Spina Bifida Surgery

What is spina bifida surgery?

Spina bifida surgery is an operation that closes an opening in a baby’s back where the spine and the tissue covering the spinal cord did not form completely before birth. Spina bifida is a type of neural tube defect. The neural tube is the structure in an embryo that develops into the brain, the spinal cord, and the bones and tissues that protect them. When part of the tube does not close during the first weeks of pregnancy, a gap can remain in the bones of the spine (the vertebrae), and in more severe forms the spinal cord and its coverings can bulge through the skin.

Surgery is used mainly for the open forms of the condition:

• Myelomeningocele is the most serious and most common open form. A sac containing spinal fluid, the membranes that cover the spinal cord (the meninges), and part of the spinal cord itself pushes through the gap in the spine. Myelomeningocele repair is the operation that places these tissues back inside the spinal canal and closes the skin over them.
• Meningocele is a less common form in which the sac contains fluid and membranes but not the spinal cord. It is also usually closed with surgery.
• Spina bifida occulta is a mild, closed form in which the skin is intact. Most people never need surgery for it unless a related problem, such as a tethered spinal cord, causes symptoms.

There are two main timings for repair. Spina bifida surgery after birth (postnatal repair) is the traditional approach and is usually done in the first days of life. Fetal surgery for spina bifida (prenatal repair) is an operation performed on the baby while still in the womb, usually in the second trimester. Both types of surgery are carried out by pediatric neurosurgeons, often working with fetal surgeons, obstetricians, neonatologists, and other specialists. In many hospitals these operations are coordinated through a neurosurgery department together with maternal-fetal medicine teams.

Who is a candidate

Almost every baby born with an open myelomeningocele is a candidate for surgical closure. Leaving the spinal cord exposed carries a high risk of infection, including meningitis (infection of the membranes around the brain and spinal cord), as well as further nerve damage and leakage of spinal fluid. For this reason, closure after birth is considered standard care rather than an optional treatment.

Fetal surgery is more selective. Based on published clinical experience, prenatal repair is generally considered when:

• The baby has an open myelomeningocele confirmed by ultrasound and, in many cases, fetal MRI (a detailed scan using magnetic fields).
• The pregnancy is within the gestational window used by the treating center, which is usually in the range of roughly 19 to 26 weeks.
• There is only one baby in the pregnancy.
• Genetic testing has not shown a major chromosomal problem, and there are no other serious birth defects.
• The mother is in good enough health to safely have major abdominal surgery and general anesthesia.

Fetal surgery may not be suitable when the mother has a very high body mass index, a history of preterm birth, a shortened cervix, placenta previa (the placenta lying over the opening of the womb), certain medical conditions, or when the pregnancy is beyond the accepted gestational window. Some babies also have a brain finding called Chiari II malformation, in which part of the brain is pulled downward into the top of the spinal canal; this is common in myelomeningocele and is usually a reason to consider fetal repair rather than a reason to rule it out, but the overall picture must be assessed by the specialist team.

Surgery is also used later in life for complications. The most frequent is tethered spinal cord, where scar tissue holds the cord in place so it cannot move freely as the child grows. Untethering surgery may be recommended if this causes new weakness, pain, bladder changes, or worsening curvature of the spine.

How the procedure works

Myelomeningocele repair after birth

Before surgery. The baby is usually delivered in a hospital with a neonatal intensive care unit. The exposed area on the back is covered with a sterile, moist dressing, and the baby is positioned on the side or stomach to avoid pressure on the sac. Antibiotics are commonly given to reduce the risk of infection. Doctors examine the baby’s movement, bladder and bowel function, and head size, and often perform an ultrasound of the head or an MRI to check for hydrocephalus (a buildup of fluid inside the brain).

During surgery. The operation is done under general anesthesia, meaning the baby is fully asleep. Most centers aim to close the defect within the first one to three days after birth. The surgeon carefully separates the flat, exposed spinal cord tissue (called the placode) from the surrounding skin, gently folds it into a more normal tube shape, and places it back inside the spinal canal. The dura, which is the tough outer membrane around the spinal cord, is closed over it to create a watertight seal that keeps spinal fluid in. Muscle and skin are then brought together over the repair. If the opening is large, the surgeon may need to shift nearby skin or tissue to cover it. The procedure itself often takes about one to three hours.

After surgery. The baby returns to the neonatal unit and is kept lying flat on the stomach or side for several days so the wound is not compressed. The team watches closely for spinal fluid leaking from the incision and for signs of hydrocephalus, such as a rapidly enlarging head or a tense soft spot. A sizeable share of babies with myelomeningocele need a second operation to manage hydrocephalus, most often placement of a shunt (a thin tube that drains fluid from the brain to the abdomen) or, in selected cases, a procedure called endoscopic third ventriculostomy that creates a new drainage pathway inside the brain.

Fetal surgery for spina bifida

Before surgery. The mother has detailed imaging, genetic testing, blood tests, and consultations with fetal surgeons, neurosurgeons, anesthesiologists, and counselors. The risks to both mother and baby are discussed in depth, because the mother is undergoing major surgery for the benefit of the baby.

