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The Team Approach in the Care of the Child with Myelomeningocele

John V. Banta, M.D.
Robert Lin, C.P.O.
Mary Peterson, M.S.N., R.N.
Theresa Dagenais, M.S., R.P.T.

Introduction

Myelomeningocele is the most complex congenital multi-system disorder, which affects not only the central nervous system, but the kidneys and bowel, as well as the musculoskeletal system. Although the condition was known to occur in antiquity and was well described in 1654 by Nicholas Tulp, a Dutch physician,¹ it was the development of successful valve shunts in 1957 to control hydrocephalus that ushered in the modern treatment era.

Incomplete closure of the neural tube by the twentieth day of embryonic development results in an open placode of neural tissue at the center of the bifid spine, overlaid by a thin meninges which may be ruptured during the neonatal period. Early descriptions of the lesion imply that the pathologic lesion was an absence of anterior horn cells. However, the majority of patients with myelomeningocele demonstrate an upper motor neuron lesion, as described by Stark and Drummond.² Clinicians have attempted to classify patients' neurologic levels based upon the lowest neurosegmental level of anti-gravity function. This hierarchal system allows team members to make reasonable estimates of predictable functional capabilities for the newborn child with myelomeningocele. Gross estimates of motor function can be inaccurate if they do not include the upper motor neuron abnormalities. Recognition of tethered spinal cord syndromes, hydromyelia of the spinal cord and detailed pathologic anatomy of the Chiari malformation is now possible with magnetic resonance imaging (MRI) techniques. Close collaboration between the orthopaedist, neurosurgeon and physical therapist is necessary to accurately assess the musculoskeletal deformities.

Limb deformities may arise as a result of intrauterine posture, muscle imbalance, weight-bearing, and positioning, gravity and growth. The neurologic lesion is not necessarily stable through growth. Early neurosurgical closure is the best means of preventing neurologic deterioration and neonatal sepsis.³

Orthopaedic Treatment

Orthopaedic treatment is directed to correct lower extremity deformities before the child develops upright stance (between 12 and 20 months of age). To maintain plantigrade foot control, stability and upright mobility, some form of orthotic support is normally required regardless of the neurosegmental level of innervation. The orthotic needs are apparent at high levels of paralysis nevertheless, children with sacral level function benefit from proper foot alignment with ankle-foot orthoses to prevent deformity with further growth.

The ability to walk is implicit in the orthotic prescription for the child with myelomeningocele. Longitudinal studies of children with paralytic residuals reveal that certain factors, such as the level of paralysis, obesity, age and motivation, directly affect walking ability.⁴ However, energy expenditure is the ultimate determinant of orthotic assisted gait versus wheelchair mobility. Energy expenditure for walking can be best defined as energy per unit of time or oxygen consumption expressed in milliliters of oxygen consumed per kilogram of weight per minute. This reflects the power. The actual work performed is the energy consumed per distance traveled, which is expressed as the oxygen consumed per kilogram of weight per meter travelled.⁵ Williams⁶ compared 15 children with myelomeningocele with 60 normal controls, matched for age, and demonstrated that the myelomeningocele child voluntarily chose a slower gait velocity, thereby consuming more oxygen per meter traveled resulting in a 218 percent less energy efficient gait. At equal walking velocities, the affected children's rate of oxygen consumption rose above normal values, suggesting earlier fatigue. A swing-through gait pattern was 33 percent more efficient than a four-point gait pattern. The wheelchair provided the most energy efficient means of mobility but was still only 38 percent as efficient as normal walking.⁷

The major dilemma facing orthopaedic surgeons in the treatment of paralytic residuals of myelodysplasia is the presence of an infinite number of changing patterns of neurologic function and a no-less infinite variety of surgical procedures to correct these deformities. The goals of treatment are to correct deformity, provide postural stability, as well as joint mobility, facilitate ambulation or mobility and free the upper extremities.

Hip surgery directed to reduction of subluxations or dislocations may reduce pelvic obliquity, increase sitting balance and reduce the incidence of pressure sores. Reduction of dislocated hips will not increase the motion of the joint, reduce bracing demands or improve the level of independent ambulation. The major prerequisites for hip surgery include a level pelvis beneath a compensated spine and a stable unchanging neurologic state.

