Spina Bifida - Dr Rohit Bhaskar

Spina Bifida
©2021 Dr Rohit Bhaskar PT https://www.pt-pedia.com/
PRESENTED BY
DR ROHIT BHASKAR
PHYSICAL THERAPIST

“Split Spine” caused by incomplete
closure of the neural tube, usually in
the lumbar or sacral region
Spina bifida

Types
Several classifications that vary in
severity depending on location and
extent of opening
1-Spina bifida occulta
2-Spina bifida cystica
▪ Meningocele
▪ शyelomenigocele
3-Spina bifida ventralis

1-Spina bifida occulta – “hidden”
❖The bony vertebra is open, but the spine is within the spinal
canal
❖The skin may have a lipoma (small benign fatty tumor),
some discoloration (birthmark), or a small tuft of hair
overlying the spinal defect
❖Most patients with spina bifida occulta do not know they
have it
❖There may be tethering of the spinal cord

Spina bifida occulta – tethered spinal cord
❖ Often occurs later in life
❖ Caused by limitations of movement of
the spinal cord within the spinal column
❖ Patients often have low back pain,
weakness in the legs, and/or incontinence
depending on the site of tethering

Spina bifida cystica – meningocele
❖The bony vertebra is open, part of the meninges is
protruding out of the spinal canal
❖Since the spinal cord is not protruding, there is often
normal function
❖Some cases of tethering have been reported

Spina bifida cystica – myelomeningocele
❖ The bony vertebra is open, part of the meninges and part or all
of the spinal cord is protruding out of the spinal canal
❖ Since the spinal cord is protruding, it is often not fully developed
❖ Involved nerve roots are often not developed resulting in weakness,
pain, and/or paralysis

Spina bifida cystica – myelomeningocele
❖ Arnold Chiari malformation II is often associated with myelomeningocele
and occurs when the cerebellum is forced downward
❖This can result in life-threatening situations because the build-up of
cerebrospinal fluid can cause pressure on the brain
❖ Patients with Arnold Chiari malformations often require placement of a
shunt to drain the excess fluid

Causes spina bifida
❖- The exact cause of spina bifida
is unknown
❖- All research to date has indicated
both a genetic and environmental
influence
❖- The developmental process that results
in spina bifida is well studied

Causes of spina bifida
● Neural Tube Defect:
● When the neural tube fails to properly close
during the 4thweek embryogenesis.

Development of spina bifida in utero

What would prevent the neural tubes from
closing properly?
❖ Folate seems to play a large role in the closing of the neural
tube – but it is unknown exactly how folate works in this
process.
❖ Folate influence was discovered by the increased incidence in
spina bifida seen in Irish babies born in late summer and early
fall. The lack of leafy green vegetables caused the mother to have
low levels of folate during conception.
❖ Genetics also play a role in the development of spina bifida.
❖ Mothers with one child with spina bifida have an increased
risk of additional children having spina bifida
❖Studies with folate-resistant mice

Valproic acid (Depakote)
❖Oral medication used to treat seizures/convulsions,
migraines, and bipolar disorder
❖Mechanism of action – thought to increase GABA
levels in the brain
❖Pregnant women taking Valproic acid have an
increased risk of having children with spina
bifida

Clinical Pictures of Spina Bifida

Primary clinical pictures
1-Abnormal nerve conduction, resulting in:
❖ Somatosensory losses
❖ Motor paralysis, including loss of bowel and bladder
control (all are below level of lesion)
❖ Changes in muscle tone

Motor level
Lesion Level
❖Above L3
❖L4 and
below
❖S1 and
below
Spinal-related disability
Complete paraplegia and dermatomal para-
anesthesia, Bladder incontinence, Nonambulatory
Same as for above L3 except preservation of hip
flexors, hip adductors, knee extensors; Ambulatory
with aids, bracing orthopedic surgery
Same as for L4 and below except preservation of feet
dorsiflexors, and partial preservation of hip
extensors and knee flexors; Ambulatory with
minimal aids
❖S3 and below
Normal lower extremity motor function; Saddle
anesthesia; Variable bladder-rectal incontinence

Sensory Levels
❖T4
❖T1
0
❖L1
❖L2
❖L3
❖L4
❖L5
❖S1
❖S2
❖S3-
S5

An enlarged head caused by:
Hydrocephalus (“water on the brain”)
Arnolds Chairi Malformation

Urinary and Bowel symptoms
Urinary symptoms:
●In lumbosacral spina bifida cystica, few children attain
urinary incontinence
●They require urodynamic testing, including cystometrography,
uroflowmetry, and EMG of the urinary sphincter
●Types of lesions
1. “Keepers”- UMN
2. “Leakers”- LMN
According to results and consulting urologist patient may need
intermittent catheterization, pharmacological agents,
implantation of an artificial urinary sphincter or a combination.

