Sunday, October 10, 2004

Repair Of Lumbosacral Meningomyelocles: An Added Layer Of Protection

Richard L Agag, MD, Mark S Granick, MD, Parsham Ganchi, MD, PhD, and J Catrambone, MD.

The repair of lumbosacral meningomyeloceles involves closure of exposed neural elements which are then covered with vascularized tissue. Various techniques have been developed to provide soft-tissue coverage of these defects. Potential complications include infection, wound dehiscence, and flap failure. Such adverse events can subsequently complicate the neurosurgical repair. The placement of acellular cadaveric dermal matrix (ACDM) over the neurological repair provides an additional safety layer in preventing dural exposure. Because neural tube anomalies are a common congenital anomaly, it is important to improve upon the procedure of repairing these defects. This in turn will lower the associated morbidity and mortality. Seven cases of patients with large lumbosacral meningomyeloceles are presented. The first case was a neonate born with a large lumbosacral meningomyelocele. After repair by the pediatric neurosurgical service, the patient developed a skin slough which exposed the underlying dural repair. The dural repair remained intact throughout this course. The plastic surgery service was consulted and the patient was taken back to the operating room where an ACDM patch was placed over the dural closure with the dermal-epidermal interface side of the ACDM facing towards the dural repair. It was then covered with a split-thickness skin graft (STSG), 4/1000 of an inch in thickness. On post-operative day two, a surgical house officer removed the dressing and inadvertently stripped the split-thickness graft off of the underlying ACDM which remained intact. No further procedure was performed. The ACDM became vascularized and completely healed within 2 weeks after the plastic surgical procedure. The second case involved a seven year-old boy with untreated spina bifida and an extensive spinal defect. The neurological repair by neurosurgery created a wound that extended from the scapula to the level of the iliac crest with the middle section being the widest. After elevating latissimus dorsi flaps, a piece of ACDM was placed over the central portion of the defect where the spinal elements were exposed. The wound was then closed in layers. In the post-operative period the patient developed a fluid collection under the flaps and a small wound dehiscence in the upper-middle part of the flap. The patient was taken back to the operating room and a layer of ACDM was place over this upper portion, sealed in place with fibrin glue, and the wound closed in layers. After this second operation the patient again suffered a small dehiscence in this upper region, however, the ACDM remained intact, uninfected, and the patient was allowed to heal secondarily. The remaining five patients where neonates all born with lumbosacral meningomyelocele defects. A layer of ACDM was placed over the dural repair and under the closure of the overlying skin. All patients healed without complication. ACDM can be used as an added layer of protection in neurosurgical repair of meningomyeloceles.