The incidence of spinal deformity in myelomeningocele is directly related to the level of paralysis. Additional factors that contribute to a higher incidence of scoliosis include asymmetric motor levels, the presence of reflex motor activity and the level of the bone dysraphism.⁸ Progressive deformity secondary to congenital scoliosis is best managed by early in situ fusion followed by orthotic support of the spine until mature sitting height is achieved when extension of the fusion is often required. For those children demonstrating progressive paralytic scoliosis, combined anterior and posterior arthrodesis of the spine is recommended.⁹ Often, paralytic spinal deformity can be controlled by the use of a custom-fitted total contact orthosis until the patient attains puberty when fusion is most appropriate. Post operative orthotic support of the dysraphic spine with a bivalved, custom-fitted, total contact spinal orthosis is recommended until the fusion has matured.

Better recognition of a child's neurologic defect allows the team to provide a more effective long-range treatment plan for the child which should be explained to the parents. The natural history of children with myelomeningocele with various levels of paralysis is better delineated now as a result of long-term follow-up studies which allow team members to better predict ultimate functional goals for the child with a dysraphic spinal disorder. The optimum delivery of the care to these children is best provided in the multi-disciplinary setting in which the various specialists can provide a truly collaborative approach for the children and their families.

Physical Therapy

To help the child attain mobility, the physical therapist must determine the child's neurologic level as well as the anti-gravity motor level. Only when these observations are made can realistic goals be set before ordering the appropriate equipment.

The functional motor level is defined as the lowest neurosegmental level at which a child has full, active, voluntary movement against gravity, rated grade 3 on the Medical Research Council System. Because the lesion is often a combination of both upper and lower motor neuron involvement, the neurological pattern within a given neurosegmental level is not always uniform. Furthermore, neurologic function may vary with age, with alternations in muscle function as a result of associated central nervous system anomalies such as the Chiari malformation, hydrocephalus, syringomyelia, or tethering of the spinal cord.¹⁰ It is imperative, therefore, that manual muscle tests be repeated annually until the child attains skeletal maturity.

In the presence of spasticity or reflex motor activity of the lower extremities, the child is unable to isolate movements which further interfere with function and mobility. Such upper motor neuron involvement can lead to joint contractures and deformity that will interfere with the fitting of orthoses and even the ability to walk. Spasticity of the upper extremities can cause weakness, lack of coordination and severely impair the child's ability to use crutches.¹¹

Orthotic Selection

Upper body strength, stability of the shoulder girdle and the amount of control the child can provide are critical to orthotic-assisted walking. The upper extremities, which are essential for weight-bearing during transfers, also provide balance and modulate the alternating shift of body weight during the gait cycle. In the patient with a lesion above the L3 neurosegmental level, the energy demands on the upper extremity and trunk muscles greatly limit the ability for community ambulation.¹² These patients are best fitted with a reciprocating gait orthosis (RGO) with crutches or a walker. If balance control is poor at a young age, a parapodium or swivel walker is often preferred as a transition device. This allows the child greater stability while the concept of trunk shift, essential for the proper use of the RGO, is developed. In patients with lesions at the L3L4 level, hip-knee-ankle-foot orthoses (HKAFOs) with crutches are appropriate. When the child demonstrates proper rotational control of the lower extremities in the presence of stable hips, often the pelvic band can be discontinued with growth and improvement in motor control.

Children with an L5 level lesion usually can walk with only an ankle-foot orthosis (AFO); however, caution must be exercised if the patient does not have excellent medial and lateral hamstring control. With imbalance or major weakness between the quadriceps and the hamstring muscles, progressive genu valgum, external tibial torsion and occasionally the development of Charcot arthropathy can occur with laxity of the knee ligaments with repetitive micro-trauma. Patients with sacral level involvement should be provided ankle-foot orthoses to prevent calcaneal deformity, progressive crouch gait and forefoot and midfoot deformities. Patients with minimal lower sacral root involvement can often be aided with a posterior leaf spring ankle-foot orthosis or, on occasion, with a UCBL (University of California Biomechanics Lab) orthosis for control of the hindfoot and midfoot. If these factors are overlooked during the decision-making process, an inappropriate orthosis may be prescribed, severely limiting the child's walking potential. Frequently, these children have visual-perceptual, fine motor and perceptual-motor dysfunction with dyspraxia¹³ and they may also have difficulty sequencing movement during reciprocal ambulation, controlling crutches, determining foot placement and operating strapping and locking mechanisms on orthotic devices. Easy distractibility, attention deficits and poor proprioceptive skills contribute to these problems and will alter the type of training the children will require and the level of independence they will achieve. Children with moderate deficits will require more intense and direct training, more time to complete a task, and may never achieve complete independence in donning and doffing their orthoses. They also experience greater difficulty in progressing from a walker to crutches and may never, in fact, accomplish this task. A child's level of intelligence and understanding will also influence the training potential, since visual-perceptual impairment is common in patients with lower intelligence.