Musculoskeletal deformities (scoliosis)
Joint and extremity deformities (joint contractures,
club foot, hip subluxations, diminished growth of non-
weight bearing limbs)
Abnormal or damaged nerve tissue which can
lead to loss of extroceptive and prorioceptive
sensation .
Musculoskeletal deformities (scoliosis)

Secondary clinical pictures
❖Skin Breakdown
❖Decubitus ulcers and other types of
skin breakdown
❖Obesity
❖Latex Allergy
❖Osteoporosis

Management of spina bifida
❖1-Screening and dignosis
❖2-Treatement
❖3-Followup and observation
❖4- Prevention

Screening and Diagnosis
Evaluation
Analysis of individual medical history Physical
examination
Evaluation of critical body systems Imaging
Studies
X-rays Ultrasound
CT scan MRI
Gait Analysis

Treatment
❖ No cure
❖ Regular check ups with physician
❖ Surgery (24 hours after birth)
❖ Medication
❖ Physiotherapy

Surgical Treatment
▪ Surgery
❖In some cases the spinal cord is exposed
to the environment or tethered
❖Surgery is performed in order to cover
the spinal cord with muscle and skin or to
untether the spinal cord
❖In utero surgery has also become a
viable option for some cases

▪ Surgery (continue)
❖Surgery for spina bifida involves a variety of
neurosurgical, orthopedic, and urologic
procedures.
❖ Surgical procedures include the following:
●Closure of the defect over the spinal cord
●Spinal deformity reconstruction
●Lower-extremity deformity correction

▪ Medical treatement
❖Antibiotics
In some cases the spinal cord is
exposed to the environment
-Antibiotics are essential in preventing
infection of the CNS and urinary tract
system

▪ Physical Therapy
❖ General functional expectations have been developed
for patients in each lesion-level group to help direct
physical therapy goals within an appropriate
developmental context from infancy through
adulthood.
❖ The therapy programs should be designed to parallel
the normal achievement of gross motor milestones.

❖ In managing the cases of newborns with
myelomeningocele, the physical therapist
establishes a baseline of muscle function.
❖ As the child develops, the physical therapist
monitors joint alignment, muscle imbalances,
contractures, posture, and signs of progressive
neurologic dy sfunction.
❖ The physical therapist also provides caregivers with
instruction in handling and positioning techniques
and recommends orthotic positioning devices to
prevent soft tissue contractures.

❖ Provide the infant with sitting opportunities to
facilitate the development of head and trunk control.
❖ Near the end of the first year of life, provide the child
with an effective means of independent mobility in
conjunction with therapeutic exercises that promote
trunk control and balance.
❖ For patients who are not likely to become
ambulatory, place emphasis on developing
proficiency in wheelchair skills

❖For patients who are predicted to ambulate,
pregait training should begin with use of a
parapodium or swivel walker.
❖Exercise or household-distance ambulation may be
pursued with use of traditional long leg braces (eg,
hip-knee-ankle-foot orthosis, knee-ankle-foot
orthosis) or the reciprocating gait orthosis [RGO]).

▪ Occupational Therapy
● Children with spina bifida often have impairment in
fine motor skills and conducting activities of daily
living (ADL).
● Initiate training early to compensate for these
deficits and progress along the developmental
sequence as closely as possible.

❖Upper-extremity stabilization and dexterous hand
use require adequate postural control of the head
and trunk.
❖In the first year of life, encourage development of
these postural mechanisms or substitute passive
support, if necessary, to promote eye- hand
coordination and manipulatory skills.
❖When adequate fine motor skills have been achieved,
the occupational therapist provides instructions for
use of adaptive equipment and alternative methods
for self-care and other ADL for preschool- and school-
aged children.

PRESENTED BY

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Spina Bifida - Dr Rohit Bhaskar

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