BAHIRDAR UNIVERSITY, COLLEGE OF MEDICINE AND

HEALTH SCIENCES, SCHOOL OF PUBLIC HEALTH

EPIDMOLOGY DEPARTMENT ASSIGNMENT.

Presentation on meningomyelocele case

report

Authors-Agumas Fentahun
- workneh Gedamu
-Biresaw Nega
-Amare Yetwale

Submitted to: -Instructor: - Mr. Birhanu Elfu

(Assistant professor of Epidemiology and biostatistics)

Bahir Dar Ethiopia

March/2017

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 I. Acknowledgment
First of all we wish to acknowledge Bahir Dar University College of medicine and health
science school of MPH department of epidemiology and biostatics for their help to learn
this program and to do this case report.

Second, we want to acknowledge Felege Hiwot referral hospital card room workers and
other staffs for their cooperative in case selection and showing data source.

We are really grateful because we managed to complete our Epidemiology assignment

within the time given by our Instructor Mr. Birhanu Elfu. This assignment cannot be
completed without the effort and co-operation from our group members, Eskedar(MD),
Agumas Fentahun, Workneh Gedamu, Biresaw Nega And Amare Yetwale.

We also sincerely thank our lecturer of Epidemiology, for the guidance and
encouragement in finishing this assignment and also for teaching us in this course.

Last but not least, we would like to express our gratitude to our friends and
respondents for the support and willingness to spend some times with us to organize
this case Report

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 II. Acronyms
BID Two times per day

CDC Center of disease control and prevention

CNS Central Nervous system

CVS Cardio vascular system

GA General A prance

GUS Genitourinary system

INT Integumentary system

IV Intravenous

LGS Lymphograndular system

LNMP Last Normal Menstrual period

MPH Master of public Health

MRN Medical Registration Number

MSKS Musculoskeletal system

NICU Neonatal Intensive care unit

US Ultra sound

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 III. Table of Contents
page No.
I. Acknowledgment.................................................................................................. II

II. Acronyms............................................................................................................ III

III. Table of Contents............................................................................................. IV

1. Myelomeningocele case report............................................................................ 1

2. Keywords.............................................................................................................. 1

3. Abstract................................................................................................................ 1

4. INTRODUCTION.................................................................................................... 2

5. Time line.............................................................................................................. 2

6. Patient Information/ History.................................................................................3

7. Chief compliant.................................................................................................... 3

8. Physical Examination........................................................................................... 3

9. Diagnostic Assessment/Investigation/..................................................................4

10. Diagnosis/Assessment/..................................................................................... 5

12. Interventions/ Management/............................................................................. 5

13. Follow up and out come........................................................................................ 6

14. Discussion......................................................................................................... 7

15. Reference......................................................................................................... 9

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 1. Myelomeningocele case report

2. Keywords
Spinal bifida, myelomeningocele, Neonate, lumbosacral area, Case
report

3. Abstract
Background: Spinal Bifida means "split spine there are 4 types of Spina Bifida:

Spinal bifida occult a, Meningocele, Spina bifida cystic (Myelomeningocele) and Lip

meningocele. Meningomyelocele is the most severe type of spinal bifida. This occurs
due to failure of closure of the neural tube during the third week of gestation due to
abnormal differentiation of the embryonic neural tube. In Meningomyelocele, a cystic
swelling occurs over the site of the spinal defect which contains meninges, nerve roots,
and the spinal cord itself which has left the vertebral canal. It has 1-2/1000 live birth,
slightly higher in females than in males (1.2:1) [1].

Myelomeningocele is the most common open spinal diastrophism eligible for surgical

Repair. Traditionally, myelomeningocele patients that received no surgical intervention

had a dismal prognosis. [2]

Case summary: A15 hours female neonate was presented with mass over lumbo-
sacral area since Birth. Otherwise no fever, no abnormal body movement, she can
move all extremities.

Conclusion: In this case report the neonate has a sever type of spinal bifida called
myelomeningocele but no neurological defect based on neuron-sign chart for this case.

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 4. INTRODUCTION
Myelomeningocele is the most common birth defect that involves the spine. Its etiology

Is unknown but there is evidence of genetic and environmental influence. In August

1991, the CDC (Centers for Disease Control and Prevention) recommended the use of

folic acid during the pre- conception period. This recommendation was based on a

Randomized, double-blind, multicentre executed in Europe which clearly demonstrated

the protective effect of foliate in preconception reducing the recurrence of spinal bifida.

The Myelomeningocele presumably occurs when the posterior neurosporene fails to

close or reopens as a result of the relaxation of the central canal of the spinal cord. This

abnormality of the spinal cord is only part of a large complex of central nervous system

including: hydrocephalus, dysgenesis of the corpus call sum and Chari malformation

Type II.

5. Time line

This case report is organized and conducted from 19/06/09 to 24/06/09 E.C.

Day one - visiting hospital

Day two - selecting the case, assemble necessary materials and data collection

Day three and day four - organizing the data and consulting the physicians

Day five presenting the case report

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 6. Patient Information/ History
A15 hrs old female neonate with MRN 556412 born from a 36 years old para v all alive
mother at G.A of 39 +2 weeks from Bahir Dar town with reliable last normal menstrual
period (LNMP) has no privies similar history .She had ANC follow up and she was not
vaccinated with TT B/C she was completed in previous pregnancy. She was
supplemented with iron and folic acid for 1 month at the 4th month of Gestation.

