Obesity in Patients With Spina Bifida

Obesity in Patients With Spina Bifida


About 1,500 babies in a year are born with spina bifida. The condition usually manifests in the lower back and can be classified into three types, depending on the severity.

  • Spina bifida occulta is the mildest form that affects five percent of people with SB. Its manifestations in the baby might either be in the form of a dark spot, a hairy patch, a dimple, or swelling on the spine. The condition, however, can go undetected until the baby becomes an adult.

  • Meningocele presents as a herniation wherein there’s a sac of fluid on the back of the infant.

  • Myelomeningocele manifests as an open birth defect and it’s the most common yet most severe form among the three types.

Some patients, particularly those with spina bifida occulta, might experience little disability and medical problems. Others, however, might have health complications, such as poor bladder and bowel control, hydrocephalus, and issues with mobility or paralysis.

Diagnosing Spina Bifida

Doctors diagnose meningocele and myelomeningocele as soon as the baby is born. In this case, the family must be referred to a specialist since the baby will need lifelong medical care.

The diagnosis of spina bifida occulta, on the other hand, might arise because of other conditions since there can be no visible signs of the birth defect. Occulta actually means “hidden” and the patient might only learn about it after an X-ray for a separate illness.

Among the symptoms of spina bifida occulta include:

  • Frequent back pain that can extend to the legs

  • Weakness in the legs

  • Numbness in the back

  • Scoliosis

  • Deformities of the feet and legs

  • Sensitivity on the back, especially if there’s pressure

Spina Bifida Concerns for the Obese

Being obese poses a huge problem for people diagnosed with spina bifida as the extra weight limits a person’s mobility to complete his or her day-to-day activities. When mobility is limited, the patient won’t have much independence to perform tasks and take care of personal needs. He or she might also burn less calories which can result in further weight gain.

Unfortunately, young people with spina bifida become less and less active as they grow up, thus raising the risk of developing obesity. According to experts, the prevalence of obesity in children with spina bifida ranges from 28 to 50 percent and in teens and adults, 34 to 64 percent.

Obesity can lead to a host of other health complications like heart disease, diabetes, fatty liver, and various orthopedic problems. Secondary complications include muscle loss, depression, and pressure sores due to being in bed or sitting most of the time. It’s important, therefore, for family members to come together to ensure that the patient’s quality of life is optimal despite the birth defect.

Managing and Treating Spina Bifida If Obese

An accurate monitoring of weight with a reliable bathroom scale is essential to track one’s weight (and weight loss progress). The basics of a balanced and healthy diet should also be taught to a child with spina bifida early on so that he or she can develop good eating habits and have an in-depth understanding of how healthy food can benefit their condition. Physical activities and exercise play an important role as well – everything from swimming and aquatic therapy, to exercising with a stability ball or even playing sports adapted for wheelchair use.

Healthy eating and routine fitness also help address overweight issues in adults who have just been diagnosed with spina bifida occulta. They must make this a priority to manage the condition, especially since occulta has no known medical treatment.

Treating meningocele and myelomeningocele, on the other hand, will require surgery as an infant. Follow up surgeries might be necessary to close the defect in the spinal cord and prevent infections.

People with spina bifida, whether diagnosed later in life or following extensive surgeries as an infant or child, are commonly found to have limited capacity to do aerobic exercises because their energy levels are lower. Doctors acknowledge that they do have special needs, thus they need consistent assessments and consultations with their primary care doctor and other specialists such as a neurologist, orthopedic doctor, or urologist to determine the best care option.

In recent years, many children diagnosed with spina bifida have successfully transitioned and survived with their birth defect as adults with the help of their healthcare providers.

Some Spina Bifida-Related Orthopedic Problems

Some Spina Bifida-Related Orthopedic Problems

Many people who suffer from spina bifida and other chronic illnesses know all too well that the corollary consequences of the disease may be almost as bad as the condition that caused them. Since it is a birth defect that involves the spinal cord, it’s not surprising that spina bifida often causes some orthopedic issues. Some specific causes include excess pressure on the spine, poor blood circulation, subtle neurological changes, and edema (swelling) in the lower extremities.

The good news is that the resulting orthopedic illnesses can be quite manageable given the proper approach.

Arthritic Knees

For the most part, the advanced treatments available to spina bifida victims enable them to live much longer and more active lives. Unfortunately, as its victims progress into adulthood, spina bifida sometimes creates new problems that prior generations did not have to deal with.

Spina bifida creates a lifelong wobbly gait that often places excess pressure on the lower joints, particularly the knees. The stress often creates osteoarthritis, a degenerative condition that involves chronic inflammation of the knee joint. That usually causes persistent pain and loss of mobility. Understandably, most people like to walk unassisted for as long as possible. The resulting stress on the knees when walking without crutches often makes arthritis worse.

To partially reverse this cycle and reduce dependence on pain medications that may aggravate other medical conditions, there are a number of non-medical arthritis remedies that have some very pleasant side effects.

  • Walking: Anything that involves moving stiff and painful joints may not seem like a good idea, but as little as thirty minutes of reasonably brisk walking per day substantially loosens knee joints, relieving discomfort and adding range of motion.

  • Tai Chi/Yoga: These slow-movement exercises essentially combine the physical benefits of walking with the mental benefits of meditation and relaxation. If arthritis sufferers focus on something other than their pain for a few minutes, there is often a long-lasting effect which is roughly the same as an opioid pain pill.

  • Diet: Many foods, such as fish, nuts, olive oil, and whole grains, are natural anti-inflammatories. The effect will not be immediate, but relief builds up over time. These foods also have benefits in terms of health management and weight management, which leads us to. . .

  • Weight Control: Anything that relieves the pressure on knee joints is a good thing. Even a few pounds per month make a substantial difference. Moreover, there is emerging evidence that fat cells contain various toxins. These substances may especially create significant problems for people with other medical conditions, such as spina bifida.

Spina bifida-related knee osteoarthritis cannot be cured or even treated effectively, but its symptoms are very manageable.


Surgery can often correct this unnatural sideways curvature in the spine, provided that the condition is diagnosed soon enough. Other related conditions that pediatric surgery may resolve include:

  • Kyphosis (hunchback),

  • Unilateral talipes equinovarus (one club foot), and

  • Bilateral talipes equinovarus.

