#defination #spina bifida types #prognosis #diagnosis #PT management #surgical management #medical management #images of spina bifida patient

1. SPINA BIFIDA

2. DEFINITION
• congenital defect in the post. bony wall of
the spinal canal involving the laminae, is
known as spina bifida.
• This is most commonly seen in lumbosacral
region.

4. TYPES
1. spina bifida occulta-
There is failure of the neural
arches to unite and a small gap
exists in one of the vertebral arches ,
yet there is no protrusion of the
cord or membrane.
Frequently one vertebra is affected
and gap is filled with fibrous tissue.

5. 1. SPINA BIFIDA OCCULTA-

7. 1. SPINA BIFIDA OCCULTA-
•Clinical features-
• 1. present since birth
• 2. some abnormality in the skin either a dimple or
a local patch of hair or a lipoma.
• 3. Neurological examination
• backache,
• nocturnal enuresis,
• local anaesthesia,
• local paresis

8. 2.SPINA BIFIDA APERTA-
•1. meningocele-
•protrusion of the
meninges occurs
through the defect in the
neural arch.
• Such protrusion contains only
C.S.F so gives rise to a
cystic swelling.

9. 1. MENINGOCELE-
•Clinical Features-
•overlying skin is normal
•Free on careful palpation
the edge of the bony
defect is palpable
•Neurological
manifestations are
usually absent.

12. 2.SPINA BIFIDA APERTA
(2)Meningomyelocele-
• the normally developed spinal cord or
cauda equina is protruded along with the
meninges
• these structures may be adherent to the
post.

14. (2)MENINGOMYELOCELE
Clinical Features-
• Commonest variety in living
children.
• bony defect may usually extend
over 3 or more segments.
• Skin may be absent or
• atrophic at the summit of the
swelling so here meninges are
exposed.

15. (2)MENINGOMYELOCELE
• Clinical Features-
• Neurological manifestations
always present.
• sensory disturbances along with
trophic changes in the lower
extremities.
• motor disturbances
• urinary incontinence.
• Abnormalities of the vertrebrae,
like
• scoliosis or kyphosis

16. SYRINGOMYELOCELE
•The central canal of the spinal cord
is dilated and the spinal cord lies
within the sac together with the
peripheral nerves arising from the
cord.

17. (3)SYRINGOMYELOCELE-
•Clinical features-
• gross neurological
deficits and paralytic
manifestations are
present.

18. MYELOCELE
This is the gravest form of spina bifida,
in which besides the bony defect there is
also defect of development of the
spinal cord.
The development is arrested before the
time of closure of the neural furrow.
At the top end of the defect the central
canal of the spinal cord opens on the
surface discharges the cerebrospinal fluid

19. MYELOCELE
•Majority of the cases are still
born, even if they are born alive,
they die within a few days from
infection of the spinal cord and
meninges.

23. •Clinical features

37. PRENATAL DIAGNOSIS
• Raised levels of maternal serum
alpha-fetoprotein (AFP) at 16-18
weeks of gestation are found in
neural tube defects.
• The 18- to 20-week fetal anomaly
screening ultrasound scan allows
detection
• diagnosis of neural tube defects and
is much more specific.

38. INVESTIGATION OF CONFIRMED
SPINA BIFIDA
• Screening blood:
• to detect any evidence of
impairment of other organ
systems,
• particularly renal impairment.
• Urine culture and urodynamics
• may be needed to detect any
abnormality of the urinary tract
caused by impaired bladder
innervation.

39. PLAIN X-RAYS OF THE SPINE
•can help to detect
•scoliosis and
•hip dysplasia
•dislocation.

40. CT AND/OR MRI SCANNING
•of the head and spinal cord
may be conducted to look for
the major complications of spina
bifida, such as:
•Hydrocephalus due to
Arnold-Chiari II
malformation.
•Tethering of the spinal cord

41. DIAGNOSIS
•Gait analysis
•may be needed to
evaluate a patient's
functional mobility
•allow intervention to
improve independent

43. SURGICAL
MANAGEMENT
•Spina Bifida Meningocele:
•Surgery is often performed early
after birth, but severity of
deficits after surgery depends on
if there is neural tissue in the sac.

