**5. Symptomatology**

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

**4. Etiology and pathophysiology**

regions with mandatory folic acid fortification [9].

metabolism and utilization of folate and folic acid.

**4.4 Decompensated diabetes mellitus**

**4.2 Positive family history of spina bifida**

**4.1 Folate deficiency**

**4.3 Medications**

**4.5 Obesity**

tube defect.

**4.6 Hyperthermia**

week [8]. Overall prevalence of spina bifida is lower in countries with mandatory folic acid fortification of grain products opposite to countries with voluntary or no

Detailed etiology of spina bifida is not known but it is assumed to result from a combination of more factors - genetic, nutritional and environmental risk factors. Genetic risk factor is a family history of neural tube defect. Most important nutritional factor is folate deficiency. Even though exact mechanisms leading to spina

Folate is a natural form of vitamin B9. Its synthetic form is folic acid. Folate is important for proper intrauterine development of fetus. Its deficiency is connested not only with spina bifida, but also with occurence of all neural tube defects. Spina bifida is significantly more common in countries without legislation regulating full-coverage folic acid fortification of the food supply and less common in world

Genetic factors seem to play important role in etiology of spina bifida. Couples with child born with spina bifida are at higher risk of having another child born with this defect. At higher risk of having child affected by spina bifida are also women who were born with neural tube defect and also higher frequency is in twins than in singletons. All this indicates a genetic contribution to etiology. But low frequency of families with multiple neural tube defects makes research more difficult [11].

Some drugs are under suspicion in contributing to higher risk of developmental

Women with decompensated or inadequatelly compensated glucose levels during

disorders of neural tube. Mostly anti-convulsants (anti-seisure mediacation), such as valproic acid, when taken during pregnancy. They probably interfere with

early stages of pregnancy are at higher risk of having child with spina bifida.

Spina bifida and all neural tube defects are more common in women with obesity. It is important to have adequate body mass index also prior to pregnancy.

Increased body temperature in early stages of pregnancy due to infection or using of sauna is believed to be potencially risky for having a child with neural

fortification [9, 10]. More affected are females and whites and Hispanics.

bifida are not clearly known, there are some of researchers interest [11].

**30**

Severity of symptoms depends on type of spina bifida ranging from no symptoms in spina bifida occulta to most severe in myelomenigocele. There are also interindividual differences. Spina bifida occulta is neurologically asymptomatic because there is no involvement of neurologickal structures.

#### **5.1 Skin lesions or visible sac**

Cutaneous lesions mostly in lumbar region could be associated with spina bifida or tethered spinal cord. Visible change of skin above the defect is usually an abnormal tuft of hair, dimple, subcutaneous lipoma or a birthmark [12]. Such skin lesion could also be a symptom of spinal cord abnormality that is covered by skin.

Sacral dimple is a common skin lesion and is found in 1,8 to 7,2% of newborns [13]. However, in most of newborns it is only a simple skin lesion without any effect on neurological functions. Possitive ultrasonography findings are usually filar cyst (24,8%), echogenic filum terminale (13,5%) and low-lying spinal cord (11,7%). Some literary sources consider filar cyst as a normal finding [14].

Simple solitaire sacral dimple in asymptomatic newborn with diameter less than 5 mm located no more than 25 mm above anal opening have extremely low risk of having spinal abnormality [15]. Considering this very low risk (approx. 0,34%), more recent guidelines state that sipmple solitaire non risky sacral dimples do not require additional imaging – only in case they are atypical, associated with other skin lesions or multiple. On the other hand around 86% of spinal dysraphisms are associated with overlying cutaneous lesion [16].

Open defect is mostly situated in the lumbar region and is characterized by opened spinal canal along more vertebras. At birth meninges, spinal nerves and spinal cord protrude above surrounding skin level forming a sac. This sac could be also covered by skin. These open defects are easily recognized whereas smaller or closed defects can present only by overlying cutaneous lesions [17].

#### **5.2 Paraparesis**

Degree of neurological impairment, walking disability and muscle weaknes depends on severity and extent of the defect, as well as on accuracy of prenatal or postnatal treatment. Neurological deficit varies from mild paraparesis to paraplegia. Myelomeningocele is the most common congenital anomaly causing physical disability [18].

