Neural Tube Defects - Treatment & Management
Although individual myelomeningocele lesions are unique and often complicated, some generalizations on future mobility can be made based on the level of the lesion. Children with sacral lesions will often be able to walk, with or without braces, though usually later than children without a NTD. Children with lower to mid-lumbar lesions will require more support to walk, including crutches, walkers, and/or bracing. These children will often become wheelchair-dependent as they move into adolescence. Children with high lumbar or thoracic lesions will usually be wheelchair dependent. Children with higher lesions that involve the upper extremities may need motorized wheelchairs for mobility. Note that power chairs can be used at developmental levels as young as two to three years.
Fractures due to osteoporosis are common in nonambulatory children, especially if additional risk factors are present (e.g., the child is taking valproic acid or a proton pump inhibitor). Children with myelomeningocele should be maintained on a diet with adequate calcium and vitamin D and weight-bearing with braces or a standing apparatus should be encouraged. Bisphosphonates should be considered if fractures occur in the setting of low bone density. Referral should be made to pediatric endocrinology if this is being considered. See Services.
ACOG practice bulletin. Neural tube defects. Number 44, July 2003. (Replaces committee opinion number 252, March 2001).
Int J Gynaecol Obstet. 2003;83(1):123-33. PubMed abstract
Since NTDs are often identified prenatally by ultrasound or following screening tests (triple screen, α-fetoprotein or AFP), the pediatrician may be involved in assisting the parents prior to the child's birth. [Bradley: 2005]. Note that the sensitivity of the entire NTD screening process is estimated to be 86% for anencephaly and 78% for open spina bifida, while the specificity is 99.99%. If the screen is abnormal, a specialized ultrasound examination will usually be done to look for NTD (other conditions may also cause elevated AFP). Diagnostic testing is also usually performed during any pregnancy at high risk for NTD, including moms with a previous history of a NTD. [Jallo: 2005]
Once diagnosed in utero, babies with a NTD are generally followed by both a high risk pregnancy program and their local obstetrician, with delivery planned at a tertiary care center. Counseling is provided regarding problems that may arise during pregnancy, birth, and throughout the child's life. Prenatal counseling is also usually available through a Spina Bifida Clinic. The type of delivery is decided by the obstetrician, but large head circumference, breech presentation, and any fetal distress are indications for C-section. A person with expertise in neonatal care, such as a neonatologist, will generally provide parent education regarding expectations at and immediately following birth.
Postnatal and ongoing care
Following birth, a spina bifida newborn protocol (for an example, see Newborn Myelomeningocele Protocol (PCMC) ( 77 KB) ) is activated. Pediatric neurosurgeons will repair the lesion and multiple evaluations are obtained to assess future management needs. Although there may be minor differences among programs, the protocol is fairly generic. Upon discharge, referrals to early intervention, a Spina Bifida Clinic, and other specialists as needed, should be in place, along with a first visit to the Medical Home.
Genetics, Prenatal (see Services below for relevant providers)
Women who are pregnant with a baby with a suspected NTD are referred to prenatal genetics.
Knowledge of the child's bowel habits should guide initial interventions. What time of day does the patient have a bowel movement? How long after eating? What is the consistency of the stool? Does the patient need an enema, a suppository, or just time on the toilet before stooling? Common considerations include:
- Interventions, including dietary manipulations, should aim for 1-2 mushy, easy-to-pass stools per day
- Diets should be high in fiber
- PEG 3350 (Miralax or Glycolax) should be added to give bulk to stools if a high fiber diet isn't helping
- For softer stools, water and prune juice should be added. Stool softeners, such as docusate, can also be added when needed
- Greasy foods should be avoided
- Meals and predictable time periods after eating for sitting on the toilet should be scheduled to utilize the gastrocolic reflex
- If timing bowel movements after meals is not successful, suppositories should be added (glycerin or biscodyl) to initiate bowel movements. Stimulants, such as senokot, or osmotic agents, such as milk of magnesia, are also sometimes helpful
- Bowel "clean-outs" are sometimes necessary when constipation has been an issue for a long period of time, usually followed by PEG 3350 daily until the colon adjusts to normal bowel movements. For details, see Constipation treatment (general).
- Consider a referral to gastroenterology if interventions are not successful.