44. SURGICAL MANAGEMENT
•Spina Bifida
Myelomeningocele:
•It is crucial during this time
period prior to surgery to
protect the nerves that are
exposed in the protruding
sac.

45. SURGICAL
MANAGEMENT
Additional surgeries:
to manage other problems in the
feet, hips, or spine.
The individuals with
hydrocephalus will also require
surgeries due to the shunt
needing to be replaced.

46. MEDICAL MANAGEMENT
•Assistive devices may be necessary to aid
the individual around the community.
•Due to the bowel and bladder problems
that are often caused by the neural tube
defect, a bowel and bladder program may
be necessary.
•This may include catherterization or a
strict bowel and bladder regimen to

47. •Physiotherapy
management

48. PREAMBULATORY PHASE-
Stage 1- before closure of the
defect
• 1. to prevent deformity and maintain
ROM- ROM exs
• positioning in prone or sidelying
• 2. soft tissue stretching given for
feet
• 3.avoid contamination of the sac
which is open

49. PREAMBULATORY
PHASE-
•Stage 2-After surgery,during
hospitalization-
•1. maintaining ROM and prevent
contractures
•2. Handling the child in such a way that
enhances parent/child/bonding

50. STAGE 2-AFTER SURGERY,DURING
HOSPITALIZATION-
• 3. proper positioning-
• supine position is avoided as child is
dominated by primitve reflexes and the
effects of gravity both.
• Prone position-
• prevents hip flexion contracture and
develops extensor musculature.
• Sidelying-

51. STAGE 2-AFTER SURGERY,DURING
HOSPITALIZATION-
• a normal sensory experience
should be presented to child-
•1. toys of various
colours,textures an shapes
should be available.

52. STAGE 2-AFTER
SURGERY,DURING
HOSPITALIZATION-
• 2. musical mobiles provide variety of
sensory experiences.
• 3. squeaky toys or human face and voice
encourages visual and auditory training.
• 4. Prevent the development of pressure
sores in the anaesthetic skin.

53. STAGE 2-AFTER
SURGERY,DURING
HOSPITALIZATION-
•5. proper splints and orthosis filled with
plastic foam material are needed to
prevent friction burns or ulceration.
•6.Skin inspection needed.
•7. There is poor circulation in lower
limbs so need to be protected from
excessive cold too.

54. STAGE 2-AFTER SURGERY,DURING
HOSPITALIZATION-
Guide the child through
developmental sequence-
to prepare the child to assume
upright posture-
A. attainment of good head and
trunk control-
for ex wt shifts in prone on elbows
position.

55. STAGE 2-AFTER SURGERY,DURING
HOSPITALIZATION-
•B.eliciting righting reactions-
•child seated on therapists lap facing
therapist and alternatively lowered
slowly backward and side to side.
•Child is now discharged from the
hospital.

56. (PREAMBULATORY
PHASE)-
•Stage 3- Infant to toddler
• 1.previous treatment continued
• 2.resting splints can be used
• 3.Development of sitting
equillibrium reactions-
• 4. midline activities and upper
extremity functions

57. (PREAMBULATORY
PHASE)-
•5.Early wt bearing is very
imp assisted standing with
normal postural alignment may
be done.
•Kneeling position can be used.

58. (PREAMBULATORY PHASE)
STAGE 3- INFANT TO TODDLER
6.For high level lesions castor cart
can be used or prone scooter can
encourage active head, trunk
and hip extension.
7.improvement of sitting balance.
8.frequent transitions from one
position to another.

