Interdisciplinary  Management of the Child with Spina Bifida  38 th  SBA National Conference  Samuel R. Rosenfeld, M.D. CH...
Disclosure <ul><li>Consultant,  Zimmer Spine </li></ul><ul><li>I have no potential conflicts with this presentation </li><...
Myelodysplasia <ul><li>Congenital defects of the vertebrae with neural element abnormalities </li></ul>
Myelomenigocele <ul><li>Exposed neural elements </li></ul>
Meningocele <ul><li>Vertebral arch defects </li></ul><ul><li>Protrusion of meninges </li></ul><ul><li>Intact overlying ski...
Caudal Regression Syndrome <ul><li>Lumbar / sacral agenesis </li></ul><ul><li>Cloacal exstrophy </li></ul><ul><li>Myelocys...
Associated Neural Axis Deformities <ul><li>Arnold Chiari malformation </li></ul><ul><li>Hydrocephalus </li></ul><ul><li>Hy...
 
Associated Musculoskeletal Deformities <ul><li>Paralysis </li></ul><ul><li>Positioning </li></ul><ul><li>Muscle imbalance ...
Motor Imbalance <ul><li>Asymmetry </li></ul><ul><li>Absence of motors </li></ul><ul><li>Position / gravity </li></ul>
 
Interdisciplinary Team <ul><li>Nurse practitioner / case manager </li></ul><ul><li>Orthopaedic surgeon </li></ul><ul><li>P...
Goals of Interdisciplinary Management <ul><li>Mainstream children </li></ul><ul><li>Develop independence </li></ul><ul><li...
Be Aware of Fluctuating CNS Pathology <ul><li>Functional deterioration </li></ul><ul><li>Progressive weakness </li></ul><u...
 
Neurosurgical Evaluation <ul><li>CT Brain </li></ul><ul><li>MRI brain, entire spinal cord </li></ul><ul><li>Cranial ultras...
 
Neurosurgical  Intervention <ul><li>Closure myelomengocele </li></ul><ul><li>Resection leptomyelolipoma </li></ul><ul><li>...
Urologic  Evaluation <ul><li>Renal ultrasound </li></ul><ul><li>Voiding cystourethrogram </li></ul><ul><li>Urodynamics </l...
 
Urologic Intervention  <ul><li>Smooth muscle relaxation  (anticholinergic / antispasmodic)  oxybutynin  (Ditropan)  tolter...
Bowel Management <ul><li>Cone enema </li></ul><ul><li>Antegrade Continence Enema  (ACE)  age 4 to 18 years  median use eve...
Orthopaedic Surgery Evaluation <ul><li>Scoliosis Xrays:  sitting, standing, supine </li></ul><ul><li>CT spine </li></ul><u...
 
Orthopaedic Intervention <ul><li>Correction spinal deformity </li></ul><ul><li>Hip management </li></ul><ul><li>Knee manag...
 
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Orthopedic and Mobility Issues in Spina Bifida – Samuel Rosenfeld, MD

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Orthopedic and Mobility Issues in Spina Bifida – Samuel Rosenfeld, MD