Pediatric Gastroenterology (see Services below for relevant providers)
If children are not responding to standard treatment and/or if an ACE procedure is being considered, a referral to gastroenterology may be helpful.
The majority of children with myelomeningocele will eventually require shunting, and most will require periodic visits with neurosurgery. The Medical Home should be watchful for signs and symptoms of hydrocephalus, such as increasing head circumference, irritability and sleepiness in infants, and headache, nausea/vomiting, and somnolence in children. Slowly increasing intracranial pressure will cause less acute symptoms than a sudden increase. Children with a shunt are at risk for shunt blockage, underdrainage, and overdrainage. They should be seen promptly if they have symptoms that might reflect shunt blockage or infection, which is more common in the first few months after shunt surgery. A shunt series and a CT scan may help identify problems. Spinal cord tethering, Chiari II malformation, and syringomyelia are also found in children with myelomeningocele. See Neurosurgical issues in children with spina bifida (general) for more details.
- Seizures and epilepsy in children with myelomeningocele are common, occurring in 10-25% of affected children. [Talwar: 1995] [Noetzel: 1991] [Bartoshesky: 1985] [Yoshida: 2006]
- Most studies have found epilepsy to be more prevalent in myelomeningocele patients with hydrocephalus than in those without (except [Noetzel: 1991]).
- The presence of shunts and shunt revisions is not correlated with epilepsy. [Klepper: 1998]
- Children with myelomeningocele and epilepsy tend to have other brain abnormalities, such as polymicrogyria or agenesis of the corpus callosum. [Talwar: 1995] [Yoshida: 2006]
- Children with myelomeningocele and epilepsy may be more likely to have mental retardation than those without epilepsy. [Noetzel: 1991]
- If seizures occur in myelomeningocele patients, they are treated similarly to seizures in the general population (see the Seizure module). Unless the child has the confounding factors of mental retardation and/or hydrocephalus, the prognosis is generally good for control of seizures. [Noetzel: 1991]
Pediatric Neurosurgery (see Services below for relevant providers)
Neurosurgery follow-up will be required in most children with myelomeningocele.
Pediatric Neurology (see Services below for relevant providers)
Referral to neurology for seizures may be helpful. Neurology will generally be part of a multidisciplinary spina bifida clinic.
- these areas are insensitive to pain
- these areas are stationary in spina bifida children in wheelchairs, unless efforts are made to increase movement voluntarily (for example, with sitting push-ups) on a frequent basis
- the spinal defect involves autonomic nerves that control the vascular supply to these areas, thus increasing the chances of getting decubitus ulcers and delaying healing when sores develop
Treatment – Prevention should be part of the ongoing educational process for the child and his/her family. Approaches include: pressure releases while in a wheelchair (10 second lifts every 15 minutes), frequent changes in positioning (for example, from a wheelchair to a mat every hour or two while at school), and position changes every two hours while lying in bed. The first step in treating a pressure sore is to ensure that the pressure causing it is removed. Consider new wheelchair cushions, a change in orthotics, or, if it is exacerbated by a contracture, antispasticity agents and a referral to surgery to release the contracture. If the decubitus is mild, thorough cleansing and possibly an occlusive dressing to keep the area moist may be sufficient. More advanced sores may require various other types of dressings (wet to dry dressings, Carrington gel), intravenous antibiotics, whirlpool treatments, and surgical debridement/skin grafting.
Latex Allergy – All children with spina bifida and their families should be taught to avoid latex in their environment. Newborns with myelomeningocele are usually put on latex precautions at birth. (see Newborn Myelomeningocele Protocol (PCMC) ( 77 KB) ) A large percentage of children with spina bifida have latex sensitivity and allergy, with symptoms ranging from itchy watery eyes to hives to fatal anaphylactic reactions. Although there are correlations between previous latex exposure history, number of previous surgeries, and the presence of other allergies, the intricacies of this allergy are not well understood. Because latex exposure to mucus membranes seems to correlate with increasing difficulty with latex allergy, sexually active adolescents and adults with spina bifida should use latex-free condoms. Specific recommendations for avoidance and lists of products that contain latex can be found at the Spina Bifida Association Website. See Latex Information (Spina Bifida Association).
Pediatric Physical Medicine & Rehab (see Services below for relevant providers)
Consider a referral to physiatry if skin ulcers are present.