According to level of defect there are various degrees of motor disability (**Table 2**). Patients with thoracic defect have flacid lower extremities, patients with high-lumbar defect usually can perform flexion in hip joint, in middle-lumbar defect also extension in knee, in low-lumbar defect is also foot dorsiflection present and sacral defect usually allows to perform also plantar flexion of foot [20].

Neurological deficit in patients with spina bifida is thought to be result of the primary insult - the congenital anomaly and the second - from direct exposure of spinal cord to amniotic fluid and intrauterine trauma [21].


#### **Table 2.**

*Functional outcome according to level of spinal dysraphism [19].*

In a study with 50 years follow up of walking ability half of the patients with severe spina bifida was able to walk for 50 m butthis ability declined with age to 27% in the age of 50 years [22].

#### **5.3 Urinary dysfunction**

Nerve damage in neural tube defect leads to loss of sensation and bladder sphincter control. Very common is neurogenic bladder that leads to symptoms such as urinary retencion, overflow incontinence, urgency, frequency and nocturia. Possible complications are incontinence, repeated or chronic urinary infections, hydronephrosis and in later stages renal damage [23] that all leads to diminished quality of life [24].

#### **5.4 Bowel dysfunction**

Most of patients living with the diagnosis of spina bifida have some degree of bowel problems called neurogenic bowel dysfuntion. The lack of bowel movement results in obstipation and lack of anal sphincter control leads to intermitent or continual incontinence [23]. Bowel dysfunction leads to decreased life quality [19, 25].

#### **6. Complications**

Possible complication affect in some degree most of patients with open forms of spina bifida. The severity of complications depend on extent of defect and also on timing of treatment. Fetal surgery gives better prognosis.

#### **6.1 Hydrocephalus**

The majority of infants with open neural tube defects also has hydrocephalus [26]. Hydrocephalus is defined as an active distension of the ventricular system resulting

**33**

*Management of Pediatric Patients with Spina Bifida DOI: http://dx.doi.org/10.5772/intechopen.97237*

from inadequate passage of cerebrospinal fluid at some point from its production within ventricles to its absorption into the systemic circulation [27]. In infants it is a condition with ventricular enlargement that leads to rapid growth of head circumference and requires surgical intervention [28]. According to observations only 1 out of 6 infants with myelomenongocele has symptoms of raised intracranial pressure at birth and 1 out of 8 has head circumference above 98th percentille at birth [29]. Many infants develop ventriculomegally that leads to increase of head circumference after postnatal closure of open spina bifida. Slight ventricular enlargement with stable neurological status could be indication for conservative observation – radiological and clinical. Rapidly developed ventricullomegaly with worsening of neurological status and signs of intracranial hypertension requires quick neurosurgical intervention [26]. Surgical treatment possibilities are insertion of ventriculo-peritoneal shunt and endoscopic third ventriculostomy with cauterisation of choroid plexus. Minority of cases is indicated for conservative treatment – only those with relatively stable ventriculomegally [26]. Infants who underwent fetal surgical repair of myelome-

ningocele were less likely to require ventriculo-peritoneal shunting [30].

Presence of hydrocephalus in children with open spina bifida requires placement

Myelomeningocele as the most severe open defect is almost invariably associated

with this malformation. Chiari malformation type II is a group of disorders that includes herniation of fetal developing cerebellum upwards into the middle cranial fossa or downwards into cervical spinal canal. This malformation is often associated with other abnormalities such as: brainstem kinking, abnormal forth ventricle location and syringomyelia [30]. The research on animal models shows that chronic intrauterine leakage of cerebrospinal fluid can lead to Chiari II malformation [31]. It is common brain malformation in children with myelomeningocele. This malformation worsens the cerebrospinal fluid circulation leading to progression of hydrocephalus. Chiari malformation type II can present with rapidly present symptoms such as: breathing problems or apnoea, bradycardia, swallowing problems and other cranial nerves dysfunction when descending cerebellum presses on brainstem [26]. Under rare circumstances can lead to indication of decompression of craniocervical junction. Chiari malformation type II, its presence and severity can in huge extent determine the outcome of patients [26]. Chiari II malformation is significantly less severe in infants who underwent fetal surgery for myelomeningocele [30]. Improvement of this malformation and subsequent decrease in hydrocephalus in children with prenatal repair of myelomeningocele support the theory of relationship between continual intrauterine abnormal leakage of cerebrospinal fluid and subsequent development of Chiari II malformation and hydrocephalus

of ventriculo-peritoneal shunt in most of the cases. Proper function of shunt is inevitable. Unfortunately, shunt related complications are frequent – mainly shunt malfunction and infection. About 95% of patients who required shunt placement have to undergo at least one shunt revision [26]. Symptoms of shunt-related complications are: headache, irritability, confusion, somnolency, nausea, vomiting, feeding problems, fixed downward gaze, seizures. In case of shunt infections also symptoms like higher body temperature, redness along the shunt catheters, elevated