Additional factors to consider in selecting an orthotic device are the persistence of joint contractures, the child's mobility out of braces, the motivation for walking and the degree of family support and involvement. Children who demonstrate good functional mobility out of an orthosis and who are motivated to walk, will achieve independent walking status sooner, progress from a walker to crutches more quickly and achieve greater independence.

Gait Training

The major focus of early gait training includes extensive strengthening exercises for both the upper extremity and trunk muscles. Strengthening is carried out through standard progressive, resistive exercises as well as through developmental and functional activity training such as creeping on hands and knees, crawling upstairs, climbing, wheelbarrow walking, dips in the parallel bars, transfer training and wheelchair pushups. Passive range of motion and stretching of the lower extremities are emphasized and started at an early age. It is particularly important to instruct the parents that these activities are to be carried out on a daily basis and to give tips on positioning, such as prone lying to stretch the hip flexors as well as to strengthen muscles of the neck, the erector spinae of the back, the latissimus dorsi and the triceps brachii, all of which will be the major muscles utilized with a walker, crutches and in transfer activities.

Starting when the child is an infant, the physical therapist must also emphasize the development of equilibrium reactions to enhance upright posture and to practice weight shifting and trunk rotation activities. Determination of a child's readiness to begin gait training is based not only on the child's chronologic and developmental age but also on the gross motor skill level, strength, motivation and home environment. When an orthosis is received, it is important that the family receive instruction in, not only its purpose and function, but also its proper application and removal, weaning and skin monitoring schedule, as well as the care and cleansing of the orthosis.

Weight-shifting activities are initiated with the child standing at a table for external support. The child performs reaching activities during play before progressing to parallel bars, a wheeled walker and, finally, to forearm crutches. The child may require a few days to several weeks in the parallel bars. To perform a reciprocal gait pattern, the child must be taught to perform an anterolateral weight-shift and to push down on the arms so as to unweight one leg to initiate forward progression in the swing phase.

The long-term goals of therapy are for the child to become fully independent in activities of daily living skills commensurate with the neurosegmental level of paralysis. Patients who require a total contact orthosis (TCO), or spinal support, frequently require assistance with dressing due to an inability to fully flex at the waist to reach the lower extremities.

The primary goals for a child who functions at the L3 level or below and has minimal upper extremity involvement are independence in dressing and transfer skills and the ability to walk with an appropriate orthotic device. Patients with higher levels of paralysis are often capable of upright stance and household walking activities but will require a wheelchair for independent mobility in the community. Although children with low lumbar level lesions are able to walk with orthoses and interact with their peers, they are unable to participate in sports requiring prolonged walking or running. To give these children the opportunity to compete and benefit from sports activities, it has been our practice to introduce the family to the concept of the sports wheelchair at an early age. This provides a more efficient means of mobility for long-distance travel as well as allowing the children to participate in organized activities such as basketball, tennis, track and field and archery. The benefits of such a program are numerous and include improvement in self-image, strength, endurance and general cardiovascular fitness.

Orthotic Treatment

Initial orthotic management generally begins when the child is between six and 18 months of age. Ideally, the timing of surgical procedures such as shunt revision, bowel and bladder surgeries and soft tissue releases should be planned as a team effort so that the optimum orthosis can be provided at the proper time. Failure to establish proper post-operative plans can result in a child developing recurrent contractures, deformity and even fracture during the convalescent period if the child is out of plaster and waiting for delivery of an orthosis that was not arranged for preoperatively.

While the motor level is the major determinant of long-term ambulation, predicting functional capabilities for the young child can be precarious and should be considered very carefully when establishing an appropriate treatment plan. Factors such as motor and sensory loss, spasticity and obesity complicate the orthotic management of these patients.

Hip Management

Initial treatment of the dysplastic or subluxated paralytic hip can be aided by orthoses. The Pavlik harness, which is relatively easy to apply and low in cost, protects the hip at risk and encourages acetabular development. With the paralytic hip, however, the harness should be modified from the traditional 90 degrees of hip flexion to between 45 and 60 degrees because of the child's propensity for developing a hip flexion contracture.¹⁴ The harness type that has been very effective for us incorporates a semi-soft boot arrangement which helps to orient the ankle-foot complex in neutral alignment while controlling the unstable hip. This design has been far superior to the "U" stirrup configuration as seen in other models.

