Multidisciplinary evaluation of occult spinal dysraphism in 47 children.

OBJECTIVE

To present the clinical (urologic, orthopedic and neurologic) and urodynamic findings of 47 children suffering from occult spinal dysraphism, together with the long-term follow-up results obtained with various treatment modalities.

MATERIAL AND METHODS

Between 1997 and 2000 a total of 47 children (27 girls, 20 boys; male:female ratio 1.3) referred to the Urology and/or Pediatrics Departments with symptoms and signs of closed spina bifida were enrolled in the study program. All patients underwent routine assessment of the urinary tract, including detailed anamnesis, physical examination and radiologic evaluation (X-ray, renal bladder ultrasonography and sacral MRI). In addition to video-urodynamic evaluation of the lower urinary tract, all patients were also evaluated by the Orthopedic Department with respect to possible lower extremity deformities.

RESULTS

The age range of the children was 2 months to 16 years (mean 6.9 years). At first referral, 23 children were found to have normal urinary and fecal continence after toilet training; among the other presenting symptoms and signs, 34% of patients demonstrated recurrent urinary tract infections and 38.2% had abnormal findings on urinary tract investigations. Evaluation of urodynamic parameters before and after conservative treatment demonstrated an increase in age-related bladder capacity in 34 patients and detrussor instability had been cured in 23/30 patients (p < 0.05). Overall, bladder capacity was found to be normal in 40 children following conservative management (p < 0.05). The conservative approach proved to be effective in 40 children (85.1%), and intravesical instillation therapy with oxybutynine hydrochloride was successful in one of the remaining seven children (14.2%). Bladder augmentation was performed in six children (12.7%) in whom conservative measures were ineffective.

CONCLUSIONS

In the light of our findings and the literature data it is obvious that a multidisciplinary approach together with early urologic evaluation to determine the extent of neurologic involvement of the lower urinary tract is essential to ensure a successful treatment outcome and to prevent the occurrence of serious functional and structural complications. Clinical, radiologic and video-urodynamic assessments should be performed to define the neuro-urologic pathophysiology and to provide management guidelines and a baseline for future comparison.