Pediatric Dermatology (see Services below for relevant providers)
Depending on local expertise and availability, a referral to dermatology for skin ulcers may be helpful.
General Pediatric Surgery (see Services below for relevant providers)
In more advanced skin ulcers, surgery may be necessary.
Pediatric Plastic Surgery (see Services below for relevant providers)
In some regions, plastic surgeons may be the most appropriate referral for repair.
Common orthopedic problems associated with spina bifida include:
- hip dislocations
- foot and knee deformities
Kyphosis, curvature of the spine in an anterior posterior plane, can cause progressive problems with seating, positioning, and pressure sores on the skin overlying the convex side. It can also lead to compression of abdominal contents and secondary interference with the function of the diaphragm and breathing. Kyphosis can be very difficult to manage, often requiring major spinal surgery to correct the deformity. Fortunately, kyphosis is less common than scoliosis in children with meningomyelocele, accounting for about 10 % of spine defects. It is more common when the myelomeningocele lesion is above T12. [Foster: 2007]
Hip dislocations are common in children with myelomeningocele, increasing in incidence with higher lesions. Muscle release surgeries may decrease the forces dislocating the hips. They may also have bony surgery to correct the deformities resulting from the muscle imbalance, improving the range of motion of the hips and knees and facilitating bracing and standing. The decision to surgically treat hip dislocation in this population is often based on the child's potential to walk, which is correlated with a lower lesion level (L3 level), and whether or not it is unilateral or bilateral.
Foot deformities are common in young children with myelomeningocele. They may require bracing if the deformity is flexible, or if the deformity is rigid, corrective surgery to relax the foot may be performed so that bracing can be effective.
Pediatric Orthopedics (see Services below for relevant providers)
Children with myelomeningocele require frequent follow-up with orthopedics. Serial exams are necessary to observe evolving changes over time. Follow-up includes serial evaluation of the mobility-oriented medical equipment, such as orthotics, wheelchairs, standing frames, and crutches.
Kidney Dysfunction – Neurogenic bladder and subsequent kidney dysfunction are major sources of morbidity and mortality in children with spina bifida. Although only about 10% will have kidney dysfunction at birth, about 50% will go on to have deterioration in kidney function, sometimes requiring dialysis or renal transplant. [Liptak: 2003] Repeated evaluations, every few months in infants and less frequently as the child gets older, and interventions as needed have prevented morbidity and mortality in many children with myelomeningocele.
Urinary Tract Infections – From birth, children with myelomeningocele should be monitored for urinary tract infections and treatment provided as needed. Frequent urinary tract infections in this population hasten kidney damage. A study performed in 2005 found no consensus among Spina Bifida Clinics in the United States regarding the management of bacteriuria. [Elliott: 2005]
Urinary Continence – Urinary management includes diapers, typical toileting with or without medications, intermittent catheterization, and surgical diversion. The achievement of urinary continence is important as the child gets older. Children with myelomeningocele who are continent have greater self esteem than children who are not continent. Adults with spina bifida identify concerns regarding continence as one of their major worries regarding sexual intimacy. [Edwards: 2004]
See Helpful Articles (below) for more information and the Patient Education section for articles about catheterization from the Intermountain Healthcare's education series.
Pediatric Urology (see Services below for relevant providers)
Urologists are usually involved with a child with myelomeningocele on the initial hospitalization and follow-up visits should be scheduled periodically.
Nutrition/Dietary (see Services below for relevant providers)
If not available through a Spina Bifida-specific clinic, consider a referral to nutrition.
For unknown reasons, children with spina bifida and hydrocephalus often exhibit precocious puberty. Although precocious puberty is more frequent in girls (possibly as high as 50%, [Proos: 1996]), it also occurs in boys with myelomeningocele and hydrocephalus. Precocious puberty causes a number of physical and emotional problems in children who may already feel socially isolated and different. These problems include:
- an early pubertal growth spurt, followed by a change to adult bone structure and cessation of growth. Adults with spina bifida are shorter than the general population; this problem is more pronounced if they experienced precocious puberty, starting their growth spurt earlier and stopping growth earlier.