Once the child has outgrown the larger Pavlik harness, conversion to a more definitive abduction system may be warranted. The Ilfeld splint with the metal cuffs and spreader bar meet the needs of these children quite well and can be used for the older child. Use of these hip orthoses must be limited to part-time wear to prevent iatrogenic abduction/flexion contractures in these children who have weak or absent hip extensors.

If persistent hip instability exists, a custom thoracolumbosacral hip (abduction) orthosis (TLSHO) can be effective. This design incorporates two femoral cuffs and a posterior trunk extension which prevent lateral trunk bending and subsequent uncovering of the contralateral hip (Figure 1) . The TLSHO is usually fashioned with a free hip joint, with or without a drop lock, which allows the orthosis to be flexed and enhances its acceptance and tolerance, allowing not only extension stability in recumbency at night but also trunk and sitting stability during daytime wear.

Spinal Management

The incidence of spinal deformity is directly related to the level of paralysis. Spinal orthoses are frequently required to support the spine during growth and to protect the fusion during the immediate postoperative period. The custom molded thoracolumbosacral orthosis (TLSO), or total contact body jacket, is widely prescribed for prophylactic, interim or postoperative use. The goals of treatment must be clearly defined before design and fabrication as they will greatly influence the components and the materials selected.

If possible, attempts should be made to attain compensation of the trunk over a level pelvis before taking a negative impression. This can be achieved through mild distraction or slight force application in the coronal plane. No attempt should be made to derotate or aggressively correct the deformity secondary to the curvature (Figure 2) .

In select cases, thoracic suspension orthosis (TSO) has proven to be a very effective alternative to the TLSO in controlling the paralytic spine.¹⁵ In many skeletally immature patients with a structural scoliosis, spinal fusion is best deferred either because of associated medical problems or to allow for further trunk growth before fusion. Interim maintenance of spinal stability is then warranted. The TSO is fabricated from polyethylene with an Aliplast foam liner acting as the patient/plastic interface. The primary difference between the TSO and the TLSO is the degree of compression and suspension achieved at the inferior costal margins. This compression allows the TSO to utilize the trunk/rib margins as the primary weight-bearing structures and the weight of the pelvis and lower extremities as a distractive and mildly corrective force, since the orthosis and the patient's upper trunk are supported by suspension davits attached to the wheelchair. The orthosis is much more successful when utilizing a ventral opening design instead of a bivalved or dorsal entry design.

The team approach to patient management is particularly important when applying spinal orthoses. The nursing staff, aids, therapists and primary care givers must thoroughly understand the fitting criteria and goals of treatment. Skin condition must be scrutinized carefully at regular intervals and weaning schedules and realistic wear times must be thoroughly understood by the patient and the family.

Ambulation-Assisting Orthotic Systems

For the purpose of this text, discussion of lower extremity management will be limited to the application of functional, ambulatory orthotic designs for patients with lesions above L3. There are major physiological and psychological benefits of an erect posture and independent ambulation for young children with high levels of paraplegia. Rose and Stallard¹⁶ stated that in order for independent ambulation to be feasible, the device must enable patients to: (1) achieve a walking speed approximating 30-60 percent of normal velocity per age at a low energy cost; (2) independently transfer from chair to walking; (3) independently don and doff the orthosis.

At Newington Children's Hospital, three orthotic systems are selectively prescribed that meet these criteria. The parapodium, swivel walker and reciprocating gait orthoses have all been used with varying degrees of success over the past 12 years.

The parapodium was the first orthosis devised in the early 1960s at Ontario Crippled Children's in Toronto, initially as a standing frame that had hip locks to allow standing or sitting.¹⁷ Design changes were introduced to allow flexibility with independently locking and unlocking joints at both the hips and knees which enabled the child to sit in a wheelchair, as well as to stand erect.

The swivel walker is a rigid hip-knee-ankle-foot orthosis (HKAFO) set in mild abduction at the hips to provide a broad base of support (Figure 3). The base consists of two swiveling foot pads ingeniously set at a slight camber which allow reciprocal forward motion as the patient actively leans his trunk to the right and left. Recent design modifications include a posterior plastic chute that allows the child to slide into the walker from a chair and new straps that allow independent donning and doffing.