**6.2 Complications of ventriculo-peritoneal drainage**

and underline the importance of fetal surgery [26, 30].

blood parameters of infections.

**6.3 Chiari malformation type II**

*Management of Pediatric Patients with Spina Bifida DOI: http://dx.doi.org/10.5772/intechopen.97237*

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

**Muscle function Ambulation**

Lack function of gluteus maximus and medius Retain quadriceps and medial hamstring function

*Functional outcome according to level of spinal dysraphism [19].*

**Sacral** Retain quadriceps and gluteus medius function

Low sacral Retain gastrocnemius function

Lack quadriceps function Children – ambulation with hip spanning orthosis

orthosis)

(hip-knee- ankle – foot orthosis or reciprocating gait

Adults – majority require wheelchair

Ambulate without braces or support

Require crutches for ambulation Most retain comunity ambulation as adults

In a study with 50 years follow up of walking ability half of the patients with severe spina bifida was able to walk for 50 m butthis ability declined with age to

High sacral Lack gastrocnemius function Ambulate with ankle-foot orthosis and no support

Nerve damage in neural tube defect leads to loss of sensation and bladder sphincter control. Very common is neurogenic bladder that leads to symptoms such as urinary retencion, overflow incontinence, urgency, frequency and nocturia. Possible complications are incontinence, repeated or chronic urinary infections, hydronephrosis and in later stages renal damage [23] that all leads to diminished

Most of patients living with the diagnosis of spina bifida have some degree of bowel problems called neurogenic bowel dysfuntion. The lack of bowel movement results in obstipation and lack of anal sphincter control leads to intermitent or continual incontinence [23]. Bowel dysfunction leads to decreased life

Possible complication affect in some degree most of patients with open forms of spina bifida. The severity of complications depend on extent of defect and also on

The majority of infants with open neural tube defects also has hydrocephalus [26]. Hydrocephalus is defined as an active distension of the ventricular system resulting

timing of treatment. Fetal surgery gives better prognosis.

27% in the age of 50 years [22].

**5.3 Urinary dysfunction**

**Level of lesion**

**Thoracic High Lumbar**

**Low lumbar**

**Table 2.**

quality of life [24].

quality [19, 25].

**6. Complications**

**6.1 Hydrocephalus**

**5.4 Bowel dysfunction**

**32**

from inadequate passage of cerebrospinal fluid at some point from its production within ventricles to its absorption into the systemic circulation [27]. In infants it is a condition with ventricular enlargement that leads to rapid growth of head circumference and requires surgical intervention [28]. According to observations only 1 out of 6 infants with myelomenongocele has symptoms of raised intracranial pressure at birth and 1 out of 8 has head circumference above 98th percentille at birth [29]. Many infants develop ventriculomegally that leads to increase of head circumference after postnatal closure of open spina bifida. Slight ventricular enlargement with stable neurological status could be indication for conservative observation – radiological and clinical. Rapidly developed ventricullomegaly with worsening of neurological status and signs of intracranial hypertension requires quick neurosurgical intervention [26].

Surgical treatment possibilities are insertion of ventriculo-peritoneal shunt and endoscopic third ventriculostomy with cauterisation of choroid plexus. Minority of cases is indicated for conservative treatment – only those with relatively stable ventriculomegally [26]. Infants who underwent fetal surgical repair of myelomeningocele were less likely to require ventriculo-peritoneal shunting [30].

### **6.2 Complications of ventriculo-peritoneal drainage**

Presence of hydrocephalus in children with open spina bifida requires placement of ventriculo-peritoneal shunt in most of the cases. Proper function of shunt is inevitable. Unfortunately, shunt related complications are frequent – mainly shunt malfunction and infection. About 95% of patients who required shunt placement have to undergo at least one shunt revision [26]. Symptoms of shunt-related complications are: headache, irritability, confusion, somnolency, nausea, vomiting, feeding problems, fixed downward gaze, seizures. In case of shunt infections also symptoms like higher body temperature, redness along the shunt catheters, elevated blood parameters of infections.

