Neurosurg Focus. 2019 Oct 1;47(4):E5. doi: 10.3171/2019.7.FOCUS19469.
Myelomeningocele (MMC), the most severe form of spina bifida, is characterized by protrusion of the meninges and spinal cord through a defect in the vertebral arches. The management and prevention of MMC-associated hydrocephalus has evolved since its initial introduction with regard to treatment of MMC defect, MMC-associated hydrocephalus treatment modality, and timing of hydrocephalus treatment.
The Nationwide Inpatient Sample (NIS) database from the years 1998-2014 was reviewed and neonates with spina bifida and hydrocephalus status were identified. Timing of hydrocephalus treatment, delayed treatment (DT) versus simultaneous MMC repair with hydrocephalus treatment (ST), and treatment modality (ETV vs ventriculoperitoneal shunt [VPS]) were analyzed. Yearly trends were assessed with univariable logarithmic regression. Multivariable logistic regression identified correlates of inpatient shunt failure. A PRISMA systematic literature review was conducted that analyzed data from studies that investigated 1) MMC closure technique and hydrocephalus rate, 2) hydrocephalus treatment modality, and 3) timing of hydrocephalus treatment.
A weighted total of 10,627 inpatient MMC repairs were documented in the NIS, 8233 (77.5%) of which had documented hydrocephalus: 5876 (71.4%) were treated with VPS, 331 (4.0%) were treated with ETV, and 2026 (24.6%) remained untreated on initial inpatient stay. Treatment modality rates were stable over time; however, hydrocephalic patients in later years were less likely to receive hydrocephalus treatment during initial inpatient stay (odds ratio [OR] 0.974, p = 0.0331). The inpatient hydrocephalus treatment failure rate was higher for patients who received ETV treatment (17.5% ETV failure rate vs 7.9% VPS failure rate; p = 0.0028). Delayed hydrocephalus treatment was more prevalent in the later time period (77.9% vs 69.5%, p = 0.0287). Predictors of inpatient shunt failure included length of stay, shunt infection, jaundice, and delayed treatment. A longer time between operations increased the likelihood of inpatient shunt failure (OR 1.10, p < 0.0001). However, a meta-analysis of hydrocephalus timing studies revealed no difference between ST and DT with respect to shunt failure or infection rates.
From 1998 to 2014, hydrocephalus treatment has become more delayed and the number of hydrocephalic MMC patients not treated on initial inpatient stay has increased. Meta-analysis demonstrated that shunt malfunction and infection rates do not differ between delayed and simultaneous hydrocephalus treatment.
脊膜脊髓膨出（MMC）是最严重的神经管缺陷，其特征是脑膜和脊髓通过椎弓根的缺陷突出。自最初引入 MMC 缺陷治疗以来，MMC 相关脑积水的管理和预防已经发生了演变，包括 MMC 缺陷的治疗、MMC 相关脑积水的治疗方式以及脑积水治疗的时机。
回顾了 1998 年至 2014 年全国住院患者样本（NIS）数据库，并确定了患有脊柱裂和脑积水的新生儿。分析了脑积水治疗的时机、延迟治疗（DT）与 MMC 修复同时进行脑积水治疗（ST）以及治疗方式（内镜下第三脑室造瘘术[ETV]与脑室-腹腔分流术[VPS]）。使用单变量对数回归评估年度趋势。多变量逻辑回归确定了住院分流失败的相关因素。进行了 PRISMA 系统文献综述，分析了研究数据，这些研究调查了 1）MMC 闭合技术和脑积水发生率，2）脑积水治疗方式，以及 3）脑积水治疗时机。
NIS 共记录了 10627 例 MMC 修复的住院病例，其中 8233 例（77.5%）有脑积水记录：5876 例（71.4%）接受了 VPS 治疗，331 例（4.0%）接受了 ETV 治疗，2026 例（24.6%）在初始住院期间未接受治疗。治疗方式的比例在一段时间内保持稳定；然而，近年来的脑积水患者在初始住院期间接受脑积水治疗的可能性较小（优势比[OR]0.974，p=0.0331）。接受 ETV 治疗的患者住院期间脑积水治疗失败的比例较高（17.5%的 ETV 治疗失败率与 7.9%的 VPS 治疗失败率；p=0.0028）。延迟性脑积水治疗在后期更为普遍（77.9%比 69.5%，p=0.0287）。住院分流失败的预测因素包括住院时间、分流感染、黄疸和延迟治疗。手术之间的时间间隔延长会增加住院分流失败的可能性（OR1.10，p<0.0001）。然而，对脑积水时机研究的荟萃分析显示，在分流失败或感染率方面，ST 和 DT 之间没有差异。
1998 年至 2014 年期间，脑积水治疗变得更加延迟，初始住院期间未接受治疗的脑积水 MMC 患者数量增加。荟萃分析表明，延迟和同时进行的脑积水治疗之间分流功能障碍和感染率没有差异。