In other situations, strengthening the muscles near the base of the spine may correct these conditions without surgery or at least provide some relief if surgery is not an option.

Arthritic Shoulders

Some spina bifida patients who are only in their 20s have significant problems due to arthritic shoulders. Something as routine as a torn rotator cuff, which is usually not much more than an inconvenience, can necessitate long-term care. In other cases, the shoulder and other joints become hyperextended because many spina bifida patients have little or no sensation in these areas. The effect is even worse if the patient uses the shoulders to ambulate.

Frozen shoulder is one of the more common spina bifida-related shoulder ailments. This condition is extremely painful, and the inflammation also causes loss of mobility. Extensive physical therapy usually alleviates the symptoms of frozen shoulder and other such conditions.

Most spina bifida patients are willing to accept side ailments if it means a longer and more active life. Some common-sense approaches make these conditions more bearable, further tipping the scales in the patient’s direction.


Travel Tips for People with Physical Disabilities

Travel Tips for People with Physical Disabilities

Millions of people will heading out on the roads and flying in planes this upcoming holiday season for vacation and family get-togethers. If you experience a physical disability that limits your own mobility or functionality, chances are travel poses a unique challenge for you. Don’t miss these essential tips for traveling smarter this holiday season:

Plan Ahead

Don’t get caught off guard when it comes to traveling and knowing which places have the best accessibility for you. Use free online tools like DisabledGo to search and find disability-friendly places (hotels, restaurants, etc), and call ahead to ask questions about accessibility, i.e. does your hotel have wheelchair-accessible doorways?

Using the restroom on a road trip or when flying can be a huge obstacle for people with physical disabilities. When traveling by car, plan to stop at easily accessible rest stops, petrol stations, and restaurants where possible to make toileting easier, and check with your airline about accessibility to plane bathrooms (i.e. moving your seat closer to one).

Stick to Your Routine

While travel can have its share of surprises and spontaneity, it’s critical to try and stick to your routine as much as possible. Your sense of stamina is very much dependent on the schedule your body is used to, so try and work this knowledge into your plans and itineraries accordingly.

For example, if you usually nap for 30 minutes in the afternoon, try to not skip napping during your holiday travels. Instead, work family get-togethers and sight-seeing around your rest times so that you can stay in peak condition when you are active as well as avoid becoming fatigued or worse, sick.

Maximize Comfort

Ensure that your prolonged ride in a car, plane, or train doesn’t take its toll on your body. Extended periods of time spent sitting in an atypical seat like the car or a train or plane can place added pressure on the spine and stress lower back and neck muscles.

Aids like memory foam seat cushions for the car can provide extra support and weight distribution to your coccyx and rear, while lumbar spine cushions or neck pillows can support good spine alignment and prevent muscle strain. Avoiding common aches and pains when traveling can mean the difference between you enjoying your vacation or not.

Avoid Inclement Weather

Getting out of the car in a giant rainstorm is difficult enough, much less when you are using a mobility aid like a wheelchair or walker. Inclement weather on the road can be dangerous for driving and for navigating slippery parking lots and walkways on your stops to fill the car with petrol or use the restroom.

Apps like DarkSky and Weather.com give you quick, accurate forecast data to help you gauge your proximity to storm systems or other bad weather. Use your smartphone or other mobile device with data to access real-time weather reports when you are traveling by car or train. And double check the upcoming forecast for your destination when traveling by plane to make sure you pack appropriately.

Keep Snacks Accessible

Staying alert, hydrated, and happy while you travel often times comes down to getting enough to eat and drink. When you have mobility limitations, making sure healthy snacks are within reach so you don’t have to get up to retrieve food or water is a must.

Keep travel snacks in your day pack, purse, backpack, or other personal item and stow away by your feet if possible. And ditch processed snacks loaded with salt and sugar – they’ll only make you feel bloated and lethargic. Aim to pack foods like carrot sticks, hummus, cheese, apple slices, nuts, and whole grain tortilla chips with you instead.

Additional Considerations

Before traveling anywhere, you will want to confirm coverage and benefits of both your health and travel insurance. In the case of a medical emergency, you will definitely want to know that you are covered for medical expenses no matter where you are. Unexpected natural disasters also present problems as it becomes much harder for those with disabilities to evacuate or seek assistance. Find out if there are evacuation protocols in place with local agencies where you are going for people with disabilities.

Spina Bifida Occulta Pictures & Images

Spina bifida occulta is the simplest form of the spina bifida in which only the bony defect is present but no protrusion of meninges (protective layers covering the spinal cord) and the spinal cord. Since images and videos play a key role in learning about and learning how to diagnose the condition, we will focus on  visual images in this article.  Therefore, this article is based on some spina bifida occulta pictures with explanations related to the causes, signs and symptoms, diagnosis and treatment of spina bifida occulta.

Spina Bifida Occulta Pictures2

Figure 1: In this picture, hair tuft is shown on the skin just above the vertebra with a bony defect. A red circle is made around the hair tuft. This is the most common sign of spina bifida occulta. It is the tuft of hair on the lower back of a child that makes the neurosurgeon think about spina bifida occulta (Source: www.medical-dictionary.thefreedictionary.com)

Spina Bifida Occulta Picture2

Figure 2: Spina bifida occulta is a neural tube defect that appears in the fetus at 28th days as shown in this picture. The neural tube is not closed properly, perhaps  due to the deficiency of folic acid in the mother’s blood. Folic acid is a vitamin that is helpful in the metabolism of proteins needed for the proper closure of the neural tube to become spine in a developing baby. Note the red circle in the right hand picture where the defect is shown in the spine. (Source: www.glogster.com)

Spina Bifida Occulta Pictures2

Figure 3: In this picture, a dimple is shown on the lower back in the midline. A red circle is made around the dimple. It is also a common sign of spina bifida occulta. Due to a bony defect on the posterior side of vertebra, a space develops and skin is depressed at that point making a dimple on the skin. (Source: www.spinabifidainfo.nl)