The reciprocating gait orthosis also originated at the Ontario Crippled Children's Center in Toronto and has been refined at the Louisiana State University Department of Orthopaedics.¹⁸ The orthotic design incorporates two polypropylene and metal knee-ankle-foot orthoses (KAFOs) attached to a pelvic band with a cable-hip joint mechanism that allows for a smooth reciprocal gait with the cable linking the flexion moment of the limb in swing to a hip extensor moment in the contralateral stance phase hip.

The parapodium has, in our experience, provided much less upright mobility initially than the alternative designs. While the broad base provides a stable standing posture, forward progression is difficult and tenuous for the younger patient. Because of the child's limited ability in the parapodium, we have found that the swivel walker is the initial orthosis of choice. Even children in the two-to-three-year-old age group readily adapted to the weight-shift mechanisms necessary to initiate forward progression in the swivel walker. The major drawback of the swivel walker is that smooth surfaces are required; most children had difficulty with uneven terrain or thick carpeted surfaces. The swivel walker can easily be accommodated for growth and, in our experience, has had significantly less "down time" for repairs than other systems. A properly fitted swivel walker can be used for three to four years compared to approximately 18 months of use for an RGO.

At approximately five years of age, as the child becomes more active at both home and school and recognizes that the swivel walker cannot meet everyday needs, conversion to the reciprocating gait orthosis is most appropriate. To date, we have delivered more than 50 RGOs for patients with myelomeningocele. This orthosis affords the most functional gait pattern, as well as enhanced energy efficiency, improved cosmesis, velocity of gait and ease of gait over uneven terrain, as well as compatible with wheelchair use. The major disadvantage of the RGO has been the inability to fit it to patients with significant hip flexion contractures which interfere with the child's ability to initiate single limb progression. Our patients wear the RGO on an average of eight hours per day while using a wheelchair as an auxiliary mode of mobility. This compatibility is therefore critical. In patients with higher levels of paraplegia who had graduated from the swivel walker to the RGO, we found that their earlier experience in the walker made the transition somewhat easier due to familiarity with weight shift mechanisms and upright stability. This facilitation is not significant enough, however, to warrant the prescription of the swivel walker purely as a precursor or preparatory orthosis to the RGO.

Another major disadvantage of the RGO is a high incidence of breakdown at the hip joint/cable mechanism. This requires multiple repairs or component replacement for patients who are vigorous walkers. In addition, because of the intimate fit of the KAFO section, the average length of time in a particular set of RGOs was 14-18 months, after which time growth necessitated replacement. The only true contraindications that we have noted have been significant weakness in the upper extremities and hip or knee flexion contractures exceeding 25 degrees. Such patients have profound problems with the use of parallel bars, rollator walkers and Lofstrand crutches. The other reported contraindications such as obesity and mild contractures can be accommodated through careful fitting of the RGO and proper design and component selection. A promising new development appears to be the Para Walker which was developed at the Orthotic Research and Locomotor Assessment Unit in Oswestry.¹² A hybrid system has been developed that incorporates a Para Walker with a functional surface electrode stimulation of the gluteal muscles under patient-operated, crutch-mounted switch controls to achieve a hip abduction in extension assist on the stance leg. Although we have had no personal experience with this system, the concept is a sound one for patients with traumatic paraplegia and may prove applicable to children with dysraphic disorders of congenital origin.

Skin Care

Although advances in medical technology have improved the quality of life for children with myelomeningocele, the presence of paralytic deformity and anesthetic skin continues to place these children at major risk for pressure sores.¹⁹ A pressure sore results from excessive skin pressure which causes reduced capillary flow, tissue anoxia and eventual skin necrosis. Excessive pressure is manifested early as a reactive hyperemia, a blister, and later as an open sore or overt necrosis. Chronic untreated open sores can lead to osteomyelitis which can lead eventually to sepsis or even death.

The incidence of pressure sores in patients with myelomeningocele has been reported to be as high as 85-95 percent in large patient populations.²⁰ The magnitude of this problem can be appreciated in a recent retrospective report by Harris and Banta²¹ in which 75 patients required a total of 202 hospital admissions for skin breakdown unrelated to fractures, surgeries or cast problems. A total of 6,000 hospital days were required, and room and board expenditure alone approached $2,000,000.

