SPINA BIFIDA

SPINA BIFIDA
is a spinal defect usually diagnosed
at birth by the presence of an
external sac on the infants back.
The sac contains meninges and
spinal chord tissue protruding through
a dorsal defect in the vertebrae.
This defect may occur at any point
along the spine but it
is most
commonly located in the lumbar
region.

Spina Bifida

The

sac covered by a transparent

membrane with neural tissue attached
to its inner surface or the sac maybe
open with the neural tissue exposed.
The lateral border of the sac has bony
protrusions formed by the unfused
neural arches of the vertebrae.
The defect maybe large, with many
vertebrae involved, or it maybe small,
involving only one or two segments. The
size of the lesion is not by itself
predictive of the childs functional

Etiology
Etiology of spina bifida is complex; both
polygenics inheritance and environmental
influences seem to contribute in a
multifactorial manner.
.

The malformation are attributed to

abnormal interaction of several regulating
and modifying genes in nearly fetal
development. The female to female
prevalence ratio was 1.2 in two United
States Surveillance System.

ANATOMY

it helps to understand the anatomy of

the spine and spinal cord. The back

includes the spine and the structures that
surround the spine.
The spine is an upright row of stacked
bones, called the vertebral column.
Individual bones of the spine are called
vertebrae.
The vertebral column starts under the
skull and continues to the buttocks.
Bones of the spine: a.)Bones of the
cervical, b.) Thoracic and c.) Lumbar

Vertebral column

Types of Spina Bifida

1.Spina Bifida Occulta an abnormality
is confined to the vertebrae only and
is due to an unclosed posterior
vertebral arch.
Approximately 40% of all Americans
may have spina bifida occulta, but
because they experience little or no
symptoms, very few of them ever
know that they have it.

Types of spina bifida

Meningocele-In this instance, the

vertebrae are malformed, forming a
passageway for the lining of the
spinal cord. The spinal cord lining
protrudes through the opening,
forming a bulge under the skin in the
back. The bulge may not contain any
nerve tissue. This is the least
common form of spina bifida.

2.

Types of spina bifida

3.) Myelomeningocele-aka-

meningomyelocele-is the most severe form of

SB. In this type, the involved area is
represented by a flattened, plate-like mass of
nervous tissue with no overlying membrane.
The exposure of these nerves and tissues
make the baby more prone to life-threatening
infections such as meningitis or
hydrocephalus.
Elements of the cord also protrude through
the defect, resulting in severe neural deficits.
1 out of 1,000 births

RISK FACTORS
Race & sex
Medically diagnosed obesity.
Use of certain anti-seizure
medications.
High temperatures in early pregnancy
(prolonged fevers).
A previous pregnancy with a defect
increases the chances.

RISK FACTORS

Low preconceptional intakes of plant

proteins, iron, magnesium, and niacin
are associated with a 2 - 5 fold
increased risk of spina bifida.
Women with diabetes are more likely to
have a baby with spina bifida, compared
to other females.
Folate deficiency-folic acid

Prognosis

In previous generation long-term of survival of

children with spina bifida was reported to range from

as low as 1% without treatment to 50% with treatment.
A survival rate of more than 90% is not expected
when aggressive treatment is provided to the spinal
defect and its associated problems.
This chapter represents the primary problems for this
population of children, including hydrocephalus, motor
and sensory deficits in the lower extremities and
urologic impairments as well as the secondary issues
that are of clinical significance.

The

use of antibiotics to limit infection in the

open spine starting in 1947, and the surgical
insertion of ventricular shunts in 1960 to limit
hydrocephalus were major advances in the
treatment of spina bifida.
Early and consistent use of clean, intermittent
catherization to completely empty the bladder
has also dramatically improved the survival rate
by controlling urinary infection and the renal
deterioration, both of which have been major
causes of mortality.
The measure along with the practice of early
back closure, continue to improve the chances
of survival of children with spina bifida.

awareness evolved for the associated

problems that were neither evident nor priority
for the treatment in the past.

The number of severely affected children

who have survived has increase.

Additionally, there is an increased number
of less severely involved individuals who
would have not have lived with earlier, less
aggressive treatment protocols.
Therefore, the full spectrum and
complexity of the disability can now be
appreciated. Clinicians have the
opportunity, unavailable in previous eras,
to work with and learn a great deal from
this heterogeneous group.

Diagnosing

Diagnosis

spina bifida In the majority of cases,

spina bifida is detected when the pregnant mother
has a routine ultrasound scan pregnant women
may be offered spina bifida and other birth defect
screening tests.
The tests are not 100% accurate. MSAFP
(maternal serum alpha-fetoprotein) test - this
is a blood test. Blood is sent to the lab and tested
for AFP (alpha-fetoprotein). AFP is a protein the
fetus produces. AFP does not usually get into the
mother's bloodstream, if it does it usually means
the fetus has abnormally high levels and probably
has a neural tube defect, which could include
anencephaly (incomplete skull and underdeveloped
brain) or spina bifida.
Cranial imaging using ultrasonography, CT scan,
or MRI is done to look for hydrocephalus.