Spina Bifida Occulta Pictures2

Figure 4: In this picture another sign of spina bifida occulta is shown. A tuft of hair on the lower back is one of the typical signs of spina bifida occulta. A red circle is made around the hair tuft on this picture. (Source: www.synapse.koreamed.org)

Spina Bifida Occulta Pictures2

Figure 5: In this picture, an abnormal curvature of the spine is shown which is called lordosis. This is also a sign of spina bifida occulta. Lordosis develops in the patients suffering from spina bifida as a space is present in the spinal vertebra and skin depresses due to this space and the curvature of the spine becomes irregular. (Source: www.gopixpic.com)

Spina Bifida Occulta Pictures2

Figure 6: This is a picture of an x-ray of a patient with spina bifida occulta. A red circle is made on the x-ray around the bony defect. Spina bifda occulta is a hidden disease and it is often diagnosed accidently while performing x-rays for another problem. (Source: www.commons.wikimedia.org)

Spina Bifida Occulta Pictures2

Figure 7: Another x-ray of a patient of spina bifida occulta in which bony defect is shown. Note the red circle made around that defect. A red arrow is indicating the exact position of defect on the x-ray film. (Source: www.plkshooter.hubpages.com)

Spina Bifida Occulta Pictures2

Figure 8: This is the picture of CT scan of the spine of a patient with spina bifida occulta. When the diagnosis is not confirmed on x-ray film, a CT scan of the spine is advised to confirm the diagnosis. A red circle is made on the picture where the bony defect is evident in vertebra. (Source: www. en.academic.ru)

Spina Bifida Occulta Pictures2

Figure 9: In this picture, the bony defect in the vertebra is shown. A red circle is made around the defect to indicate the exact position of spina bifida occulta. (Source: www.bioklinika.lv)

Spina Bifida Occulta Pictures2

Figure 11: This is another picture of an ultrasound scan of the fetus while in the mother’s womb where a defect is present on the lower end of the spine through which communication is present between the spinal canal and amniotic fluid. Alpha fetoprotein is an enzyme that is present only in the spinal canal. Due to the communication between spinal canal and amniotic fluid, alpha fetoprotein enters the amniotic fluid from where it is transported to the mother’s blood. This, raised level of alpha fetoprotein in the mother’s blood indicates a neural tube defect. A red circle is made on the picture to point out the exact position of the neural tube defect in the fetus. (Source: www.feto3d.com)

Spina Bifida Occulta Pictures

Figure 12: This is the picture of magnetic resonant imaging (MRI) of the spine of a person that has spina bifida occulta. MRI is the investigation of choice. When spina bifida occulta is not diagnosed by any investigation i.e. x-ray, CT scan or ultrasound, then MRI is the final investigation that is done to diagnose spina bifida occulta. A red circle is made in this slide of MRI to identify the point where the defect in spine in present. (Source: www.radiozen.wordpress.com)

Spina Bifida Occulta Pictures

Figure 13: This is another picture of an MRI scan of a patient with spina bifida occulta. A bony defect in the vertebra is shown. A red circle is made around the specified area on the image that has a defect in vertebra. Depression on the skin is also marked in the red circle. This is seen in the MRI due to high quality of imaging. (Source: www.yhoccongdong.com)

Spina Bifida Occulta Pictures

We hope that the above collection of spina bifida occulta pictures will help you a lot!


  1. Horton D,Barnes PPendleton BDPollay M. Spina bifida occulta: early clinical and radiographic diagnosis. J Okla State Med Assoc 1989;82(1):15-9.
  2. Gregerson DM. Clinical consequences of spina bifida occulta. J Manipulative Physiol Ther 1997;20(8):546-50.




Spina Bifida Occulta Symptoms (complications, signs, treatment)

Spina bifida (SB) is a type of neural tube defect (NTD) in which spine fails to enclose some of its bony components. SB is of many types. Spina bifida occulta (SBO) is one of the types of spina bifida. It is the simplest and mildest type of SB. Most of the time, it is missed or not diagnosed because it is covered by skin and no external deformity is seen. The meaning of occulta is hidden. It is hidden by the skin so it is called spina bifida occulta. The only finding in this condition is a small dimple on the skin, tuft of hairs or a red mark on the skin at the site of spinal defect. It can affect any vertebra in the spine but it usually affects the lower vertebra (lumber) of the spine.

It is often found accidently in a person when an x-ray, CT scan or MRI to diagnose another  problem is performed for that person.  Nothing but a small portion of missing vertebra is  shown in the x-ray.

SBO is the most common type of spina bifida, but the prevalence of this disease is still not known properly. According to surveys, about 22 percent to 23 percent people are living with SBO in the United Kingdom.

Complications and Symptoms

Spina bifida occulta is such a mild and simple type that it seldom shows symptoms that are  associated with complications. Although there is a mild chance that a patient with  SBO presents with a slipped disc  and complains of pain radiating to the lower limbs. A slipped disc  applies pressure on the associated spinal nerves [1]. Due to compression of spinal nerves, pain radiates to that region from where these nerves send signals. If a person during his or her childhood life has no complaint of SBO, he/she will never have any complaint in his adulthood life.

In SRO plates of bones that are helpful for the formation of the spinal arch cannot fuse completely. This form of spinal defect usually involves the one vertebra which often is the lowest vertebra of the spinal column. Because this form does not have any effect on the spinal cord or spinal nerves, there is no abnormality or problem associated with bladder, bowel and legs.

However, some patients present with other problems because these problems are related to condition where vertebra is not formed properly. For these people, this problem is more extensive with the spine as compared to the SBO.

If more than one vertebra is involved in the spina bifida lesion, it is referred as occulta spina dysraphism (OSD). This problem may cause the back of person to be little short and rigid. The usual curvature of the back may be overstated and there is abnormal and unusual curvature of the spine. There may be visible bony protrusion in the central line of the back of patient. A bony peg may be formed at some place in the spinal canal and a fibrous band may be formed across it dividing it in two parts. The spinal cord may become extremely wide due to the presence of unusual fibrous tissue in the spinal canal. Due to the disturbance of the spinal canal, the function of bladder, bowel and lower limbs may be affected.

