Surana R H, Quinn F M, Guiney E J, Fitzgerald R J
Children's Research Centre, Our Lady's Hospital for Sick Children, Dublin, Ireland.
Eur J Pediatr Surg. 1991 Dec;1 Suppl 1:35-7. doi: 10.1055/s-2008-1042537.
Management of spina bifida is still controversial. At one extreme is the policy of total care in all cases while some form of selection is practised in many centres. We reviewed 104 patients treated over the last five years. Forty-nine patients, who had one or more adverse criteria, were managed conservatively. Twenty-four of these 49 patients required VP shunt insertions subsequently. Four patients had delayed closure of back lesions, three of them were followed by shunts. There was an overall increased (57%) incidence of surgical intervention in conservatively managed patients over the last five years as compared with 34% from our previous report. We found no difference in the timing of insertion of shunts in actively and conservatively managed patients in this study. The mortality in the actively and conservatively managed patients was 7% and 47% respectively. Eighty-five per cent of the patients who had no surgery died at an average age of 23 days. Patients who died without surgical intervention did not survive long enough to warrant surgery, while the mortality was 20% and had among those who survived surgical intervention. Paraplegia alone was not a predictor of high mortality but the presence of two or more adverse criteria were more accurate indicators of poor prognosis. As 78% of all the deaths in conservatively managed patients occurred within three months, reappraisal of management policy is necessary in the infants surviving beyond three months of age as death is less likely after this time.
脊柱裂的治疗仍存在争议。一种极端的做法是对所有病例都采取全面护理，而许多中心则实行某种形式的筛选。我们回顾了过去五年中治疗的104例患者。49例有一项或多项不良标准的患者采用保守治疗。这49例患者中有24例随后需要插入脑室腹腔分流管。4例患者背部伤口愈合延迟，其中3例随后进行了分流手术。与我们之前报告的34%相比，过去五年中保守治疗患者的手术干预总体发生率有所增加（57%）。在本研究中，我们发现积极治疗和保守治疗的患者在插入分流管的时间上没有差异。积极治疗和保守治疗患者的死亡率分别为7%和47%。85%未接受手术的患者平均在23天时死亡。未接受手术干预而死亡的患者存活时间不足以进行手术，而接受手术干预的患者死亡率为20%。仅截瘫并不是高死亡率的预测指标，但两项或更多不良标准的存在是预后不良更准确的指标。由于保守治疗患者中78%的死亡发生在三个月内，因此对于存活超过三个月的婴儿，有必要重新评估治疗策略，因为在此之后死亡的可能性较小。