  1. 1. Interdisciplinary Management of the Child with Spina Bifida 38 th SBA National Conference Samuel R. Rosenfeld, M.D. CHOC Childrens Hospital Rancho Los Amigos National Rehabilitation Center University of California, Irvine 26 June 2011
  2. 2. Disclosure <ul><li>Consultant, Zimmer Spine </li></ul><ul><li>I have no potential conflicts with this presentation </li></ul>
  3. 3. Myelodysplasia <ul><li>Congenital defects of the vertebrae with neural element abnormalities </li></ul>
  4. 4. Myelomenigocele <ul><li>Exposed neural elements </li></ul>
  5. 5. Meningocele <ul><li>Vertebral arch defects </li></ul><ul><li>Protrusion of meninges </li></ul><ul><li>Intact overlying skin </li></ul>
  6. 6. Caudal Regression Syndrome <ul><li>Lumbar / sacral agenesis </li></ul><ul><li>Cloacal exstrophy </li></ul><ul><li>Myelocystocele complex spinal dysraphism 5% of all covered spina bifida 50% associated with cloacal exstrophy all with hydrocephalus and hydromyelia </li></ul>
  7. 7. Associated Neural Axis Deformities <ul><li>Arnold Chiari malformation </li></ul><ul><li>Hydrocephalus </li></ul><ul><li>Hydromyelia </li></ul><ul><li>Syringomyelia </li></ul><ul><li>Arachnoid cyst </li></ul><ul><li>Diastematomyelia </li></ul><ul><li>Spinal cord tethering </li></ul><ul><li>Leptomyelolipoma </li></ul>
  8. 9. Associated Musculoskeletal Deformities <ul><li>Paralysis </li></ul><ul><li>Positioning </li></ul><ul><li>Muscle imbalance </li></ul><ul><li>Spasticity </li></ul><ul><li>Mixed tone: spastic and flaccid </li></ul>
  9. 10. Motor Imbalance <ul><li>Asymmetry </li></ul><ul><li>Absence of motors </li></ul><ul><li>Position / gravity </li></ul>
  10. 12. Interdisciplinary Team <ul><li>Nurse practitioner / case manager </li></ul><ul><li>Orthopaedic surgeon </li></ul><ul><li>Pediatrician </li></ul><ul><li>Neurosurgeon </li></ul><ul><li>Urologist </li></ul><ul><li>Physical therapist </li></ul><ul><li>Occupational therapist </li></ul><ul><li>Orthotist </li></ul><ul><li>Psychologist </li></ul><ul><li>Social worker </li></ul><ul><li>Dietician </li></ul>
  11. 13. Goals of Interdisciplinary Management <ul><li>Mainstream children </li></ul><ul><li>Develop independence </li></ul><ul><li>Competence in the community </li></ul><ul><li>Personality development </li></ul><ul><li>Transition into adulthood </li></ul>
  12. 14. Be Aware of Fluctuating CNS Pathology <ul><li>Functional deterioration </li></ul><ul><li>Progressive weakness </li></ul><ul><li>Spasticity </li></ul><ul><li>Scoliosis above the dysraphic defect </li></ul><ul><li>Cognitive impairment </li></ul><ul><li>Foot deformity </li></ul><ul><li>Intrinsic hand atrophy </li></ul><ul><li>Neurogenic bladder changes </li></ul>
  13. 16. Neurosurgical Evaluation <ul><li>CT Brain </li></ul><ul><li>MRI brain, entire spinal cord </li></ul><ul><li>Cranial ultrasound </li></ul><ul><li>Shunt survey </li></ul><ul><li>Shunt O Gram </li></ul>
  14. 18. Neurosurgical Intervention <ul><li>Closure myelomengocele </li></ul><ul><li>Resection leptomyelolipoma </li></ul><ul><li>Shunting hydrocephalus </li></ul><ul><li>Endoscopic third ventriculostomy </li></ul><ul><li>Brainstem decompression </li></ul><ul><li>Fenestration of syrinx </li></ul><ul><li>Central canal subarachnoid shunt </li></ul><ul><li>Release spinal cord tethering </li></ul>
  15. 19. Urologic Evaluation <ul><li>Renal ultrasound </li></ul><ul><li>Voiding cystourethrogram </li></ul><ul><li>Urodynamics </li></ul><ul><li>Uro-flow with pelvic ultrasound </li></ul><ul><li>Renal scan </li></ul>
  16. 21. Urologic Intervention <ul><li>Smooth muscle relaxation (anticholinergic / antispasmodic) oxybutynin (Ditropan) tolterodine (Detrol) </li></ul><ul><li>Clean intermittant catheterization </li></ul><ul><li>Urinary diversion </li></ul><ul><li>Vesicostomy </li></ul><ul><li>Bladder augmentation </li></ul><ul><li>Ureteral reimplantation </li></ul><ul><li>Continent stoma </li></ul>
  17. 22. Bowel Management <ul><li>Cone enema </li></ul><ul><li>Antegrade Continence Enema (ACE) age 4 to 18 years median use every other day must have committed support from specialist nurse major psychological issues </li></ul>
  18. 23. Orthopaedic Surgery Evaluation <ul><li>Scoliosis Xrays: sitting, standing, supine </li></ul><ul><li>CT spine </li></ul><ul><li>Xrays of hips, knees, feet: standing, supine </li></ul><ul><li>Scanogram </li></ul><ul><li>Bone age </li></ul><ul><li>Dexa bone densitometry </li></ul>
  19. 25. Orthopaedic Intervention <ul><li>Correction spinal deformity </li></ul><ul><li>Hip management </li></ul><ul><li>Knee management </li></ul><ul><li>Correction of foot deformity to facilitate orthotic management </li></ul><ul><li>Orthotic collaboration </li></ul>
  20. 27. #4
  21. 28. #18

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