In a 6-year period 163 unselected newborn infants with open myelomeningocele were assessed. 48%, considered to have the most favourable prognosis, were selected for early back closure and vigorous subsequent treatment. The more severely affected remainder were given only symptomatic treatment unless long-term survival seemed likely. The major adverse criteria were severe paralysis, gross head enlargement, and spinal deformity such as kyphosis. More than 70% of selected infants were alive at 6 years, whereas more than 80% of untreated infants were dead at 3 months.
The follow-up results are compared with those of routine early operation (Lorber, 1971a). After 1 year, the overall survival levelled out at 40% (cf 60%). The survivors were, however, less severely handicapped. Only 25% were mainly or entirely in wheelchairs (cf 49%). Only 16% had upper urinary tract damage in addition to incontinence (cf 34%). A combination of mental and severe physical handicap occurred in only 20% (cf 36%). Severe disability was encountered mainly in children who had suffered from complications, e.g. ventriculitis, unforeseeable at birth.
It is concluded that the overall results of selective early operation compare favourably with those of purely conservative management on the one hand, and with routine early operation on the other. It is suggested that this policy offers the best prospects of independence for the less severely affected child, and the least distress and suffering for the grossly afflicted.
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