Pressure sores create not only a major financial hardship for society, but also the loss of school and work time, and the added stress on both the patient and the family are significant. The tragedy is that, in most cases, pressure sores are entirely preventable. Prevention, however, requires a solid understanding of the causes of skin breakdown and meticulous daily attention on the part of the patient and family, as well as the health care team.

Patients with myelomeningocele have decreased mobility, decreased activity, impaired sensory perception and poor tissue tolerance. All these factors can lead to excessive skin pressure with the insidious onset of soft tissue destruction ²²Figure 4a and Figure 4b show an 11-year-old boy with a thoracic level myelomeningocele who had congenital kyphosis with scoliosis. He was ill-advisedly braced for a rigid deformity with poor overlying skin which resulted in a pressure sore developing over the apex of his kyphosis. Subsequently, the patient required extensive hospitalization time for wound debridement, a skin graft to the area, a rotational full thickness skin flap with a split thickness graft to the donor area, followed by a spinal fusion and a properly fitted orthosis.

Before any patient receives an orthosis, it is important to take a thorough history. First, it must be established what the child's and family's goals and expectations are regarding bracewear and whether the child has ever worn a cast or an orthosis. Then one should inquire about general hygiene practices, skin sensitivities and history of skin breakdown. If skin breakdown occurred previously, its location, type and the results of treatment should be documented. The patient's skin must be inspected and evaluated for color, pigmentation, signs of any lesions, cyanosis, bruising, scars, superficial vascularity, edema or moisture. During assessment, the skin is palpated and the skin temperature, texture, elasticity and turgor are noted. The sensory status should also be evaluated, noting any hypersensate or insensate regions.

Proper skin care and orthosis care must be thoroughly reviewed with the family and patient. It is important to stress the importance of daily bathing and keeping the skin clean and dry. A clean cotton T-shirt or cotton tights should be worn under the orthosis, whether it be a spinal or a lower extremity design. Talcs and powders are not to be used and fabric softeners should not be used in the laundry on undergarments because it can lead to skin irritation. The orthosis should be washed daily with mild soap and water and patted dry with a towel. Velcro straps can be cleaned with a toothbrush to remove lint deposits.

Before an orthosis is delivered, the patient and family must be instructed about the "weaning" schedule (Table 1) . We recommend that patients receiving a thoracolumbosacral orthosis, or body jacket, wear the orthosis for a half hour followed by a half hour out of the orthosis for inspection of the skin. If there is no redness or other skin problem, the half hour on-off schedule is repeated two to three times the first day at hourly intervals. Instruction in a sequential weaning program is also essential before the delivery of lower extremity orthoses to help prevent skin problems which can easily occur about the foot and ankle in patients with lower levels of paralysis. It must be remembered that although patients with a sacral level lesion have good motor control and can walk, often independently, they nevertheless lack full protection sensation and have a greater incidence of ulceration about the foot than patients with higher level lesions.

If the skin appears red after an orthosis is worn, one should observe whether the redness blanches on pressure and if there is a quick, brisk, capillary refill. If the redness doesn't disappear within 20 minutes or if the skin is dusky or cyanotic or if there are vesiculations or breaks in the skin, the orthotist and physician should be consulted. The orthotist and physician should also be consulted if other brace-related skin problems develop, includiing blisters, rashes, open lesions or infections.

In summary, before a patient is sent home with a new orthosis, it is important to assess skin integrity and the fit of the orthosis. The patient's activities of daily living and the weaning schedule for orthosis wear must be reviewed with the patient and family. It is important that the family understand the prerequisites of proper skin care, the weaning schedule and the need for appropriate follow-up appointments.

Before 1940, the mortality rate associated with myelomeningocele approached 95 percent. Today, the majority of patients born with myelomeningocele can be expected to live into adulthood but these patients have complex disorders that require coordinated care by a multi-disciplinary team. However, with a thorough understanding of the causes and prevention of potential problems, greater patient satisfaction will be obtained in the interdisciplinary management of these patients.

John V. Banta, M.D., is with the Department of Orthopaedic Surgery at Newington Children's Hospital, 181 East Cedar Street, Newington, CT 06111.

Robert Lin, C.P.O., is with the Department of Orthotics at Newington Children's Hospital.

Mary Peterson, M.S.N., R.N., is with the Department of Nursing at Newington Children's Hospital.

Theresa Dagenais, M.S., R.P.T., is with the Department of Rehabilitation Services at Newington Children's Hospital.

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