1. Facing the primary level viva
Spina Bifida
Facing the primary level viva
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2. Spina Bifida Umbrella term Cranial neural tube defects
Spinal neural tube defects
SB cystica
Meningocele
Meningomyelocele
Lipo MMC
SB occulta
Tethered cord syndrome
Intraspinal lipoma
Diastematomyelia

3. Start with history Family Prenatal Intrapartum Post natal
Abortion, miscarriages, consanguinity, mental retardation
Prenatal
Anemia, diabetes infection (TORCH), teratogenic influences (radiation, drugs, alcohol), folic acid
Intrapartum
Fetal movements, premature rupture of membranes, method of delivery , breech, polyhydramnios.
Post natal
Apgar scores, birth weight, diminished activity and cry, head size, apnea, poor sucking.
Urinary leaking, fecal incontinence (perineal excoriation)
Symptoms due to raised ICT or menningitis (high grade fever, irritable vomitting child)

4. Examination At the level of lesion Below the level of lesion
Above the level of lesion

5. At the level of lesion
The swelling (describe it under the usual S Das headings)
Site
In relation to the vertebras
No of segments involved
Skin over the swelling
Ulcer
CSF leak sac integrity
Marginal epithelization
Neural placode
dimensions
Obvious deformity of the spinal column
Kyphosis, scoliosis

6. Below the level of lesion
To see the sensory and motor involvement below the lesion
Sensory level difficult in new born and infants more useful in bigger children
Limbs – motor involvement
Grading of limb movements
No movement on stimulus 0
Some movement on painful stimulus 1
Movement on tickling 3
Passive movements 4
Against gravity (spontaneously flexed limbs) 5

7. Below the level of lesion
Symmetry of the paralysis – may be more on one side
Spastic type of paralysis – limbs in constantly extended position
Clonus or focal fasciculations
Muscle bulk , trophic ulcers
Movements at the joints indicates the spinal segment involved

8. Below the level of lesion
Knee
L4-L5 Knee Extension
L5-S2 knee flexion
Hip
L1-L3 hip flexion
L5-S2 hip extension
Ankle
Sacral roots S3-S5 Plantar flexion

9. Below the level of lesion
Bulbo cavernosus reflex
Press the glans of penis gently while finger appreciates the wink in the external anal sphincter
Anocutaneous reflex
Gentle stroking of the perineal area causes a wink in the external anal sphincter
Cremastric reflex – S2
Indicates the integrity of the sacral nerve roots and the perineal sensation

10. Below the level of lesion
Anal canal
Lax, patulous, anal grip, leaking fecal matter on abdominal pressure
Urinary bladder
Palpable with full bladder, bladder emptying on slight abdominal pressure (Credes method )

11. Above the level of lesion
Hydrocephalus
Head size
Fontanelles
Neck rigidity
Second lesion
Abnormal head shape
Raised ICT protuberant eyes, irritable vomiting child
Others
Abnormally protuberant abdomen
Hydronephrosis lump
Vertebral anomalies

12. General examination Level of alertness Cry
Cranial nerve examination (I have never done it )

13. Possible questions What is u r diagnosis Embryological aspects
Structural anatomy
Why is hydrocephalus present
What is Arnold Chiari
How will u proceed
Timing of surgery
Principles of repair
Basics of shunt surgery

14. Diagnosis statement - Lumbosacral MMC with lower limb paresis with bladder bowel involvement

15. Embryological aspects
Simple non closure theory
Overgrowth and non closure theory
Reopening theory

16. Structural anatomy

17. Why is hydrocephalus present
Four reasons for associated hydrocephalus
Obstruction to the outlet of 4th ventricle (part of AC malformation)
Cork in the bottle phenomenon
Secondary aqueductal stenosis
Defect in CSF absorptions

18. What is Arnold Chiari Malformation
Main pathologic group is chiari malformations
Chiari malformations are of 4 types
Type 2 malformation is also called as Arnold chairi malformation which is commonly associated with spina bifida
It has Caudal displacement of cebellar vermis, 4th ventricle and lower brain stem below the plane of foramen magnum

19. How will u proceed Investigations
Spinal x rays ap/lat views – it is difficult to decide the segment involved but tells about the vertebral anomalies above and below
Skull x rays – lacunar deformity, reversal of normal curve of bassi-occiput

20. Minimum recommended Invg
USG
Most imp invg
Done for swelling as well as the cranium and the abdomen CT
Of spine not very useful but good in demonstrating hydrocephalus
MRI Spine
tells the exact anatomy of the defect very usefull in lipo MMC where intraspinal lipoma is anticipated
Diagnosis of AC malformations
Minimum recommended Invg
X ray spine AP/LAT
Usg of swelling and cranium
MRI spine
General hematology

21. Timing of surgery Presenting immediately after birth
Good skin cover, no infection - wait till the child is physiologically mature – operate at 4 weeks +
Very thin cover, impending rupture – no infection – operate within 7 days
Ruptured MMC – antibiotics for 2 days – operate
Delayed presentations
Good skin cover, no infection – elective surgery
Leaking MMC, infection – antibiotics for hours- repair
Spina bifida occulta
Operate before 1 year to de tether the cord.

22. Principles of repair Preservation of the neural elements
Closure of the dural defect

23. Shunt surgery Timing Types
At the time of MMC repair is hydrocephalus is documented
Close the MMC, watch for Hydrocephalus
Types
Ventriculoperitoneal
Ventriculoatrial