#### **6.3 Chiari malformation type II**

Myelomeningocele as the most severe open defect is almost invariably associated with this malformation. Chiari malformation type II is a group of disorders that includes herniation of fetal developing cerebellum upwards into the middle cranial fossa or downwards into cervical spinal canal. This malformation is often associated with other abnormalities such as: brainstem kinking, abnormal forth ventricle location and syringomyelia [30]. The research on animal models shows that chronic intrauterine leakage of cerebrospinal fluid can lead to Chiari II malformation [31]. It is common brain malformation in children with myelomeningocele. This malformation worsens the cerebrospinal fluid circulation leading to progression of hydrocephalus. Chiari malformation type II can present with rapidly present symptoms such as: breathing problems or apnoea, bradycardia, swallowing problems and other cranial nerves dysfunction when descending cerebellum presses on brainstem [26]. Under rare circumstances can lead to indication of decompression of craniocervical junction. Chiari malformation type II, its presence and severity can in huge extent determine the outcome of patients [26]. Chiari II malformation is significantly less severe in infants who underwent fetal surgery for myelomeningocele [30]. Improvement of this malformation and subsequent decrease in hydrocephalus in children with prenatal repair of myelomeningocele support the theory of relationship between continual intrauterine abnormal leakage of cerebrospinal fluid and subsequent development of Chiari II malformation and hydrocephalus and underline the importance of fetal surgery [26, 30].

### **6.4 Tethered spinal cord**

Tethered spinal cord is a neurological disorder that is caused by abnormal attachment of the spinal cord to surrounding structures. In case of patients with myelomeningocele spinal cord is mostly attached to scar from previous operation [32]. Symptoms are caused by increased tension and stretch-induces dysfunction of the caudal spinal cord and conus and include motor and sensitive dysfunction, gait abnormalities, symptoms of cauda equina syndrome and urological symptoms [12, 32].

Filum terminale lipoma can cause cord tethering, lipoma is the most common cause of thick filum terminale. That is why detection of abnormal thickening of filum terminale is important. Initial detection is usually performed by ultrasonography [2] followed by MR imaging [12]. Tethered cord syndrome must be suspected when conus medullaris is placed dorsaly in the spinal canal and terminates below the superior aspect of L3 vertebral body. Also thickened filum terminale can be present. MR imaging is indicated in ultrasonography evidence of tethered cord or in case of doubts [3].

Although some patients with anatomic cord tethering do not develop symptoms, most of the patients are symptomatic and do not naturally improve without surgical untethering. Neurosurgical intervention is the treatment of choice, though with varying results [33]. Timing of the surgery is also important – early intervention after symptom development is necessary for recovery or at least improval of neurological functions. Early surgical intervention as a prevention of further neurological damage requires early diagnostics [12].

#### **6.5 Meningitis**

Infants with open neural tube defects can experience meningitis – inflammation of brain and spinal cord surrounding meninges. Meningitis could develop as a consequence of open defect, as a complication of surgical procedures as well as a complication of shunting procedures. In case of bacterial meningitis there is a need for massive antibiotic therapy.

#### **6.6 Urological complications**

Most of the patients with severe spinal dysraphism suffer from neuropathic bladder impairment [24]. As the nerve damage causes urological complication by means of neurgenic bladder, this situation also brings specific possible complications. Usual problem is urinary retention that could lead to overflow incontinence, renal damage and urinary tract infections, that could be repeated or chronic and often requires antibiotic treatment.

It is necessary to maintain proper urine derivation with no residual urine left. These patients require long time follow up by urologist. Urological complications and renal disease as a consequence is very common cause of higher morbidity mainly in older children and adults with open spinal defect. Severe bladder mortality is most frequently present in patients with huge spinal defects without covering membrane. This verifies the theory of increased damage of nerve roots from direct exposure to amniotic fluid [34].

#### **6.7 Gastrointestinal complications**

One of the most common problems of patient with spina bifida in adulthood is neuropathic bowel dysfunction with constipation and incontinence, but these patients also often suffer from dysphagia – mainly patients with brain stem compression.

