Spina Bifida

Latex allergy - Between 10% and 73% of spina bifida patients are latex-allergic, and reactions can be anaphylactic. Run a latex-free room from the start — gloves, drains, tourniquets, vial stoppers — and it begins at the newborn exam, where non-latex gloves are used specifically to prevent sensitization.

Chiari II and the brainstem - Look for stridor, a weak or hoarse cry (vocal cord paralysis), sleep apnea, and unexplained bradycardia. Chiari II severity drives most of the mortality in infants with open defects and predicts the postoperative airway and apnea problems you will own in recovery.

Hydrocephalus and shunt status - Most patients need a ventriculoperitoneal shunt after closure. Ask when the shunt was last revised and look for headache, vomiting, somnolence, or newly worsening scoliosis — worsening scoliosis is a recognized signal of shunt malfunction, tethered cord, or hydromyelia and warrants evaluation before an elective case. Until the shunt is proven working, plan around raised ICP.

Neonatal closure - Repair is done within 24 to 72 hours to limit infection and further neurologic decline, prone under general anesthesia. Position the infant lateral or prone from delivery onward with the lesion covered by a moist dressing or plastic wrap, which is also the main thing limiting evaporative heat loss.

Temperature - An exposed neural placode, a prone neonate, and a large wet dressing add up to significant evaporative and radiant loss. Warm the room and start forced-air warming before the drapes go on.

Neuraxial anesthesia - Cord anatomy is abnormal: tethering, an abnormal termination level, prior repair, and scar. Review the MRI or operative record for the defect level before offering a spinal or epidural — MRI localizes the functional level to within one to two vertebral segments in 89% of cases.

Positioning - Contractures, foot deformities (equinovarus, calcaneus, rocker bottom), scoliosis in about 33%, and osteopenia with an increased fracture rate. Pad and position to the patient's fixed range, not to the table, and move limbs deliberately.

Renal function - Neurogenic bladder with detrusor-sphincter dyssynergia is the rule. Urinary tract infections affect about 48% of patients and 6% progress to renal failure, so check a creatinine and the most recent surveillance renal ultrasound before dosing renally cleared drugs.

Seizures - Epilepsy affects about 12% of patients. Continue antiepileptics perioperatively and confirm the drug and last dose in the chart.

Chronic pain - About 29% of patients live with chronic pain. Get the home analgesic regimen before you build the postoperative plan rather than after.

Sensory level - Motor and sensory loss below the lesion is common and often complete in myelomeningocele. Know the level before you rely on movement or withdrawal as a monitor, and before you assume a positioning injury would be reported.

Fetal repair - In-utero repair is offered between 19 and 25 weeks for a fetus with a T1-to-sacral lesion and Chiari malformation. It reduces later shunt need, repositions the cerebellum, and improves leg function, at the cost of prematurity and significant maternal complications — the maternal anesthetic is built around preserving uteroplacental perfusion.

Spina bifida is failure of neural tube closure, typically between days 17 and 30 of gestation. Occulta (closed dysraphism) is a hidden vertebral defect with minimal neural involvement. Aperta (open dysraphism) exposes neural tissue — a meningocele extrudes meninges and CSF, while a myelomeningocele extrudes meninges, CSF, and functioning neural elements and carries the real functional deficits. Folate deficiency is the most common environmental cause; valproic acid raises risk roughly tenfold.

Open defects usually come with Arnold-Chiari II malformation, which obstructs posterior fossa CSF flow and produces hydrocephalus, plus motor loss, spasticity, and neurogenic bowel and bladder at and below the lesion level. For anesthesia the trouble is all downstream: raised ICP and shunts, brainstem dysfunction, latex anaphylaxis, distorted spinal anatomy, scoliosis with contractures, and renal impairment from years of detrusor-sphincter dyssynergia.