Spina Bifida Surgery Recommended in Utero

A new study suggests that for children with spina bifida (myelomeningocele), surgery conducted while the fetus is still in the uterus is more cost effective, due to the costs associated with caring for a child with significant deficits.

Researchers at Johns Hopkins University (JHU; Baltimore, MD, USA) built a decision model to evaluate the costs and effects to the health care system of in utero surgery, compared to surgery shortly after birth for children with spina bifida. The researchers assumed that prenatal surgery was associated with improved neurological outcomes and changed the need for other surgical interventions in offspring, such as ventriculoperitoneal (VP) shunting, surgery for tethered spinal cord, and Chiari malformation. The researchers also accounted for adverse outcomes due to prenatal surgery and unintended risks for future pregnancies after prenatal surgery. The primary outcome was the incremental cost-effectiveness ratio (ICER).

The researchers found that the model predicted that every 100 fetal myelomeningocele repairs result in a cost savings of USD 3,135,557, and an improved quality of life (QALY), calculating the ICER to be USD 48,993 per QALY gained. The researchers further estimated that for every 100 prenatal repairs, QALYs are increased by 96 for the neonates with myelomeningocele, but maternal QALYs are reduced by 23, and future sibling QALYs are reduced by 9. In all, prenatal surgery was found to be cost saving in 55% of simulations, and cost-effective in 72%. The study was presented at the Society for Maternal-Fetal Medicine annual meeting, held during February 2012 in Dallas (TX, USA).

“Given the large costs associated with caring for a child with significant deficits, the improved outcomes with in utero surgery make it less costly over a lifetime than surgery after delivery,” said study coauthor Erika Werner, MD, of the JHU department of gynecology and obstetrics.

Spina bifida is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube; if the opening is large enough, this allows a portion of the spinal cord to protrude through the opening in the bones. Myelomeningocele is the most significant form of spina bifida, with the most common location of the malformations in the lumbar and sacral areas. Spina bifida can be surgically closed after birth, but this does not restore normal function to the affected part of the spinal cord. The incidence of spina bifida can be decreased by up to 70% when daily folic acid supplements are taken prior to conception.

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