Some other things that are related to this site and influence the normal function of person are given below:

  • Disturbance of the spinal cord and spinal nerves coming out of the spine due to the tough (fibrous) tissues
  • Tumors related to fat cells in the spine, beneath the skin or surrounding tissues
  • Cysts around the spine under the skin
  • Cysts filled with cerebrospinal fluid (CSF) in the affected site of spine
  • Tethered spinal cord or attached to the walls of spinal canal

These structures are not visible and present internally. In addition to these structures, some signs are present on the skin and visible showing that there is underlying problem with the spinal cord. These signs are given below:

  • A tuft of hair on the lower back of person
  • A sinus tract visible on the skin from the skin surface down to the spinal cord
  • A mass under the skin that is visible externally
  • A undeveloped tail
  • A bluish colored swelling over the lower part of spine called “capillary haemangioma”. It is most commonly present over the back of head and not associated with any risk.

Effects of Occulta Spina Dysraphism

As spinal nerves and roots are affected at the spot of lesion, it is said that any problem or disorder from the waist and below in the spine is most commonly due to OSD. The symptoms are mild, moderate and severe depending upon the amount of neural tissue association. The most common symptoms are mentioned below [2]:

  • Muscular weakness of legs or feet
  • Sensory loss in lower limbs
  • Foot deformity
  • Gait problems
  • Problems associated with urinary tract system, i.e. incontinence
  • Problems associated with bowl
  • Abnormal curvature of the spine
  • Back pain

Incontinence problem

If a child has incontinence, he/she can present with the problems given below:

  • Bedwetting that is still present in the child after toilet training
  • Not having awareness of when to pass the urine
  • Inability to control the urine even for a few seconds
  • Continuous dribbling of urine even after passing the urine
  • Recurrent urinary tract infections (UTIs)

Lower Limb Problems

Most patients suffering from OSD have no problems with their lower limbs (muscles or bones). If any problem appears he/she is referred to an orthopedic surgeon for proper management.

Back Pain

Back pain is the most common complaint of every person in our society. Back pain due to OSD is difficult to identify and should be investigated to know the actual cause.

Spina Bifida Occulta Symptoms

This is a picture of spina bifida occulta. A red circle is made around the tuft of hair present on the lower back of patient (Source: www.hello-berlin.net)

Spina Bifida Occulta Symptoms

This is an x-ray film of spina bifida occulta.  A red circle is made around the bony defect present in lumbar region (Source: www. doubtnichts.wordpress.com).


1.     Srinivas S, Shetty R, Collins I. Symptomatic lumbar disc protrusion causing progressive myelopathy in a low-lying cord. Global Spine J 2012; 2(2):115–8,

Tavafoghi V, Ghandchi A, Hambrick GW Jr, Udverhelyi GB. Cutaneous signs of spinal dysraphism. Report of a patient with a tail-like lipoma and review of 200 cases in the literature. Arch Dermatol 1978;114(4):573-7.

Spina Bifida Surgery in Utero

Spina Bifida (SB) is a disease in which a defect is present in the bony component of vertebra. It is a congenital disease which occurs before birth. It is diagnosed by screening tests during pregnancy. It is worrisome for a pregnant woman when SB is diagnosed in her developing baby. She worries about the pregnancy, fetus, and the congenital disease of the baby.

One of the options to manage SB is the termination of the baby and that could be very painful for the mother. Now, new options are available for treating SB in utero as surgery has been started in utero to treat spina bifida [1].

Written below are the details of every step of surgery that is performed to correct the SB during pregnancy [2]:

First of all anesthesia is selected for a patient. There are two options: general anesthesia and spinal anesthesia. General anesthesia has many complications, such as,  fetal distress because oxygen saturation is decreased during general anesthesia. Spinal anesthesia is the safest anesthesia for this type of surgery.

Spinal anesthesia is given while the patient is sitting on the operation table. Before anesthesia is given, all the baseline investigations are carried out to check whether any problem is present or not. Then systematic evaluation of the patient is done. If there is no problem,, then the patient is ready for anesthesia to be given.

The patient is brought to the operation theatre and laid on the operation table. All vitals, i.e. pulse, blood pressure, temperature, respiratory rate and oxygen saturation are checked. Folley’s catheter is placed. The patient is preloaded with intravenous fluids. In a sitting position, the back of the patient is exposed and antiseptic measures are performed. An accurate spinal space is identified. A specialized long thin needle called a lumbar puncture (LP) needle is inserted into the located space. When cerebrospinal fluid (CSF) dribbles out of the needle, an injection of anesthesia is injected. After that LP needle is removed and the position of the patient is changed to a supine position immediately,  to avoid falling of blood pressure. Vitals are strictly monitored during the operation.

When the effect of anesthesia appears, the surgeon embarks on the surgery. The patient is exposed and antiseptic measures are performed. An incision is made in the patient’s abdomen where an incision for a  C-section is made. The skin and the tissue below the skin are cut. Muscles are retracted. The uterus is identified and located. It is pulled out of the abdominal cavity. And now, the main steps of surgery commence. The position of the baby is located with the help of ultrasound and the baby is positioned in such a way that  surgery can be performed easily. It is a very delicate surgery; therefore, fine surgery is required.

Magnifying glasses are required to perform this procedure. Sutures used during the surgery are so tiny that they cannot be seen with the naked eye. A special type of cannula called Tulipan-Bruner’s trocar is used to drain the protective fluid around the unborn baby (amniotic fluid) and to place other surgical instruments inside the uterus. Trocar is placed on the uterine wall and amniotic fluid is drained to a warmer. Amniotic fluid is saved in a warmer because it is to be placed again into the uterus after completing the procedure.

When the baby is positioned as needed,  a small and tiny incision is made on the uterus to open the uterus. Now a  tiny baby is in your hand. The defect in the lumbar region on the back of the baby is identified. It is a small jelly like sac. An ultrasound probe is placed on the sac and the type of defect is assessed. An incision is made on the out-pouching. The spinal cord and spinal nerves are positioned back into the spinal canal. The spinal cord is covered with its sheath. The sac is closed with tiny sutures. The bony defect is repaired. The skin of the baby is closed with sutures. Now the main surgery to repair the defect is completed. The baby is placed back into the uterus. Now uterus is ready for closure. Before closure of the uterus, the amniotic fluid that is kept safe in warmer is placed back into the uterus. Now the uterus is closed with fine absorbable sutures.