**35**

*Management of Pediatric Patients with Spina Bifida DOI: http://dx.doi.org/10.5772/intechopen.97237*

later to peptic ulcer disease [34, 35].

complications [34].

(club foot) [37].

**6.10 Latex allergy**

**6.9 Orthopedic complications**

quadriceps and hamstring muscles [11].

**6.8 Bronchopulmonal complications**

Brain and spinal cord nerves modulate activity of enteric nervous system. Patients with severe and highly located forms of open spina bifida and resulting Chiari II malformation have impaired function of nerves leading to dysfunction of gastrointestinal tract mobility. Gastrointestinal problem that these patients suffer from is diminished bowel movements causing obstipation or opposite also diarrhea.

Patients often suffer from anal incontinence from mild to severe degree [19]. Patients with large and high located myelomeningocele often suffer from dysphagia. Development of dysphagia in children with myelomeningocele is caused by cervicomedulary kinking and brainstem compression due to crowding in the posterior fossa in Chiari II malformation. Dysphagia leads to swallowing difficulties, feeding difficulties, failure to thrive, bronchopulmonary complications and

Children with large and high located myelomeningocele display also other complications such as Chiari II malformation that often leads to dysfagia. Severe dysphagia causes swallowing and feeding problems that might cause complications as aspiration pneumonia, pulmonary disease, reactive airway disease, bronchiectasis, stridor or apnoea [35]. Although almost all children with open spina bifida live into adulthood, patient suffering with brainstem dysfunction leading to such bronchopulmonary complications are at higher risk of fatal

Children with thoracic and thoracolumbar levels of defect might in some cases also have impaired function of the accessory respiratory muscles. They also often have scoliosis that could lead to reduced forced vital capacity of the lungs [36].

Orthopedics deal in patients with spina bifida with congenital and acquired deformities. Because of weak muscles of spine and lower extremities, these patients with open spinal defects can present with variety of orthopedic problems. Most frequently occuring problems are: scoliosis, kyphosis, muscle contractions, bone and joints deformities, hip dislocation, abnormal growth and talipes

Scoliosis is present in almost all children with severe and highly located myelomeningocele. Children born without covering membrane of the defect tend to have neuromuscular imbalance and spinal cord tethering which are conditions leading to scoliosis. Severe paraparesis leading to full-time use of wheelchair also enables occurrence of scoliosis [34]. Scoliosis also leads to pelvic obliquity with subsequent changes in sitting balance and contributes to unequal pressure during sitting. This factor together with lack of sensitivity leads to skin breakdowns [36]. One of the most important factors for maintaining ambulation in adulthood is strength of

Many patients with open spinal defects are at higher risk of latex allergy. This means allergic reaction to natural rubber and latex products. Symptoms could be mild – such as rush, sneezing, itching, conjunctivitis and rhinitis, as well as very severe condition – anaphylaxis, that is potentially life threatening situation. This is a potential reason for using latex-free gloves at labor and also at giving care to these patients. Latex allergy could also lead to perioperative complications [11].

*Management of Pediatric Patients with Spina Bifida DOI: http://dx.doi.org/10.5772/intechopen.97237*

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

Tethered spinal cord is a neurological disorder that is caused by abnormal attachment of the spinal cord to surrounding structures. In case of patients with myelomeningocele spinal cord is mostly attached to scar from previous operation [32]. Symptoms are caused by increased tension and stretch-induces dysfunction of the caudal spinal cord and conus and include motor and sensitive dysfunction, gait abnormalities, symptoms of cauda equina syndrome and

Filum terminale lipoma can cause cord tethering, lipoma is the most common cause of thick filum terminale. That is why detection of abnormal thickening of filum terminale is important. Initial detection is usually performed by ultrasonography [2] followed by MR imaging [12]. Tethered cord syndrome must be suspected when conus medullaris is placed dorsaly in the spinal canal and terminates below the superior aspect of L3 vertebral body. Also thickened filum terminale can be present. MR imaging is indicated in ultrasonography evidence of tethered cord or in case of doubts [3]. Although some patients with anatomic cord tethering do not develop symptoms, most of the patients are symptomatic and do not naturally improve without surgical untethering. Neurosurgical intervention is the treatment of choice, though with varying results [33]. Timing of the surgery is also important – early intervention after symptom development is necessary for recovery or at least improval of neurological functions. Early surgical intervention as a prevention of further neurological

