**4. Spine care**

*Spina Bifida and Craniosynostosis - New Perspectives and Clinical Applications*

the importance of avoiding latex material since the beginning of care [9].

**3. Pathologic fractures**

at improving these patients' quality of life [7]. Intellectual disability is present only in approximately 20% of the patients and is usually the consequence of hydrocephalus [8]. Patients usually present with bladder and/or bowel incontinence, renal failure, propensity to infections and skin ulcers due to skin insensitivity, hydrocephalus, tethered cord and Arnold Chiari II type of malformation [9]. One in three of these patients will be allergic to latex, some having anaphylactic reactions. This is thought to be the consequence of repeated surgical and medical procedures, thus

Due to the lack of ambulation, physical exercise and axial bone load spina bifida patients can present with osteoporosis and osteoporosis induced fractures [10]. The

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**Figure 1.**

*radiographic images of post-reduction and casting (B).*

*Right distal femur fracture in a myelomeningocele patient without an obvious traumatic mechanism (A) and* 

Besides the posterior element defect in the spine, spina bifida patients also present with severe congenital deformity and contractures of the spine. These deformities can pose a restriction to everyday activities as well as pulmonary function [17]. A third of the patients will have scoliosis, which is usually of an early onset and has a tendency to progress and cause pelvic obliquity [18]. Scoliosis has different causes in these patients such as muscle imbalance or primary malformations like hemivertebra and vertebral fusions. Kyphosis may also be present in approximately 15% of the patients (**Figure 2**). Is usually progressive and mostly located in the lumbar region [19]. The deformity can be so severe to cause skin breakdown at the level of the deformity (**Figure 3**). Surgery is necessary to correct the deformity and is not free of complications in these patients. Usually there is no role for bracing spine deformity in these patients and the skin insensitivity can predispose to skin ulcers and infection. Surgical correction is indicated in patients with progressing curves who are good candidates for surgery. Posterior fixation is the most common procedure performed but other options such as an anterior fusion or combined ones are used as well when appropriate. In patients with pelvic obliquity the fixation should be extended until the pelvis level, this is particularly important in non-ambulatory patients (**Figure 4**) [20]. Surgery can be associated with higher risks of infection, anesthesia complications, bleeding, non-union, hardware failure, loss

**Figure 2.** *Myelomeningocele patient with marked lumbar kyphosis.*

#### **Figure 3.**

*Myelomeningocele patient with marked kyphosis with skin breakdown at the level of the deformity (A) and accompanying radiographic images of the deformity (B).*

#### **Figure 4.**

*Myelomeningocele patient radiographic image depicting scoliotic curve (A) and postoperative radiographic study depicting spinopelvic fusion (B).*

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**Figure 5.**

*Postoperative skin breakdown and infection in a myelomeningocele patient.*

*Orthopedic Approach to Spina Bifida*

*DOI: http://dx.doi.org/10.5772/intechopen.94901*

*Orthopedic Approach to Spina Bifida DOI: http://dx.doi.org/10.5772/intechopen.94901*

*Spina Bifida and Craniosynostosis - New Perspectives and Clinical Applications*

**94**

**Figure 4.**

**Figure 3.**

*accompanying radiographic images of the deformity (B).*

*study depicting spinopelvic fusion (B).*

*Myelomeningocele patient radiographic image depicting scoliotic curve (A) and postoperative radiographic* 

*Myelomeningocele patient with marked kyphosis with skin breakdown at the level of the deformity (A) and* 

**Figure 5.** *Postoperative skin breakdown and infection in a myelomeningocele patient.*

of correction, pressure sores, subsequent operations and even death (**Figure 5**) [21]. Some studies have suggested a higher rate of union when using a combined anterior and posterior approach [22].

Another spine problem spina bifida patients may present with is tethered cord syndrome. This occurs when the spinal cord is stretched because it remains attached distally, usually to scar tissue from prior surgical procedures. Most patients have some degree of cord tethering but only 30% manifest clinically. Patients who have symptoms present with progressive scoliosis, new gait abnormalities or changes, weakness, spasticity or back pain [23]. Neurosurgeons are the specialists who treat this problem surgically by untethering the cord.
