Spina Bifida In Jan Tecklin's Pediatric Physical Therapy

Imagine a couple who has just found out that they are pregnant. Just like other parents, they want nothing more than to have a happy, healthy baby. Last year, these parents were my neighbors. Although they did not know it, their daughter Kelsey was going to be born with spina bifida and have no feeling in her lower left leg because of it. Most people have never even heard of spina bifida or know what it is. According to the Center for Disease Control and Prevention, “Each year, about 1,500 babies are born with spina bifida” (“Data and Statistics”). This is a problem and it should not go unnoticed. We need to educate people on the importance of this defect and what can be done about it.
In Jan Tecklin’s book, Pediatric Physical Therapy, he states that “spina bifida is the second most common birth defect after Down syndrome” (163). Spina bifida includes any birth defect where the spinal canal is not completely closed. It is considered to be a neural tube defect or an NTD. The

neural tube is the embryonic tissue that creates the spinal cord and the brain. Researchers are not entirely sure what causes spina bifida, but many believe that genetics and dietary factors could be a possible issue. Although the cause is not completely known, there is a possible prevention.
The main theory being considered today is the lack of folic acid or folate in a woman’s diet. Folic acid is a B vitamin that helps to create new and healthy cells. This is most important for a woman to have during the first trimester of her pregnancy. According to the Center for Disease Control and Prevention, the U.S. Public Health Service suggests that women who are planning on getting pregnant or are able to become pregnant should “consume 400 µg of folic acid daily” (“Spina Bifida”). Women can meet this recommendation by taking supplements of folate or by eating a certain number of servings of fruits and vegetables daily. After this recommendation was put into effect, the number of cases of spina bifida and other neural tube defects decreased.
There are three main types of spina bifida—meningocele, myelomeningocele, and spina bifida occulta. All three of these involve an incomplete spinal cord, but they have different signs, symptoms, and effects on the infant. (See Figure 1) Meningocele is “a condition where the tissue covering the spinal cord sticks out of the spinal defect but the spinal cord remains in place” (“Myelomeningocele”). This is usually noticeable at birth. Symptoms include lack of bladder control, possible paralysis of legs, and weakness in the legs or the hips. This usually occurs near the top of the spine, but can occur in other areas of the spinal column. Meningocele has very little or no effect at all on the nervous system. In some cases, the skin that is part of the sac does not fully develop. This can cause the sac to leak fluid which can in turn lead to infection if it is not treated right away.
Myelomeningocele or MM is the most common and the most severe type of spina bifida. The National Center for Biotechnology Information writes that “it is a neural tube defect in which the bones of the spine do not completely form, resulting in an incomplete spinal canal” (“Myelomeningocele”). As a result, the tissues over the spinal cord and the spinal cord itself protrude from the child’s back in a sac over the opening. This can occur anywhere along the spinal column. Symptoms can include lack of bladder control, lack of sensation, and an inability to move part of or the whole leg. Myelomeningocele is said to affect 1 in 1000 births in the United States (Tecklin). MM can lead to other birth defects including hydrocephalus. Hydrocephalus occurs when there is a buildup of fluid around the brain. “Approximately 90% of the children with MM have hydrocephalus, which is not fatal if treated promptly before brain tissue is destroyed” (Ekvall). If hydrocephalus develops, a shunt must be used to ease the pressure from the fluid. Many children who have been diagnosed with MM develop a learning disability of some kind.
Spina bifida occulta is the least severe of the three forms of the defect.

This form does not cause nervous system issues and can sometimes go undetected. It is defined as “a condition is which the bones of the spine do not close but the spinal cord and meninges remain in place and skin usually covers the defect” (“Myelomeningocele”). The meninges are membranes that cover the central nervous system. Symptoms include a dark spot or an area with less skin color, a lump, or a dimple over the affected area. This usually occurs on the infant’s lower spine. Not all of these symptoms indicate that a person has spina bifida. Because this type is not as harsh as the other two, it can only be detected through an examination. Even though spina bifida occulta is the least severe, there are more severe types within spina bifida occulta. One of these types causes the spinal cord to become tethered which can lead to different neurological issues. These kinds of spina bifida occulta are less likely to

occur.

Fig. 1 Three types of spina bifida
From http://forum.baby-gaga.com/
Spina bifida does not have a cure. It can be treated, but any neurological damage cannot be repaired. If a child is diagnosed with spina bifida in the womb, there is currently no way to completely fix it before birth; however, some of the damage can be repaired. Surgery is recommended very shortly after the child is born to remove the sac or to attach the spinal cord and get rid of the dimple in the child’s back. This will help reduce any further damage to the spinal cord. If any infections developed, antibiotics can be used to treat them. In Adrian Sandler’s book, Living with Spina Bifida: A Guide for Families and Professionals, a young mom tells the story of her son Sam who was born with spina bifida. She describes his life shortly after his surgery.
Sam is now eighteen months old. He is walking, running, climbing, dancing, just like any other eighteen-month-old-child. He did not develop hydrocephalus and so he never had to have a shunt. Sam is unquestionably a miracle baby, and I know the chances of a child with spina bifida turning out to be this healthy are slim, but it happened. (8)
Once diagnosed with spina bifida, most children can live well into adulthood and lead normal lives. More severe cases—like those with full paralysis or other brain defects—may not live as long. It all depends on the severity of the case.
Most children have some kind of nerve damage occur when they have spina bifida. Physical therapy is used to help with any muscle, joint, and skeletal issues. In addition, orthopedic braces can be used to help with these problems. The type of physical therapy done depends completely on the type of damage caused. Therapy can occur before a child goes through surgery or it can happen after depending on the case. The same therapists will usually work with their patient until he or she is ready to move onto a different clinic or until the patient can do the therapy on their own. The purpose of this is so the therapist can monitor any changes in the patient and make adjustments accordingly.
Recently, researchers and doctors have been working together to find a way to prevent spina bifida. Fetal surgery has been found to be rather successful when it comes to fixing spina bifida. A study was completed where 80 babies had surgery to close their spine after they were born, while another 80 babies had the spine closed while in the womb. Two babies from each of these groups died. Pam Belluck—journalist for The New York Times—writes, “Babies with a form of spina bifida…were more likely to walk and experience fewer neurological problems if operated on before being born rather than afterward.” Although these results have been found, the surgery is extremely risky and has not helped every case of the defect. Dr. Joe Leigh Simpson says, “It’s a good start, a step in the right direction. It showed improvement and that there’s reason to continue looking for a better mousetrap” (Belluck).
Even though most people do not know what spina bifida is, it is our duty as a society not to overlook this disease. It is our duty to teach and prepare expecting parents for what could happen to their unborn child. It is our duty to educate the general public about the severity of this defect. It is our duty to try to give children like Kelsey and Sam the chance to live a normal, happy, and healthy life. Once we understand spina bifida, we will begin to see the answer to the problem of how to treat and prevent it effectively.