.
Closure is required in essentially every case. The reconstructive question is how the cover will be achieved, not whether to operate.
The baby is nursed face down or on the side and the defect covered with sterile saline dressings to stop it drying out.
The neural tissue is freed from the skin edges, returned into the canal, and the dura closed around it as a watertight layer.
The defect is measured once the repair is done. This determines whether direct closure is possible or flaps are needed.
For a wide defect, skin, fat and sometimes the back muscles are mobilised from either side so the midline can be closed without tension.
Muscle and fascia are brought over the repair first, then fat, then skin, so that there is more than one barrier over the dura.
The scar is planned so that the child does not lie or sit directly on it.
Nursed prone or on the side to keep pressure off the wound. Antibiotics. Head circumference measured daily for hydrocephalus.
Wound heals. A shunt is inserted at this stage if hydrocephalus develops. Feeding is established and baseline neurological function documented.
Scar matures. Physiotherapy and orthotics begin. Urology assessment of bladder function is arranged.
Regular follow up for shunt function, bladder and bowel management, spine and hip development, and mobility.
Closure reliably protects the repair and prevents infection, and that is its purpose. It does not restore nerve function. Weakness, altered sensation and bladder or bowel problems present at birth generally persist, and most children need long term care from neurosurgery, urology, orthopaedics and physiotherapy together. Families are told this clearly before surgery, because the operation is sometimes mistakenly expected to fix the legs. The scar on the back is substantial and is placed to avoid pressure points where the child will lie and sit.
These are newborns having urgent surgery, and the risks are discussed with parents in that context.
The first fortnight is about keeping the wound clean, dry and free of pressure.
Closure protects what function exists. Nerve function absent at birth is generally absent permanently. This is explained before surgery because the expectation is common and the disappointment afterwards is severe.
Closure is the first step. Hydrocephalus, bladder and bowel management, hip and foot deformity and cord tethering are all followed for years.
Wide defects need flaps, and flaps leave longer scars. A longer scar that stays closed is far better than a short one that breaks down over the repair.
The soft tissue half of this operation decides whether the neurosurgical repair stays covered. Planning the flap before the skin is opened, rather than improvising once the defect turns out to be wider than expected, is what prevents breakdown.
Newborn surgery of this kind is commonly covered by health insurance and by government schemes including PM JAY. Cost depends on the length of neonatal intensive care and on whether a shunt is required. Treatment is not delayed for financial arrangements.
The questions asked in the first day, almost always by frightened parents.
Ask your question →Because the opening is a direct route for bacteria to reach the spinal fluid, and meningitis in a newborn is extremely serious. Closing within the first two to three days substantially reduces that risk.
That depends on the level of the defect and on the nerve function present at birth, not on the surgery. Children with lower defects often walk, some with braces. Higher defects more often mean using a wheelchair. The neurological examination after birth gives the most honest guide.
Because if the skin is pulled together under tension over a wide defect it will break down, and it will break down directly over a dural repair that must stay watertight. Flaps bring in tissue from the sides so the closure is relaxed.
A shunt drains excess fluid from around the brain. Many children with meningomyelocele develop hydrocephalus, often in the weeks after closure, and need one. Head circumference is measured regularly for exactly this reason.
Folic acid before and in early pregnancy substantially reduces the risk of neural tube defects, which is why it is recommended for anyone who might become pregnant. It does not eliminate it, and it is not a reason for parents to blame themselves.
Seeing patients from across the city and beyond: read about the practice on the plastic surgeon in Surat page, or check what a written estimate covers on the costs and insurance page.