Prevention

Women

of childbearing are were to

consume 0.4 mg of folic acid prior to
becoming pregnant and during the first
trimester of pregnancy, the incidence
of folic acid preventable spina bifida
and anencephaly could be reduced by
up to 75%.
Folic acid= a common water soluble B
vitamin, is essential for the functioning
of the human body.
Folic acid can be found in
multivitamins,
fortified
breakfast
cereals, dark green leafy vegetables
such as broccoli and spinach, egg
yolks, and some fruits and fruit juices.

treatment
A.)

surgery -

this is usually done to repair the

spine within two days of birth. The surgeon replaces
the spinal cord and any exposed tissues or nerves
back into the patient's body. The gap in the
vertebrae will then be closed and the spinal cord
sealed with muscle and skin. If the child develops
problems with bone development, such as scoliosis
or dislocated joints, further corrective surgery may
be needed (orthopedic surgery).
For scoliosis a back-brace may be used.
Meningocele- involves surgery to put the
meninges back in place and close the opening in
the vertebrae.
Myelomeningocele- also requires surgery, usually
within 24 to 48 hours after birth

Hydrocephalus - surgery will be required to

treat a buildup of CSF (cerebrospinal fluid) in

the brain. The surgeon implants a shunt (thin
tube) in the baby's brain. The shunt drains away
excess fluid, usually to the abdomen. The
patient will probably need a permanent shunt.
Further surgery may be needed if the shunt
becomes blocked or infected, or a larger one is
needed as the child grows.

B.)Prenatal surgery- In this procedure

which takes place before the 26th week of
pregnancy surgeons expose a pregnant
mother's uterus surgically, open the uterus and
repair the baby's spinal cord.

C.)Ongoing

Treatment doesn't end

with the initial surgery, though. In babies
with
myelomeningocele,
irreparable
nerve damage has already occurred and
ongoing care from a multidisciplinary
team of surgeons, physicians and
therapists is usually needed. Babies with
myelomeningocele may need further
operations for a variety of complications.
Paralysis and bladder and bowel
problems often remain, and treatment
for these conditions typically begins
soon after birth.
care-

treatment

D.)Physical therapy (UK:

physiotherapy)- this is a vital part of
the child's treatment, which will help
him/her become as independent as
possible, as well as preventing the lower
limb muscles from weakening. Special
leg braces may help keep the muscles
strong.

E.)Occupational therapy - the aim here

is to help the child perform everyday
activities more effectively, such as
getting dressed. Occupational therapy

treatment
F.)Assistive technologies - a patient
with total paralysis of the legs will
need a wheelchair. Although
electric wheelchairs are more
convenient, manual ones help
maintain upper-body strength and
general fitness. Those with partial
paralysis may need leg braces.
Computers and specialized
software may help children with

G.)Urinary

the patient will

probably be referred to a urologist for
assessment. The child may be taught to use
CIC (clean intermittent catherterization), a
technique to empty the bladder at regular
intervals in which the child and/or parent
place the catheter through the urethra and
into the bladder to empty it.
child
may
be
prescribed
The
antimuscarinics, medications used for urinary
incontinence in adults - these medications
increase the amount of urine the bladder can
hold, thus reducing the number of times the
child has to pee.
incontinence

If the child's bladder contracts abnormally

(hyper-reflexic bladder), the doctor may

recommend a botulinum toxin injection, which
paralyzes the muscles. If it works, the patient will
need repeat treatment every six months.
Artificial urinary sphincter (AUS) - this is
surgically implanted. It has a silicone cuff,
surrounded by a liquid, a pump and a balloon. It
is attached to the urethra and the balloon is
placed in the abdomen. The pump is placed
under the skin of the scrotum in males and under
the skin of the labia in females. When the child
wants to pee they press the pump, which
temporarily empties the fluid from the cuff into
the balloon, releasing the pressure on the cuff
and opening the urethra, allowing urine to be

H.)Bowel incontinence - this may involve having

to go on special diets and some toilet training
techniques. A healthy-balanced diet with plenty of
fiber is essential to avoid constipation However; the
patient must not go to the other extreme and end up
with diarrhea. A food diary will help the parent and/or
child know which foods are best for him/her.
Anal plugs can prevent soiling. They are made of
foam and inserted into the anus. As soon as it gets
wet it expands, thus blocking the passage of any
feces and liquid. Anal plugs work for about 12 hours;
they can be taken out by pulling an attached string.
A colostomy involves diverting a section of the
colon so that it connects to a stoma, which is
attached to a pouch. The pouch collects stools. If the
diversion is at the end of the small intestine the
procedure is called an ileostomy.

Goals of Intervention

Teaching gross motor and spatial skills

to facilitate coordination.
Developing and maintaining fitness

and flexibility to emphasize self

sufficiency.
Encouraging movement and fitness to
overcome susceptibility to obesity.
Developing physical skills that
generalize to activities of daily living
and vocational skills.
Promoting social development in
recreational and group play activities,
such as aquatics.
Providing appropriate social outlets for

Conclusion

The range of problems requires a

multidisciplinary treatment team. Specific

concerns of comprehensive functional
rehabilitation are prevention of deformities.
There's good reason to hope, however, because
most people with spina bifida live active,
productive and full lives - especially with
encouragement and support from loved ones.
most children can walk for at least short
distances, usually with the assistance of braces,
canes or crutches, although they may require
wheelchairs for longer distances. Using these
devices can help a child compensate for his or
her condition and gain more independence.

Presented by: Ann Dimco

Noime Joy, Javerle

References
PEDIATRIC REHABILITATION. 3rd edition book by

Gabriells E. Molnar,MD & Michael A Alexander,MD

PEDIATRIC PHYSICAL THERAPY . 4rth edition by Jan
S Tecklin.
http://www.mayoclinic.org/diseasesconditions/spina-bifida/basics/risk-factors/con20035356
http://www.medicalnewstoday.com/articles/22042
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