Infants with open neural tube defects can experience meningitis – inflammation of brain and spinal cord surrounding meninges. Meningitis could develop as a consequence of open defect, as a complication of surgical procedures as well as a complication of shunting procedures. In case of bacterial meningitis there is a need

Most of the patients with severe spinal dysraphism suffer from neuropathic bladder impairment [24]. As the nerve damage causes urological complication by means of neurgenic bladder, this situation also brings specific possible complications. Usual problem is urinary retention that could lead to overflow incontinence, renal damage and urinary tract infections, that could be repeated or chronic and

It is necessary to maintain proper urine derivation with no residual urine left. These patients require long time follow up by urologist. Urological complications and renal disease as a consequence is very common cause of higher morbidity mainly in older children and adults with open spinal defect. Severe bladder mortality is most frequently present in patients with huge spinal defects without covering membrane. This verifies the theory of increased damage of nerve roots from direct

One of the most common problems of patient with spina bifida in adulthood is neuropathic bowel dysfunction with constipation and incontinence, but these patients also often suffer from dysphagia – mainly patients with brain stem compression.

**6.4 Tethered spinal cord**

urological symptoms [12, 32].

damage requires early diagnostics [12].

for massive antibiotic therapy.

**6.6 Urological complications**

often requires antibiotic treatment.

exposure to amniotic fluid [34].

**6.7 Gastrointestinal complications**

**6.5 Meningitis**

**34**

Brain and spinal cord nerves modulate activity of enteric nervous system. Patients with severe and highly located forms of open spina bifida and resulting Chiari II malformation have impaired function of nerves leading to dysfunction of gastrointestinal tract mobility. Gastrointestinal problem that these patients suffer from is diminished bowel movements causing obstipation or opposite also diarrhea. Patients often suffer from anal incontinence from mild to severe degree [19].

Patients with large and high located myelomeningocele often suffer from dysphagia. Development of dysphagia in children with myelomeningocele is caused by cervicomedulary kinking and brainstem compression due to crowding in the posterior fossa in Chiari II malformation. Dysphagia leads to swallowing difficulties, feeding difficulties, failure to thrive, bronchopulmonary complications and later to peptic ulcer disease [34, 35].

#### **6.8 Bronchopulmonal complications**

Children with large and high located myelomeningocele display also other complications such as Chiari II malformation that often leads to dysfagia. Severe dysphagia causes swallowing and feeding problems that might cause complications as aspiration pneumonia, pulmonary disease, reactive airway disease, bronchiectasis, stridor or apnoea [35]. Although almost all children with open spina bifida live into adulthood, patient suffering with brainstem dysfunction leading to such bronchopulmonary complications are at higher risk of fatal complications [34].

Children with thoracic and thoracolumbar levels of defect might in some cases also have impaired function of the accessory respiratory muscles. They also often have scoliosis that could lead to reduced forced vital capacity of the lungs [36].

#### **6.9 Orthopedic complications**

Orthopedics deal in patients with spina bifida with congenital and acquired deformities. Because of weak muscles of spine and lower extremities, these patients with open spinal defects can present with variety of orthopedic problems. Most frequently occuring problems are: scoliosis, kyphosis, muscle contractions, bone and joints deformities, hip dislocation, abnormal growth and talipes (club foot) [37].

Scoliosis is present in almost all children with severe and highly located myelomeningocele. Children born without covering membrane of the defect tend to have neuromuscular imbalance and spinal cord tethering which are conditions leading to scoliosis. Severe paraparesis leading to full-time use of wheelchair also enables occurrence of scoliosis [34]. Scoliosis also leads to pelvic obliquity with subsequent changes in sitting balance and contributes to unequal pressure during sitting. This factor together with lack of sensitivity leads to skin breakdowns [36]. One of the most important factors for maintaining ambulation in adulthood is strength of quadriceps and hamstring muscles [11].

#### **6.10 Latex allergy**

Many patients with open spinal defects are at higher risk of latex allergy. This means allergic reaction to natural rubber and latex products. Symptoms could be mild – such as rush, sneezing, itching, conjunctivitis and rhinitis, as well as very severe condition – anaphylaxis, that is potentially life threatening situation. This is a potential reason for using latex-free gloves at labor and also at giving care to these patients. Latex allergy could also lead to perioperative complications [11].
