Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.
Physical Medicine and Rehabilitation, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.
Ultrasound Obstet Gynecol. 2023 Jun;61(6):728-733. doi: 10.1002/uog.26180. Epub 2023 May 12.
First, to investigate the correlation between prenatal presurgery anatomical and motor levels of the lesion with motor level at birth in cases undergoing prenatal repair of open spina bifida and, second, to identify factors leading to a loss of two or more motor levels between the presurgery and postnatal assessments.
This was an observational study of singleton pregnancies undergoing prenatal repair of open spina bifida, conducted between March 2011 and May 2022. All fetuses underwent an ultrasound assessment at 20-24 weeks of gestation to determine the motor and anatomical levels of the lesion before surgery. The anatomical level of the lesion was defined as the highest open posterior vertebral arch. The motor level was determined by systematic observation of the lower limb movements and was defined as the most distal active muscle present. Prenatal repair was performed at 23-26 weeks. At birth, motor level was assessed by a rehabilitation specialist by physical examination. Cases of intrauterine death or termination of pregnancy and those delivered at other sites were excluded from the neonatal assessment. The agreement between presurgery motor level and motor level at birth, and between presurgery anatomical level and motor level at birth, was assessed using the weighted kappa index (wκ). Logistic regression analysis was used to assess factors leading to a loss of two or more motor levels between the presurgery and postnatal assessments.
Presurgery motor and anatomical levels were assessed in 61 fetuses at a median gestational age of 22.7 (interquartile range (IQR), 21.6-24.4) weeks. Prenatal repair was performed at a median gestational age of 24.6 (IQR, 23.7-25.7) weeks. Motor level at birth was assessed in 52 neonates after exclusion of nine fetuses due to loss to follow-up or fetal loss. There was moderate agreement between presurgery motor level and motor level at birth (wκ = 0.42; 95% CI, 0.21-0.63), with a median difference of 0 (IQR, -2 to 9) levels. Factors leading to a loss of two or more motor levels between the presurgery ultrasound assessment and postnatal examination were higher presurgery anatomical level (odds ratio (OR), 0.59 (95% CI, 0.35-0.98); P = 0.04) and larger difference between the anatomical and motor levels before surgery (OR, 1.85 (95% CI, 1.12-3.06); P = 0.017). None of the other ultrasound, surgery-related or neonatal variables assessed was associated significantly with a loss of two or more motor levels. There was slight agreement between the presurgery anatomical level of the lesion and motor level at birth (wκ = 0.07; 95% CI, -0.02 to 0.15).
There is moderate agreement between fetal motor level of the lesion before prenatal repair of open spina bifida and motor level at birth, as opposed to only slight agreement between presurgery anatomical level and motor level at birth. A loss of two or more motor levels between the presurgery and postnatal assessments is associated with a higher presurgery anatomical level and with a larger difference between the presurgery anatomical and motor levels. Consequently, motor level, rather than the anatomical level, should be used for prenatal counseling. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
首先，探讨开放性脊柱裂产前手术解剖学和运动学水平与出生时运动学水平之间的相关性；其次，确定导致产前和产后评估之间运动学水平丧失两个或更多水平的因素。
这是一项关于 2011 年 3 月至 2022 年 5 月间接受开放性脊柱裂产前修复的单胎妊娠的观察性研究。所有胎儿均在妊娠 20-24 周时接受超声评估，以确定手术前病变的运动和解剖学水平。病变的解剖学水平定义为最高的开放性后椎弓根。运动学水平通过系统观察下肢运动来确定，并定义为存在的最远端主动肌肉。在妊娠 23-26 周进行产前修复。出生时，由康复专家通过体格检查评估运动学水平。排除宫内死亡或终止妊娠病例以及在其他地点分娩的病例，不进行新生儿评估。使用加权 κ 指数（wκ）评估产前运动学水平与出生时运动学水平以及产前解剖学水平与出生时运动学水平之间的一致性。使用逻辑回归分析评估导致产前和产后评估之间运动学水平丧失两个或更多水平的因素。
在 61 名胎儿中，中位妊娠 22.7（四分位距（IQR），21.6-24.4）周时评估了产前运动学和解剖学水平。中位妊娠 24.6（IQR，23.7-25.7）周时进行了产前修复。排除 9 名因失访或胎儿丢失而失访的胎儿后，52 名新生儿接受了出生后运动学水平评估。产前运动学水平与出生时运动学水平之间存在中度一致性（wκ=0.42；95%置信区间，0.21-0.63），中位数差异为 0（IQR，-2 至 9）个水平。导致产前超声评估与产后检查之间运动学水平丧失两个或更多水平的因素包括较高的产前解剖学水平（比值比（OR），0.59（95%置信区间，0.35-0.98）；P=0.04）和术前解剖学水平与运动学水平之间的较大差异（OR，1.85（95%置信区间，1.12-3.06）；P=0.017）。评估的其他超声、手术相关或新生儿变量均与运动学水平丧失两个或更多水平无显著相关性。产前病变的解剖学水平与出生时运动学水平之间的一致性仅为轻微（wκ=0.07；95%置信区间，-0.02 至 0.15）。
与产前手术前病变的运动学水平相比，开放性脊柱裂产前修复后的胎儿运动学水平与出生时运动学水平具有中度一致性，而产前解剖学水平与出生时运动学水平之间仅存在轻微一致性。产前和产后评估之间运动学水平丧失两个或更多水平与较高的产前解剖学水平以及术前解剖学和运动学水平之间的较大差异有关。因此，应该使用运动学水平而不是解剖学水平进行产前咨询。