After closing the uterus, it is placed back into the pelvis and positioned properly. All the pedicles are assessed. All bleeding and oozing of blood is secured. Now it is time to close the abdominal cavity. The peritoneum is stitched. The retracted muscles are also stitched. Fibrous tissue and the tissue below the skin are stitched. In the end, the skin is closed with fine sutures. Antiseptic dressing is placed  on the wound.

On the completion of the surgery, post-operative anesthesia assessment is made. Pulse, blood pressure, respiratory rate and oxygen saturation are checked. The response of the patient to the stimulus is checked. If the patient  is responding well then she is shifted to the recovery room.

This is, a full description of in utero surgery for spina bifida.  It is a very difficult procedure. Very fine surgery is required to perform this operation.

Here are some pictures of  the surgery for the repair of spina bifida while the baby is in mother’s womb.

Spina Bifida Surgery in Utero

Figure 1: This is a picture of spina bifida surgery in utero. In this picture, the uterus is shown outside of the abdominal cavity with an incision made on it. The tiny hand of the fetus is out of the uterus to shake it with the surgeon’s hand to appreciate him for his achievement (Source: www.singularityhub.com)

Spina Bifida Surgery in Utero

Figure 2: In this picture, the spina bifida defect repair is shown. A  red circle is made around the procedure. The spinal cord is placed into the spinal canal and the spinal covering (duramatter) is stitched (Source: www.spinabifidaeffects.com).

Spina Bifida Surgery in Utero

Figure 3: In this picture, the abdominal cavity is opened and the fetus with a spina bifida sac is shown in the uterus. For fetal surgery the uterus is opened and the fetus is placed in such a way that spina bifida sac comes in view of the surgeon. A red circle is made around the sac and incision of the uterus (Source: www.reference.medscape.com).


1.     Adzick NS. Fetal surgery for spina bifida: past, present, future. Semin Pediatr Surg2013;22(1):10-7.

2.     Foster MR. Surgery for spina bifida. Available at: http://emedicine.medscape.com/article/2040493-overview. [Last updated May 30, 2014; Accessed on Nov 29, 2014]

Spina Bifida Tests (blood, fetoprotein, ultrasound, Amniocentesis)

Spina bifida is a form of neural tube defect (NTD) that develops in the fetus during intra uterine life. Generally, every mother seems worried about her child whether the baby is normal or suffering from any congenital abnormality. Various screening spina bifida tests are performed during pregnancy to assess the baby while it is growing in its mother’s womb. If intrauterine screening tests are positive for  spina bifida, many other confirmatory tests are also carried out because sometimes these confirmatory tests are positive but the baby is delivered as normal and has no defect. Even though these tests are negative, there is also a chance of having spina bifida in the baby but the chance is very low. Thus, to confirm the initial findings, false negative and false positive tests must be ruled out by performing some additional screening tests.

Blood tests for spina bifida

The following blood tests are performed for screening of spina bifida in the antenatal period, the period before the baby is born:

Maternal serum alpha fetoprotein test

This is a very common test used to check the NTDs in the developing baby. In this test, the mother’s blood is drawn and sent to the laboratory where alpha fetoprotein is checked in the serum of the blood sample [1]. Alpha fetoprotein is a protein that is produced by the baby in the cerebrospinal fluid. A small amount of it crosses through the placenta and appears in the mother’s blood. Normally it is not detected in the mother’s blood. When the baby is with NTDs, alpha fetoprotein found in the CSF achieves a free communication with the fluid which baths the child in uterus (amniotic fluid). From amniotic fluid, it crosses the placenta to reach the mother’s blood. High level of alpha fetoprotein detected in the serum of mother’s blood indicates a NTD is present in the fetus. As alpha fetoprotein is also raised in many other conditions such as liver cancer, testicular tumors and twin pregnancy. If a high level of AFP is detected, the test is repeated after some duration. If again the level is raised in the serum of mother’s blood, then confirmation is done by performing some other tests and ultrasonography.

Other blood tests

Other blood tests performed for screening of the spina bifida include the level of different hormones such as serum beta HCG level, inhibin A level and estriol level. These tests are called triple screen. These tests are not specific for NTDs.


Ultrasonography is also used to screen the fetus for spina bifida [2]. If AFP level is found high in the mother’s blood, the obstetrician goes for ultrasonography to assure the presence of abnormality. With the help of the ultrasound scan, age of the developing baby and the total number of babies present in the uterus are identified. These two factors also disturb the AFP level. So, it must be determined why the AFP level is high. If gestational age is accurate and fetus is alone in the uterus, then high level of AFP is most probably due to spina bifida. High quality ultrasound scans by an expert sinologists get good images of the fetus in which spina bifida is identified. Severity of the spina bifida is also identified by the ultrasound scan of baby. It is the safest method to identify the problem for both mother and fetus. Ultrasound waves do not produce any harmful effects on the body of mother or the fetus. Most commonly ultrasound scans are performed two times during antenatal period. The first scan is done around the 8th to 14th week of gestation. During this scan, any problem with the spine of baby is indicated if the defect is of a severe type.

The second ultrasound scan is usually done around the 18th to 21st week of pregnancy. This scan is called anomaly scan. The main purpose of this scan is to identify any physical problem with the fetus. In this scan, spina bifida is easily identified.


Amniocentesis is the test that is performed on the amniotic fluid to detect the level of alpha fetoprotein in amniotic fluid. Amniotic fluid is obtained under the guidance of ultrasound. After aseptic measures, probe of the ultrasound is placed on the abdomen of the mother. The mother is placed in lateral position. In the position, maximum fluid collects on one side. The position of the fetus is assessed by the scan. A needle is inserted through the abdominal wall under the guidance of ultrasound. The needle reaches into the amniotic cavity. Amniotic fluid is aspirated and sent to the lab for the measurement of alpha fetoprotein level in amniotic fluid. Only a small amount of alpha fetoprotein is normally present in the amniotic fluid. A high level indicates the NTD in the fetus. The high level of alpha fetoprotein results because there is no skin present on the spine to cover it due to open spina bifida and hence alpha fetoprotein is leaked to the amniotic fluid. This test is mildly risky because there is mild risk for termination of pregnancy.