During surgery. In the open technique, the mother is placed under general anesthesia, which also anesthetizes the baby. The surgeon makes an incision in the lower abdomen, exposes the uterus, and uses ultrasound to position the baby so the back is accessible. A small opening is made in the wall of the uterus, and the neurosurgeon closes the baby’s defect in layers, in a manner similar to repair after birth. The uterus is then closed, fluid is replaced, and the abdomen is closed. Some centers use a fetoscopic approach, in which instruments and a camera are passed through small ports rather than a large uterine opening; this may lower some risks to the uterus, but it is technically demanding and outcomes are still being studied. The operation typically takes a few hours.

After surgery. The mother usually stays in the hospital for several days and is monitored for contractions and leakage of amniotic fluid. Medication to relax the uterus is commonly given. For the rest of the pregnancy she is asked to limit activity and attend frequent checks. Because the uterus has been opened, delivery is by planned cesarean section, usually a few weeks before the due date, and future pregnancies also require cesarean delivery.

Preparation for spina bifida surgery

For repair after birth, most preparation happens during pregnancy once the diagnosis is made. Families are typically referred to a center with pediatric neurosurgery and neonatal intensive care so the baby can be delivered where the operation will take place. Your care team may discuss the safest mode of delivery; many centers recommend a planned cesarean before labor begins to protect the exposed spinal cord, although practice varies. Parents are often encouraged to meet the surgical team, ask about what to expect in the first weeks, and learn about longer-term care needs, including bladder and bowel management and physical therapy.

For fetal surgery, preparation includes:

• Confirming the diagnosis and level of the defect with ultrasound and fetal MRI.
• Genetic testing, usually through amniocentesis (sampling the fluid around the baby).
• A full medical evaluation of the mother, including blood tests and review of any past surgeries on the uterus.
• Fasting for a set number of hours before general anesthesia, as instructed.
• Arranging to stay near the treating hospital for the remainder of the pregnancy, since close monitoring is needed.

Whatever the timing, tell the team about all medications and supplements, any allergies, and any previous reactions to anesthesia in the family.

Recovery and aftercare

Recovery after spina bifida surgery is best thought of in stages. For a newborn, the immediate hospital stay after closure is often one to two weeks, though it can be longer if the baby is premature, needs a shunt, or has feeding difficulties. The incision usually heals within a few weeks. Parents are shown how to keep the wound clean and dry and how to position the baby to avoid pressure on the back.

Many babies need a shunt or other hydrocephalus treatment in the first weeks or months of life, and follow-up imaging of the head is typical. Because the nerves that control the legs, bladder, and bowel are often affected, most children are enrolled early in a multidisciplinary program that may include physical therapy, orthopedic assessment, urology (bladder specialists), and developmental follow-up. Some children learn to walk with or without braces, while others use a wheelchair; the outcome depends largely on the level of the defect on the spine.

After fetal surgery, the mother typically remains in the hospital for several days and then has weekly or more frequent checks until delivery. Physical activity is restricted for the rest of the pregnancy. Once the baby is born by cesarean, the mother’s recovery is similar to that of any cesarean delivery, often several weeks, while the baby is assessed in the same way as a baby who had repair after birth.

Long-term aftercare for anyone with myelomeningocele involves lifelong monitoring. Regular visits check shunt function, spinal alignment, skin over areas with reduced sensation, kidney health, and signs of tethered cord as the child grows. Adolescents and adults benefit from planned transition to adult specialists.

Risks and side effects

Like any operation, spina bifida surgery carries risks, and the balance of benefit and risk differs between the two timings.

Risks of repair after birth include wound infection, breakdown of the incision, leakage of spinal fluid, meningitis, bleeding, and reactions to anesthesia. The surgery cannot restore nerve function that was already lost before birth. Hydrocephalus requiring a shunt is common, and shunts can block or become infected over the years, which usually means further surgery. Tethered spinal cord may develop later and can require untethering.

Risks of fetal surgery affect both mother and baby. For the baby, the most significant risk is preterm birth, which can lead to breathing problems, feeding difficulties, and other complications of prematurity. There is also a risk of fetal death, although this is uncommon in experienced centers. For the mother, risks include premature rupture of the membranes, placental abruption (separation of the placenta from the uterine wall), bleeding, infection, blood clots, and thinning or separation of the surgical scar on the uterus. Because of the scar, all future deliveries need to be by cesarean, and the uterus may be at higher risk in future pregnancies.

Fetal surgery does not cure spina bifida. Children who have prenatal repair still often need bracing, bladder management, and ongoing follow-up, and some still require treatment for hydrocephalus.

Results and outlook

Closure after birth reliably protects the spinal cord from infection and further injury and allows most babies to go home within a few weeks. It does not reverse existing nerve damage, so the level of the defect remains the strongest predictor of future mobility and bladder and bowel function. With modern multidisciplinary care, many people with spina bifida live into adulthood, attend school and work, and lead active lives, although ongoing medical needs are usual.