- increasing difficulty with feeling alienated and different
- changes that sometimes occur with adolescence, such as moodiness, increased aggressiveness in boys, and sexual readiness are experienced earlier than in children without spina bifida and at a time when families, friends, and schools may not be anticipating them. [Liptak: 2003]
Signs of precocious puberty should be watched for by the child, family, and the Medical Home. Early changes include testicular enlargement and the development of pubic hair and acne in boys, breast development in girls. If noted, the child should be seen by a pediatric endocrinologist to consider treatment. Testing may include bone age, ultrasound examination for uterine size, blood testing for elevated levels of sex hormones and pituitary hormones, and determination of the child's rate of growth.
If precocious puberty is already well underway, treatment may not be possible. Some patients and families and their doctors choose no treatment; others will choose medication to slow the process, usually leuprolide (lupron) that monthly injections. In addition to preventing precocious puberty, treatment delays the puberty-related growth spurt, allowing the child greater adult height. Gonadotropin-releasing hormone analogs have also been used to help children with spina bifida and precocious puberty attain greater adult heights. [Trollmann: 1998]
Sexuality and Reproductive Issues
Issues of sexuality and reproduction are important for the patient, the family, and the Medical Home, and should be addressed in visits with adolescents. Questions about fertility, for both males and females, are often asked when the family first hears they will have a child with spina bifida. Teens with myelomeningocele do not feel they are given enough specific information regarding sexuality. [Sawin: 2002] [Sawyer: 1999] Usual sources of reliable information about sexuality are not likely to address issues specific to those with physical or intellectual disabilities.
Intimate relationships are sometimes limited in adolescents with myelomeningocele due to concerns regarding body image and the fear of bowel and bladder incontinence. However, surveys find that many adolescents with myelomeningocele are involved in intimate relationships. [Verhoef: 2005] Adolescents with myelomeningocele should be taught that, like other adolescents, they may be fertile and are subject to sexually transmitted disease. Because of the risk of latex allergy, sexually active patients should be taught to use latex-free condoms. Because the effectiveness of latex-free condoms in preventing pregnancy and sexually transmitted diseases is still being studied, males with NTDs should use a latex-free condom inside a regular condom and females with NTDs should have their male partner use a latex-free condom over a regular condom. See Latex-free condoms (About.com) for more information. Both males and females with NTDs may have decreased sensation in their perineal and genital regions and must watch for skin breakdown that may occur with sexual activity. Many women with myelomeningocele are able to become pregnant, although fertility rates aren't known. A small percentage of women with small pelvises might have difficulty carrying a child to full term. See [Jackson: 2005] for a discussion of reproductive issues in women with spina bifida. There is little information available about the sexual response in women with myelomeningocele. Adolescent females with myelomeningocele should take folic acid because of the risk of spina bifida in their children, which is greater for mothers with spina bifida than it is in the general population. (See Folic acid supplementation in NTD and [Toriello: 2005].)
As many as 1 in 4 males with NTDs will have undescended testicles. [Meyer: 1984] Approximately 3/4 of males with myelomeningocele will be able to have erections, although most will experience them only from local physical stimulation rather than psychogenically. The ability to have and sustain an erection is related to the level of lesion; the lower the level, the more likely the male will be able to have an erection. Even with the ability to have an erection, many men with spina bifida will be unable to sustain it long enough for sexual intercourse. Erectile dysfunction drugs currently on the market have been very helpful. If those medications fail, various surgical interventions are possible. It is unknown how many men with myelomeningocele are infertile, and whether they are infertile because they experience retrograde ejaculation or because of decreased sperm counts or motility. Artificial insemination may be an option, using their own sperm. Fertility specialists should be consulted if these questions arise. [Sawin: 2002]
Pediatric Endocrinology (see Services below for relevant providers)
Consider a referral to endocrinology if a female or male with a NTD presents with precocious puberty.
Spina Bifida Association
A voluntary health agency, with 57 chapters, offers programs, education, advocacy, research updates and services nationwide.
Spina Bifida (MedlinePlus)
from the National Library of Medicine; basic information and numerous links to other reliable sources
Spina Bifida (March of Dimes)
Information for parents from the March of Dimes Foundation
Spina Bifida (KidsHealth)
Family-focused information about spina bifida, from the Nemours Foundation
Spina Bifida for Kids (KidsHealth)
Patient-focused information about spina bifida, from the Nemours Foundation
Spina bifida fact sheet (NINDS)
Extensive information on spina bifida compiled by the National Institute of Neurological Disorders and Stroke, NIH.