Spina Bifida Test

Figure 1: This picture was taken by ultrasound scan. In this picture, the fetus is shown in the uterus. A red circle is marked around the defect. Open neural tube defect is shown in the picture. Through this defect, free communication develops between the neural tube and amniotic sac (Source: www.sonoworld.com).

Spina Bifida Test

Figure 2: This is a picture of the amniocentesis test. In this picture, a needle is passed through the abdominal cavity to the amniotic cavity.  With the needle amniotic fluid is being taken to measure the level of alpha fetoprotein (Source: www.irishhealth.com).

Spina Bifida Test

Figure 3: This is the picture of ultrasound guided amniocentesis. A needle is passed through the abdominal cavity to get amniotic fluid for analysis. The ultrasound probe is placed on the abdominal wall to assess the position of baby and amount of amniotic fluid (Source: www. pennstatehershey.adam.com).


  1. Bernard JP, Cuckle HS, Bernard MA, Brochet C, Salomon LJ, Ville Y. Combined screening for open spina bifida at 11-13 weeks using fetal biparietal diameter and maternal serum markers. Am J Obstet Gynecol 2013;209(3):223.e1-5.
  2. Bernard JP, Cuckle HS, Stirnemann JJ, Salomon LJ, Ville Y. Screening for fetal spina bifida by ultrasound examination in the first trimester of pregnancy using fetal biparietal diameter. Am J Obstet Gynecol 2012;207(4):306.e1-5.

Tethered Cord Symptoms

Tethered cord syndrome (TCS) is a disorder in which spinal cord is attached to the spinal canal during its developmental period. Normally spinal cord is not attached to the spinal canal and is freely mobile in the spinal canal. It can move up and down freely with the growth of the baby and during stretching or twisting the spine. In tethered cord syndrome, spinal cord is attached to the lower end of the spinal canal and stretch is applied on the spinal cord when the spine is bent causing tearing of the spinal cord and any spinal nerves emerging from the spinal cord. It is associated with all types of spina bifida. The signs and symptoms of the TCS are much similar to  spina bifida occult. Most often, signs and symptoms do not appeared and are minimal. Signs and symptoms are age related so they are different depending on the age groups. Surgery is the only option for symptomatic TCS and it is mainly centered on the stabilization of the neurological functions of the affected body parts.


Symptoms in Babies

The symptoms in babies suffering from this condition are related to their developmental milestones. For example, their motor reflexes are delayed. The baby is not active and cannot attain the motor milestone at the usual age.  Some signs are also visible on the baby with TCS. These signs are mentioned below [1]:

  • Abnormal growth of hair on the back of the baby at lower end of the spine
  • Abnormal swelling or mass of fatty tissue on the back of baby
  • A swelling with bluish discoloration on the back of baby in midline. This type of swelling is most common in the head region, but is not dangerous.
  • A small sinus tract on the lower back of the baby in midline

Symptoms in Adults

The tethered spinal cord in adult is most often encountered due to the presence of some abnormal tissue in the spinal cord. Therefore, spinal cord is stuck to the tissue and cannot move freely. Some of the common symptoms are given below [2]:

  • Severe back pain radiating to the lower limbs and groin area
  • Abnormal length of the affected limb with the length of the other unaffected limb
  • Abnormal gait of the patient
  • Sensory loss of lower limbs
  • Numbness and muscle weakness of both limbs
  • Urinary tract system related problems
  • Neurological symptoms
  • Bowl control problems
  • Abnormal curvature and twisting of the spine (scoliosis)


Muscular pain in the back is the most common and striking symptom of the tethered cord syndrome. It radiates to the area where spinal nerves are affected, stretched or compressed. Most affected areas include lower back, groin, premium and lower limbs. Pain can be caused by several other reasons; therefore, all possible causes must be ruled out to offer proper treatment.

Abnormal Leg Length Ratio

The length of the affected limb is decreased as compared to the normal unaffected limb due to the loss of nerve supply to the muscles of the affected limb. Muscles become paralyzed and shorter in length and the leg length ratio is altered.


Gait of a person tells many things. Abnormal gait may be associated with TCS as the effected nerve supply to the muscles of leg causes them not to work properly.

Sensory Loss of Lower Limbs

Sensations over the lower limbs are affected in TCS because spinal nerves are damaged due to stretching of the spinal cord and halted nerve supply.

Numbness and Muscle Weakness of Lower Limbs

Numbness and muscle weakness of lower limbs are common complains of a person with TCS. The reason behind this complaint is the compression of spinal nerves due to the presence of abnormal fatty tissue around the spinal cord. This abnormal tissue halts the proper nerve supply to the muscles of the lower limbs causing muscle weakness and numbness, and hence reduced or defective performance.

Neurological Symptoms

Neurological symptoms are a mixture of findings; the neurons which come from the brain to the spine and the neurons which reach to the organs from the spine can be affected. In TCS, reflexes are exaggerated, muscles are flaccid and planter responses are also abnormal.

Urinary Tract System Related Symptoms

The urinary tract system is commonly affected by TCS. Usually, the patient presents with urinary incontinence or retention. According to medical sciences, the nerve supply of urinary bladder comes from the lower sacral segments of the spinal cord. In TCS, spinal nerves of this region are affected and their supply is disturbed. Common complaints associated with urinary tract system are given below:

  • Continuous dribbling of urine
  • Frequency (multiple times urge to pass urine in a day)
  • Urgency (decreased control over the bladder to store urine)
  • Nocturia (urge of urine during sleeping hours)
  • Bedwetting even after completing training to go to the toilet

All the above symptoms may also be associated with other spinal cord disorders.  So, tethered cord syndrome should be diagnosed properly.

Bowel Control Problems

Bowel movements are often found to be disturbed by TCS. Sometimes, bowel movements are decreased causing constipation and sometimes bowel movements are so exaggerated to cause fecal incontinence. Again these problems happen to occur due to damage to the spinal nerves contained in the spinal canal of the patients with TCS.

It is vital to diagnose the tethered cord syndrome in a proper and precise way as most of the symptoms of this syndrome are shared by spina bifida occulta.