A large randomized clinical trial comparing prenatal and postnatal repair found that, on average, children who had fetal surgery were less likely to need a shunt for hydrocephalus and had better motor function and improvement in the hindbrain (Chiari II) appearance on imaging by early childhood. These benefits came with higher rates of preterm birth and maternal uterine complications. Longer-term follow-up studies suggest some advantages persist into school age, while outcomes for bladder function appear more mixed. Individual results vary widely, and your doctor may explain how the specific level and features of the defect influence what can realistically be expected.

Cost considerations

The cost of spina bifida surgery varies considerably between health systems and between individual cases. Factors that generally drive the overall expense include:

• Length of hospital stay, particularly time in the neonatal intensive care unit, which is often the largest component.
• Type of procedure: fetal surgery involves a maternal operation, extended monitoring during pregnancy, and a planned cesarean, in addition to the baby’s care.
• Devices and implants, such as a shunt system if hydrocephalus needs treatment.
• Imaging and testing, including fetal MRI, ultrasounds, and genetic studies.
• Additional operations over time, for example shunt revision, orthopedic procedures, or untethering.
• Long-term follow-up, therapy, bracing, and bladder-management supplies.

Insurance coverage and public health provision differ by country and plan, so families usually ask the hospital’s financial or patient services team for a detailed estimate based on their situation.

Frequently asked questions

When is spina bifida surgery after birth usually performed?

Most centers aim to close an open myelomeningocele within the first one to three days of life. Early closure reduces the risk of infection of the exposed spinal cord and limits ongoing fluid leakage. Until surgery, the area is kept covered with a sterile moist dressing and the baby is positioned to avoid pressure on it.

Is fetal surgery for spina bifida better than surgery after birth?

Research suggests that prenatal repair may lower the chance of needing a shunt and may improve leg function compared with repair after birth, but it also increases the risk of preterm delivery and complications for the mother. Neither approach cures the condition. Whether fetal surgery is the better option depends on the baby’s findings, the mother’s health, the timing of diagnosis, and the family’s values after detailed counseling.

How long does myelomeningocele repair take?

Repair after birth often takes about one to three hours, depending on the size of the defect and whether extra skin or tissue must be moved to cover it. Open fetal surgery typically takes a few hours in total because it includes the maternal abdominal and uterine surgery as well as the repair itself.

Will my child walk after spina bifida surgery?

Surgery protects the spinal cord but does not restore nerves that did not form or were damaged before birth. Walking ability depends mainly on where on the spine the defect is located; defects lower on the spine generally leave more leg function. Many children walk with or without braces, and others use wheelchairs for some or all mobility. Physical therapy and orthopedic care help each child reach their own potential.

Does everyone with spina bifida need a shunt?

No. Hydrocephalus is common in myelomeningocele, and many babies need a shunt or a related procedure, but not all do. Babies who have fetal surgery appear less likely to need one. Doctors monitor head growth and use imaging to decide whether treatment is required.

Can spina bifida surgery be done later in childhood or adulthood?

The initial closure is done in infancy or before birth, but related operations may be needed later. The most common is release of a tethered spinal cord if it causes new symptoms. Shunt revisions and orthopedic procedures on the spine, hips, or feet are also performed at various ages.

Does fetal surgery affect future pregnancies?

Yes. Because the uterus was opened during surgery, delivery of the current baby and of any future babies is by cesarean section, usually before labor starts. There is also a somewhat higher risk of the uterine scar weakening or separating in later pregnancies, so future pregnancies are usually followed closely.

When to see a doctor

If a prenatal ultrasound or blood screening test raises the possibility of spina bifida, prompt referral to a maternal-fetal medicine specialist and a pediatric neurosurgery team allows time for detailed imaging, counseling, and planning of delivery or possible fetal surgery. At Acibadem, care for these patients is coordinated between neurosurgery and maternal-fetal medicine services.

After spina bifida surgery, contact the care team or seek urgent assessment if any of the following occur:

• Clear fluid leaking from the wound, or the wound opening, reddening, or swelling.
• Fever, unusual sleepiness, poor feeding, or repeated vomiting in the baby.
• A rapidly enlarging head, a bulging or tense soft spot, or the eyes appearing to look downward.
• A high-pitched cry, irritability that cannot be soothed, or seizures.
• New or worsening weakness in the legs, loss of movement that was present before, or changes in bladder or bowel pattern.
• In a child with a shunt: headache, vomiting, drowsiness, or vision changes, which can indicate a blocked or infected shunt.

For a mother after fetal surgery, seek urgent care for contractions, leaking of fluid from the vagina, vaginal bleeding, severe abdominal pain, fever, or reduced movement of the baby. As children grow, new back or leg pain, changes in walking, worsening scoliosis, or new bladder problems should be evaluated for tethered cord or shunt issues. Regular scheduled follow-up remains important throughout life even when no symptoms are present.