[Surgical treatment of myelomeningocele with special reference to therapeutic policy].

With the spread of a policy that the infant with myelomeningocele should receive surgery as early as possible after birth, the survival rate of the infant with this serious malformation has greatly improved. However, this early operation for myelomeningocele has also increased the number of severely handicapped survivors. Such a dilemma in treatment of myelomeningocele forced some clinicians to select the patients for surgical treatment. Lorber advocated a policy of strict selection in which the infant with severe paraplegia, severe hydrocephalus, kyphoscoliosis, or other gross malformations should be managed conservatively without any surgical intervention. During 1969-80, 77 unselected infants with myelomeningocele received early operations almost within 48 hours after birth. There were 25 infants who had one or more of Lorber's adverse criteria on admission, out of which 13 patients (52%) are still alive. All of these survivors, however, have severe multiple handicaps especially in locomotion and bladder control. By contrast, of the remaining 52 infants who did not have any of Lorber's criteria, 45 (86.5%) are alive and 33 have no or only moderate handicaps. Severe mental retardation occurred in 6 survivors, 4 of which were those with Lorber's criteria, but this extreme handicap could be considered the result of diffuse ventriculitis caused by infection at the myelomenin gocele site. It is true that the future status in locomotion may be predicted by assessment of the leg movement of the neonate, but intellectual potential cannot be determined even when complicated with hydrocephalus. The most decisive factor influencing the functional prognosis of an infant with myelomeningocele should be its intellectual quality. Until an appropriate evaluation method for the intellectual potential at birth is established, all infants with myelomeningocele should be treated surgically regardless of the neurological status at the neonatal period.