59. (PREAMBULATORY PHASE)
STAGE 3- INFANT TO TODDLER
• Standing with help of
standing frame-
• Time should be increased
gradually so that child
adjusts to upright position in
terms of muscle strength,
endurance, and pressure on
skin surface.

60. (PREAMBULATORY PHASE)
STAGE 3- INFANT TO TODDLER
• Wt shifts in standing
• development of equilibrium reactions
in standing are important for
ambulation
• Upper limb strengthening very
imp.

61. AMBULATORY PHASE
•Stage 4- Toddler
through adolescent
.

62. STAGE 4- TODDLER THROUGH
ADOLESCENT
In this phase the goals of therapy should
also include cognitive and emotional
development too.
1. wt. shift and pivoting forward
progression can be accomplished in
standing frame by alternately pulling
arms forward.

63. STAGE 4- TODDLER THROUGH
ADOLESCENT
• 2.Permanent bracing
depends on the level of lesion
for the child.
• For thoracic and high level
lumbar lesions a parapodium
is often chosen.
• Parapodium has hinges at
hips and knees that allows for
sitting and standing.

64. PARAPODIUM

65. STAGE 4- TODDLER THROUGH
ADOLESCENT
• 3.After this swing to, or swing
through gait can be practised
by the child.
• By 4-5 yrs a swing through gait
with crutches can be taught.
• 4. Another orthosis for thoracic
or high lumbar lesion is
orlau swivel walker

66. ORLAU SWIVEL WALKER

67. STAGE 4- TODDLER THROUGH
ADOLESCENT
• 5. Another option for higher level
child with good sitting balance is
reciprocating gait orthosis.
• to prevent pronation :Moulded
foot orthoses are aimed of foot
by holding calcaneous in
position.

68. RECIPROCATING GAIT
ORTHOSIS(RGO)

69. STAGE 4- TODDLER
THROUGH ADOLESCENT
•5.Anterior floor
reaction ankle foot
orthoses may be used.
•6. KAFO may be used
until balance ability
improves than AO can
be used if there is some
weakness below knees.

70. ANT. FLOOR REACTION ORTHOSIS

71. STAGE 4- TODDLER
THROUGH ADOLESCENT
• 7. Independent sitting balance
with hands free is a prerequisite
for use of long or short leg
braces (of metal)
• 8. For children with a low lumbar
or sacral lesion, a polypropylene
shoe insert to control foot
position is needed.

72. STAGE 4- TODDLER
THROUGH ADOLESCENT
• 9.muscle strengthening specially of
trunk muscles ,
• gluteus medius,
• gluteus maximus and
• quadriceps is targeted.
• 11. Enhancement of cognitive and
psychosocial development through
0-3 yrs developmental program.

73. STAGE 4- TODDLER
THROUGH ADOLESCENT
• 13.Bowel and bladder training-
• These children suffer from
overflow incontinence
• i.e urine dribbles as it becomes
full.
• Boys may be fitted with external
collecting devices or
illeocutaneous ureterostomy and
UTI can be avoided.

74. STAGE 4- TODDLER THROUGH
ADOLESCENT
•Conservative methods of
•bladder training include-
•1.external manual pressure to lower abdomen
•2.intermittent catheterization
•Bowel training-
•it is achieved through proper diet,
•regular evacuation times,

75. STAGE 4- TODDLER THROUGH
ADOLESCENT
stage 5- Primary school through
adolescence-
Many adolescent need wheel chair for
locomotion as energy cost of walking
becomes too high.
Braces and orthoses need to be
adjusted according to growth of the
child.

76. STAGE 4- TODDLER THROUGH ADOLESCENT
•Children with thoracic lesion -rarely
ambulate.
•Upper lumbar lesion -household
ambulator
•Low lumbar lesion -community
ambulator
•Sacral –require minimal bracing and
ambulate without assistive devices.

77. STAGE 4- TODDLER THROUGH
ADOLESCENT
• Locomotion activities
• including all gait related skills such
as
• falling down,
• getting up or
• ambulation on various terrains.