Spina Bifida Handout
( 961 KB)
This 24-page document explains spina bifida, medical terms, diagnosis, symptoms, managment, latex precautions, and more, from the Southwest Institute for Families and Children with Special Needs.
ACOG practice bulletin. Neural tube defects. Number 44, July 2003. (Replaces committee opinion number 252, March 2001).
Int J Gynaecol Obstet. 2003;83(1):123-33. PubMed abstract
Spina bifida patient education materials (Intermountain Healthcare)
Several patient education documents on various aspects of spina bifida and neural tube defects, from Intermountain Healthcare; some available in Spanish
Children's Education Services,
100 N Mario Capecchi Drive
Salt Lake City, UT 84113
See all Educational Advocacy services providers (24) in our database.
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Spina Bifida Clinic,
100 Mario Capecchi Drive, Ste. 4400
Salt Lake City, UT 84113
See all Genetics, Prenatal services providers (5) in our database.
See all Neuropsychology services providers (10) in our database.
See all Nutrition/Dietary services providers (51) in our database.
See all Pediatric Dermatology services providers (2) in our database.
See all Pediatric Endocrinology services providers (5) in our database.
See all Pediatric Gastroenterology services providers (2) in our database.
See all Pediatric Neurology services providers (3) in our database.
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For other services related to this condition, browse our Services categories or search our database.
CHOP maternal fetal surgery for myelomeningocele
CHOP is one of the US centers that is part of the MOMS trial for maternal fetal surgery for myelomeningocele.
UCSF maternal fetal surgery for myelomeningocele
UCSF is one of the centers participating in the MOMS trial for maternal-fetal surgery for myelomeningocele
Rowe DE, Jadhav AL.
Care of the adolescent with spina bifida.
Pediatr Clin North Am. 2008;55(6):1359-74, ix. PubMed abstract
Scales CD Jr, Wiener JS.
Evaluating outcomes of enterocystoplasty in patients with spina bifida: a review of the literature.
J Urol. 2008;180(6):2323-9. PubMed abstract
Current approaches to the urologic care of children with spina bifida.
Curr Urol Rep. 2008;9(2):151-7. PubMed abstract
Dicianno BE, Kurowski BG, Yang JM, Chancellor MB, Bejjani GK, Fairman AD, Lewis N, Sotirake J.
Rehabilitation and medical management of the adult with spina bifida.
Am J Phys Med Rehabil. 2008;87(12):1027-50. PubMed abstract
Sinha CK, Butler C, Haddad M.
Left Antegrade Continent Enema (LACE): review of the literature.
Eur J Pediatr Surg. 2008;18(4):215-8. PubMed abstract
Gastrointestinal disorders in children with neurodevelopmental disabilities.
Dev Disabil Res Rev. 2008;14(2):128-36. PubMed abstract
Lutkenhoff, M. ed.
Children with Spina Bifida, A Parents' Guide.
2nd ed. Bethesda, MD: Woodbine House; 2007. 978-1-890627-77-5 http://www.woodbinehouse.com/main
This book is a comprehensive guide for parents. It is available from the Woodbine House website. See left side of the page under Special Needs Topic Spina Bifida.
|Reviewing Author:||Sarah Winter M.D., 10/2008|
|Content Last Updated:||2/2009|
Bartoshesky LE, Haller J, Scott RM, Wojick C.
Seizures in children with meningomyelocele.
Am J Dis Child. 1985;139(4):400-2. PubMed abstract
Bowman RM, McLone DG, Grant JA, Tomita T, Ito JA.
Spina bifida outcome: a 25-year prospective.
Pediatr Neurosurg. 2001;34(3):114-20. PubMed abstract
Bradley LA, Palomaki GE, McDowell GA.
Technical standards and guidelines: prenatal screening for open neural tube defects.
Genet Med. 2005;7(5):355-69. PubMed abstract
Edwards M, Borzyskowski M, Cox A, Badcock J.
Neuropathic bladder and intermittent catheterization: social and psychological impact on children and adolescents.
Dev Med Child Neurol. 2004;46(3):168-77. PubMed abstract
This article describes the use of intermittent catheterization from the perspective of the individuals with myelomeningocele and their families.
Elliott SP, Villar R, Duncan B.
Bacteriuria management and urological evaluation of patients with spina bifida and neurogenic bladder: a multicenter survey.