For the reason of explanation, most of the symptoms of TCS are not found in all the patients. However, as the severity increases, the number of symptoms increases.

Tethered Cord Symptoms

Figure 1: This is a picture of MRI scan of spinal cord in which tethered cord is shown. A mass is compressing the spinal cord causing tethered cord syndrome (blue arrow). A red circle is made around the specified area of spinal cord where tethered cord is present. (Source: www.guide.ispneurosurgery.org)

Tethered Cord Symptoms

Figure 2: This is a picture of a sign of tethered cord syndrome. A small sinus tract is present on the lower back of the baby in the midline. This sinus has communication with the spinal canal. The red circle is made around the sinus in this picture. (Source: www. ispn.guide.com)


1.     Hertzler DA, DePowell JJ, Stevenson CB, Mangano FT. Tethered cord syndrome: a review of the literature from embryology to adult presentation. Neurosurg Focus. 2010 Jul; 29(1):E1.

2.     Lew SM, Kothbauer KF. Tethered cord syndrome: an updated review. Pediatr Neurosurg 2007; 43(3):236-48.

Tethered Spinal Cord in Infants (causes, symptoms, diagnosis, treatment, medication)


The spinal cord is the collection of nerves that carries messages between the brain and the body. When a baby is born, the spinal cord is the  same size as the spinal column. The bones of the back around spinal cord are called the spinal column. With the growth of a baby, the spinal column grows longer  than the spinal cord. This is why, the spinal cord moves freely inside the spinal column. But in some children, a part of the spinal cord is “tethered” or attached to a part of the spinal column and the spinal cord can’t move freely. This is called tethered cord.

As the child grows, the spinal cord is stretched due to the tethered part. Stretched nerves may not work properly, and this causes problems for the child.

Tethered spinal cord is a neurological disorder. This condition is difficult to diagnose because of its non-specific symptoms. Normally the spinal cord moves freely in the spinal column but in this condition, the spinal cord is stuck to another structure in the spine, such as, scar tissue due to an operation, to a bony structure or even the presence of a tumor. This condition affects spinal cords growth and its functional ability. It affects people of all ages, especially infants and young children. Most often, it is associated with congenital conditions like spina bifida and chiari syndrome. Although its proper treatment can result in complete recovery,  the problem is that, most often, it is under-diagnosed or misdiagnosed.

Tethered Spinal Cord in Infants

Figure 1. Diagram (Source: wc1.smartdraw.com)



Following is a list of causes:

  • Spina bifida
  • Chiari syndrome
  • Split spinal cord
  • Lipoma (a benign, fatty growth)
  • Tumor
  • A spine trauma
  • Spine surgery


Symptoms are age-dependent.

  • Adult children can experience pain in their back, leg, weakness in the lower extremities and fatigue while walking.
  • Bladder infections, urinary or fecal incontinence or retention, as well as, urinary hesitancy and urgency can be the symptoms of this condition.
  • Babies and infants may exhibit delayed motor functions, such as, late walking.
  • Dark or red spots or lesions, hairy or soft masses can be present on the back.
  • They may show symptoms like scoliosis.
  • Differences in the size of the legs or feet, and foot deformities are also seen.
  • Patient may exhibit deterioration in gait.
  • Patient may show skin discoloration.

Patients with untreated tethered cord will continue experiencing their symptoms, and these symptoms may worsen with the passage of time. Particularly in children, untreated tethered spinal cord may lead to paraplegia due to growth of spinal cord and loss of bowel and bladder function. Paraplegia is the condition when the affected baby cannot move his/her all four limbs. Chronic pain in legs and back of children is not common and should not be taken lightly.


It can be diagnosed by conducting or getting help from the following tests or investigations:

  • Spinal Magnetic resonance imaging (MRI)
  • Ultrasound
  • Computed tomography scan (CT scan)
  • Myleogram (an x-ray of the spinal canal)


It can be treated or managed as mentioned below:

  • Most often, this condition is treated by surgery. This is done to prevent the chances of neurologic deterioration. An operating microscope is used during surgery. The tethered structure is moved away from the spinal cord. However, it is necessary to kept in mind that the tethered structure should be removed because if the structure is bony or tumor, it can cause re-tethering of the spinal cord. Mostly, patients regain normal functioning ability after surgery.
  • Physical therapy may also help with managing the physical problems of a tethered spinal cord.


Tethered spinal cord is not treated with medication. However, for some children, pain due to this condition can be managed with one or more of the following types of medication:

  • Analgesics (painkillers): these drugs relieve pain.
  • Muscle relaxants: these drugs prevent painful spasms of muscles by suppressing the contractions. Also, medications may be helpful for bladder incontinence.

Tethered Spinal Cord in Infants

Figure 2. Differences Diagram



Surgery is generally performed only if there are clinical signs of deterioration. Studies reveal that surgical release of tethered cord in infants improve neurological, bowel and urological functions [1]. The surgery begins by opening the skin over the tethered area.  The myelomeningocele or bony vertebrae are removed to get better exposure of the spinal cord. The covering is then opened, and the spinal cord or other abnormalities are dissected away. Once the tethered structure is separated from all of its attachments, the coverings on the  back are closed.

The patient can show normal functioning ability within a few weeks. Recovery depends upon the degree of preoperative clinical deterioration. Following are complications that may happen to occur after surgery:

  • Infection
  • Bleeding
  • Decreased muscle strength or bladder or bowel function due to damage to the spinal cord or myelomeningocele

Many children require only one surgery. Usually, children improve or at least stabilize their level of functioning. However, there is a chance for the spinal cord to re-tether as the child gets older and for this reason it is important that they should be carefully monitored as re-tethering may occur during the growth period. Ten to 20 percent of the patients with this disability require more than one surgery.

Tethered Spinal Cord in Infants

Figure 3. Surgery images for tethered spinal cord (Source: www.pediatricneurosurgery.org)


Positive and negative aspects of Surgery

The good news is that tethered cord is a treatable condition, especially when diagnosed early in the child’s life. Surgery is the only treatment for this condition. Although surgery might not restore the functioning ability of damaged and deteriorated nerves it can stop further damage. Children may have normal life after treatment.

