Kik Charlotte C, Kunpalin Yada, Kulkarni Abhaya V, DeKoninck Philip L J, Spoor Jochem K H, Van Mieghem Tim
1Department of Obstetrics and Gynecology, Mount Sinai Hospital, and University of Toronto, Ontario, Canada.
2Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
J Neurosurg Pediatr. 2025 Apr 18;36(1):3-10. doi: 10.3171/2024.10.PEDS24412. Print 2025 Jul 1.
The aim of this study was to investigate the global variability in intraoperative neurosurgical management strategies for fetal spina bifida surgery.
All prenatal fetal spina bifida surgery centers identified through the International Society of Prenatal Diagnosis website and previous literature were invited to participate in an online survey addressing various aspects of the surgery, including fetal selection criteria, surgical technique, and common intraoperative challenges.
Thirty-four centers (72%) responded to the survey, more than half of whom perform fewer than 10 surgeries annually (56%). The most common earliest gestational age (GA) for fetal surgery was 23 (36%, n = 12/33), ranging from < 21 weeks (9%, n = 3) to > 24 weeks (9%, n = 3). The latest GA for surgery varied from < 26 weeks (24%, n = 8) to 30 weeks (3%, n = 1), with the majority setting a cutoff at 26 weeks (50%, n = 17). Open fetal surgery is the predominant method in 76% of centers (n = 26), followed by a hybrid approach (laparotomy with fetoscopy on the uterus; 29%, n = 10) and fully percutaneous fetoscopic surgery (15%, n = 5). Filum terminale dissection is performed in 58% (n = 19/33) of centers and placode tubularization in 46% (n = 15/33). Myofascial flaps are routinely used in 55% of the centers (n = 18/33). When primary skin closure is not possible, 39% (n = 13/33) will use releasing side cuts and one-third of all centers will use acellular dermal matrix grafts (33.3%, n = 11/33). Extensive skin defects and suboptimal fetal access were commonly cited as the most significant intraoperative challenges.
There is variability in the fetal inclusion criteria and intraoperative management of fetal spina bifida across centers. This variability emphasizes the need for more research on best practices as well as standardized outcome reporting (ideally through "core outcomes") to allow for comparison between centers. Identified challenges, such as difficulties in skin closure, highlight specific areas for future innovations in the field.
本研究旨在调查胎儿脊柱裂手术术中神经外科管理策略的全球差异。
通过国际产前诊断学会网站和既往文献确定的所有产前胎儿脊柱裂手术中心受邀参与一项在线调查，内容涉及手术的各个方面，包括胎儿选择标准、手术技术和常见术中挑战。
34个中心（72%）回复了调查，其中半数以上中心每年进行的手术少于10例（56%）。胎儿手术最常见的最早孕周（GA）为23周（36%，n = 12/33），范围从<21周（9%，n = 3）至>24周（9%，n = 3）。手术的最晚GA从<26周（24%，n = 8）至30周（3%，n = 1）不等，大多数中心将截止孕周设定为26周（50%，n = 17）。开放式胎儿手术是76%的中心（n = 26）的主要方法，其次是混合方法（剖腹术联合子宫内胎儿镜检查；29%，n = 10）和完全经皮胎儿镜手术（15%，n = 5）。58%（n = 19/33）的中心进行终丝切断术，46%（n = 15/33）的中心进行基板管状化术。55%的中心（n = 18/33）常规使用肌筋膜瓣。当无法进行一期皮肤缝合时，39%（n = 13/33）的中心会采用松解侧切，所有中心的三分之一会使用脱细胞真皮基质移植物（33.3%，n = 11/33）。广泛的皮肤缺损和胎儿暴露不佳通常被认为是最显著的术中挑战。
各中心在胎儿脊柱裂的纳入标准和术中管理方面存在差异。这种差异强调需要对最佳实践进行更多研究，并进行标准化的结果报告（理想情况下通过“核心结果”），以便各中心之间进行比较。已确定的挑战，如皮肤缝合困难，突出了该领域未来创新的特定领域。