J Urol. 2005;173(1):217-20. PubMed abstract
Foster, Mark M.D., Ph.D.
Spina bifida outcome: a 25-year prospective.
(2007) http://www.emedicine.com/orthoped/topic557.htm .
Jackson AB, Sipski ML.
Reproductive issues for women with spina bifida.
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Neural Tube Defects.
emedicine; (2005) http://www.emedicine.com/neuro/topic244.htm.
Johnson MP, Gerdes M, Rintoul N, Pasquariello P, Melchionni J, Sutton LN, Adzick NS.
Maternal-fetal surgery for myelomeningocele: neurodevelopmental outcomes at 2 years of age.
Am J Obstet Gynecol. 2006;194(4):1145-50; discussion 1150-. PubMed abstract
King JC, Currie DM, Wright E.
Bowel training in spina bifida: importance of education, patient compliance, age, and anal reflexes.
Arch Phys Med Rehabil. 1994;75(3):243-7. PubMed abstract
A description of some toileting interventions for individuals with spina bifida.
Klepper J, Busse M, Strassburg HM, Sorensen N.
Epilepsy in shunt-treated hydrocephalus.
Dev Med Child Neurol. 1998;40(11):731-6. PubMed abstract
Evidence-based Practice in Spina Bifida: Developing A Research Agenda.
Evidence-based Practice in Spina Bifida, 2003; Washington D.C.. / http://web.archive.org/web/20040701175406/http://www.sbaa.org/site/Doc...
Lyerly AD, Mahowald MB.
Maternal-fetal surgery for treatment of myelomeningocele.
Clin Perinatol. 2003;30(1):155-65. PubMed abstract
Meyer S, Landau H.
Precocious puberty in myelomeningocele patients.
J Pediatr Orthop. 1984;4(1):28-31. PubMed abstract
Noetzel MJ, Blake JN.
Prognosis for seizure control and remission in children with myelomeningocele.
Dev Med Child Neurol. 1991;33(9):803-10. PubMed abstract
Proos LA, Dahl M, Ahlsten G, Tuvemo T, Gustafsson J.
Increased perinatal intracranial pressure and prediction of early puberty in girls with myelomeningocele.
Arch Dis Child. 1996;75(1):42-5. PubMed abstract / Full Text
Sawin KJ, Brei TJ, Buran CF, Fastenau PS.
Factors associated with quality of life in adolescents with spina bifida.
J Holist Nurs. 2002;20(3):279-304. PubMed abstract
Sawyer SM, Roberts KV.
Sexual and reproductive health in young people with spina bifida.
Dev Med Child Neurol. 1999;41(10):671-5. PubMed abstract
Talwar D, Baldwin MA, Horbatt CI.
Epilepsy in children with meningomyelocele.
Pediatr Neurol. 1995;13(1):29-32. PubMed abstract
Folic acid and neural tube defects.
Genet Med. 2005;7(4):283-4. PubMed abstract
Trivedi J, Thomson JD, Slakey JB, Banta JV, Jones PW.
Clinical and radiographic predictors of scoliosis in patients with myelomeningocele.
J Bone Joint Surg Am. 2002;84-A(8):1389-94. PubMed abstract
Trollmann R, Strehl E, Dorr HG.
Precocious puberty in children with myelomeningocele: treatment with gonadotropin-releasing hormone analogues.
Dev Med Child Neurol. 1998;40(1):38-43. PubMed abstract
Verhoef M, Barf HA, Vroege JA, Post MW, Van Asbeck FW, Gooskens RH, Prevo AJ.
Sex education, relationships, and sexuality in young adults with spina bifida.
Arch Phys Med Rehabil. 2005;86(5):979-87. PubMed abstract
Webb HW, Barraza MA, Stevens PS, Crump JM, Erhard M.
Bowel dysfunction in spina bifida--an American experience with the ACE procedure.
Eur J Pediatr Surg. 1998;8 Suppl 1:37-8. PubMed abstract
Yoshida F, Morioka T, Hashiguchi K, Kawamura T, Miyagi Y, Nagata S, Mihara F, Ohshio M, Sasaki T.
Epilepsy in patients with spina bifida in the lumbosacral region.
Neurosurg Rev. 2006;29(4):327-32; discussion 332. PubMed abstract