Spinal nerves are not for just one function. They receive messages from the body and send them to brain. So, the damage to the spinal cord may affect many other functions in the body.

Key points

  • Tethered cord means that the spinal cord cannot move freely inside the spinal column. The spinal cord is stretched.
  • This condition can cause problems with bladder control, bowel control, or walking.
  • This may be treated only with surgery.


1.     Bowman RM, Mohan A, Ito J, Seibly JM, McLone DG. Tethered cord release: a long-term study in 114 patients. J Neurosurg Pediatr. 2009;3(3):181-7.

2.     Mishra SS, Panigrahi S, Dhir MK, Parida DK. Tethered cord syndrome in adolescents: Report of two cases and review of literature. J Pediatr Neurosci. 2013 Jan-Apr; 8(1): 55–58.

Tethered Spinal Cord Surgery (procedure, medication, problems)

In a tethered spinal cord, the spinal cord is attached in the spinal canal and is unable to move freely in the spinal canal. A lot of causes are behind the tethered spinal cord. Several treatment options are available to treat this. Surgery is one of the options to manage it.

First of all, the patient must be  diagnosed properly to decide if surgery is the right decision.  The cause of the tethered cord syndrome (TCS) is evaluated because surgery is performed according to the cause of TCS. Surgery is more beneficial in early stages of life because damage of spinal nerves due to TCS is usually less in early stages of life. As the disease progresses the damage of spinal nerves increases. If left untreated, permanent or irreversible damage occurs. When damage is irreversible then there is no benefit of surgery as surgical intervention also has  complications.

First of all, the patient is prepared for surgery. During preparation, all baseline investigations are performed to identify any problem related to other systems. Checking of vitals depends upon the age of the patient. If the age of a patient is less than 13 years, pulse rate and respiratory are more important according to the anesthesia point of view while blood pressure is important in the patients with an age greater than 13. The respiratory system and central venous system is assessed thoroughly. General anesthesia (GA) is best for tethered spinal cord surgery. Anesthesia is designed to make the patient pain free. In GA, whole body is made pain free.

After assessing the patient and declaring him/her fit for anesthesia, the patient is brought to the operation theatre (OT). In OT, the patient is laid on the OT table. The injection of anesthesia is given through IV cannula to make the patient unconscious  with the effect of anesthetic injection. An endotracheal tube (ETT) is passed into the trachea (the tube which connects mouth to the lungs and helps in respiration) quickly. An oxygen mask is attached to the ETT for the artificial supply of oxygen to lungs. After doing all of this the  main surgery is started.

The patient’s position is changed from supine to prone because the spinal cord is approached through back. The affected area is exposed and antiseptic measures are performed on the exposed area.

To approach the spinal cord, laminactomy is performed first. Laminactomy refers to “a small piece of bone removed from the vertebra”. To do laminactomy, an incision is made in the skin.  The muscles and tissues under the skin are separated. Vertebra is exposed. A small piece of bone is removed from the vertebra. After removal of the bone the  spinal canal is approached.

When an approach is made to the spinal canal, the surgeon must identify the spinal cord and spinal nerves.  After identification of the location of tethered cord, the cause of TCS is identified. If any fatty tissue or mass is present, it is removed first. Any other cause is also managed accordingly. Now the  attached spinal cord is just in the range of the surgeon’s vision.

The main steps of surgery start now. The spinal cord and spinal nerves are checked. As the spinal cord and nerves are very thin and small a microscope is used to identify them. A neuro-physician is present  to check the motor and sensory nerve supply of lower limbs. Any deterioration in the function of spinal nerves is checked and conveyed to the operating surgeon. The spinal cord is separated from the spinal canal. Spinal nerves are also separated from each other and adjusted at their places. If any split or tear is present on the spinal cord or nerve, it is also repaired by stitching. After doing this, the spinal canal is closed by placing a patch on the protective covering of spinal cord. The patch is stitched with the covering. The patch is placed to avoid leakage of cerebrospinal fluid (CSF) through the operated site. Up till now, the main part of this surgery is completed. Bleeding is secured by diathermy, stitching or applying pressure on the bleeding vessels. The muscles and tissues underlying the skin are approximated. The skin is stitched with fine sutures to minimize the scar mark. Antiseptic measures are applied on to the operated site and the dressing is placed on it.

After completing all this, the patient is assessed from the  anesthesia point of view. An injection is given through IV cannula to minimize the effect of anesthesia drugs. When the patient starts to respond to a painful stimulus, ETT is removed and the patient is allowed to do spontaneous breathing. The oxygen mask is placed on the mouth to maintain the oxygen saturation until the patient starts spontaneous breathing. Again a painful stimulus is applied to check the response of the patient. When the patient is responding well and doing spontaneous breathing, he/she is considered  out of anesthesia. Now the  patient can be shifted to recovery room.

Tethered Spinal Cord Surgery

Figure 1: In this picture the spinal cord is shown. Duramater (the protective covering of spinal cord) is opened to approach the spinal cord. The location where the  tethered cord is present is identified and detethered by placing a stitch behind the spinal cord. The red circle is made around the area where spinal cord is exposed by retracting the duramater (Source: www.ispn.guide.com).

Tethered Spinal Cord Surgery

Figure 2: This is a schematic diagram of the back of the patient near the lumbosacral region. This diagram shows how the approach is made through the skin to the spinal canal. A red circle is made around the incision that is made on the skin to approach the spinal canal to perform detethering of the tethered spinal cord (Source: www.ispn.guide).

Tethered Spinal Cord Surgery

Figure 3: This is the picture of a patient to whom tethered spinal cord surgery was performed. A red circle is made on the scar mark that is made on the back of patient after the healing of wound that was made on the skin in lumbosacral region to approach spinal canal (Source: www.pinterest.com)


1.     Falci SPLammertse DPBest LStarnes CAPrenger ECStavros AT, et al. Surgical treatment of posttraumatic cystic and tethered spinal cords. J Spinal Cord Med 1999;22(3):173-81.

2.     Hüttmann SKrauss JCollmann HSörensen NRoosen K. Surgical management of tethered spinal cord in adults: report of 54 cases. J Neurosurg 2001;95(2 Suppl):173-8.