7. Chief compliant
Currently the neonate presented with swelling over the lower lumbo sacral area since
birth.

8. Physical Examination
G/A, well looking, PR, 140bpm, RR, 58bpm, T., 37.5c, Wt, 3.69kg, Head c., 34 cm

Length, 50 cm

HEENT: has pink conjunctiva

LGS: No LAP (lymphoadinopathy)

Chest: No SC/IC retraction, clear chest with good bilateral air entry

CVS: S1 & S2 are well heard, no murmur or No gallop

Abdomen: Full abdomen which moves with respiration, no mss, no palpable

organomegally, fluctuant cystic mass over lumbosacral area.

GUS: Female type external genitalia

MSKS: There is 8 x 9 cm Fluctuant cyst mass over the lumbosacral area it is

covered with thin tissue and has visible fluid. The defect is palpable over the
midline of lumbosacral area.

INT: No rash and pallor

CNS: Conscious, all neonatal reflexes are intact; Moro complete, sacking-sustained,
grasp sustained, ton norm tonic and she can move well all extremities
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 9. Diagnostic Assessment/Investigation/
Plan: CBC, BG&RH, Abdominal U/S, Trans fontanels U/S, Renal function test

Complete blood cell count

WBC 19.3x103/ul, lymph 5.2 x103/ul, Mid 2.2 x103/ul, Gran 11.9 x103/ul, Lymp% 27.1,
Mid% 11.3, Gran% 61.6, HGB 17.9 g/dl, RBC 4.5x1012/l, HCT 48.6%, MCV 108.2fl,
MCH 39.7pg, MCHC 36.8 g/dl, RDW-CV 16.2, RDWSD 69.4fl, PLT 213x103/ul, MPV
8.2fl, PDW 15.8, PCT 0.174 %.

Abdominal ultra sound

There is large back predominant cystic mass with soft tissue with fluid come Out
from the spinal canal.

Index meningomyelocele + mild asymmetric hydrocephalic

Trans fontanel ultra sound

The ventricular system mildly dilated 3rd -4.7 cm, lateral 1.2 cm.

Right lateral ventricular more dilated than the left.

Normal brain parenchyma, normal posterior tissue structure

Index mild hydrocephalus/asymmetric/, secondary to aqueduct system

Renal function test

Name Concentration unit result remark reference

Creatinin 0.69 mg/dl N 0.50-1.20
e
Urea 16 Mg/dl N 10-55
Blood Group and RH =A+

10. Diagnosis/Assessment/
Term (39+2 weeks) + NBW (3.69 KG) appropriate for gestational age (AGA) +

Meningomyelocele
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 11. Case definition

Mebingomyelocele is a birth defect in which the spinal canal and the back bone dont
close before the baby is born, the spinal cord and the meanings (the tissue that covers
the spinal cord) may actually protrude through the back.

12. Interventions/ Management/

She was admitted to Neonatal intensive care unit (NICU). The defect is

Dressed with lose soaked goose in baseline and She was being followed with neuro
sign chart and vital sign sheet.

This table shows neuron sign chart result of the neonate

Date time PR RR T Vomiting Seizure LOC Pupil size HC

22/05/09 12:00 D 140bpm 43 bpm 36.7co No no conscious Normal 34 cm

5:30 N 145bpm 48 bpm 37.1 co No no ,, ,, ,,
8:10 N 135bpm 58 bpm 37.4 co No no ,, ,, ,,
1:30 D 140 bpm 59 bpm 37.5 co No no ,, ,,
23/05/09 8:00 D 128bpm 69bpm 38.3 co No No ,, ,, 34 cm
9:05 D 132bpm 54bpm 38.2co No No ,, ,, ,,
Added orders

Admit to maternal side and Consult surgical side

Daily wound care

Ampicillin 370 mg IV BID and Gentamycine 27 mg SIV daily

Follow vital sign and urine out put

13. Follow up and out come

After she stayed in Felege Hiwot Referral hospital for one day, she develops fever at
second day of admission and received 1 episode antimenengial dose of
Ampiciline(370mg), and Gentamycin (27mg) and referred to A.A Black Lion Hospital.

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 14. Discussion
Spinal diastrophism is a congenital closing disorder of the neural tube reported in 2
4/1, 000 live births [3]. Several types of spinal bifida, involving protrusion of the spinal
cord and/or meninges, through a defect in the vertebral arch, are often referred to
collectively as spinal bifida cystic because of the cyst-like sac that is associated with
these malformations. When the sac contains meninges and cerebrospinal fluid, the
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condition is called meningocele. In case of meningomyelocele, the sac also contains
neural elements. The most severe type of spina bifida cystic is called myeloschisis, also
known as myelocele. In these cases, the spinal cord is open because the neural folds
failed to meet and fuse, and as a result, the spinal cord is flattened [4]. Meningoceles
can occur anywhere on the neural axis, but are located more often in the lumbar and
lumbosacral region than in the cervical and thoracic region. In the study of Ersahin et al.
[5] 2 out of 22 cases of spinal meningoceles were located in the upper and mid thoracic
region and Doran and Guthkelch [6] reported 65 children with a spinal meningocele of
which 7 were thoracic

Strength: Strength of this case report is it is useful for studying signs and symptoms of
meningeomyelocele, creating case definitions, very useful in providing critical
information, for hypothesis generation, also this case report has done by consulting the
physician and revving many records like radiography and laboratory results are referred.

Limitation: The limitation of this case report is the patient outcome is yet not known
because it was refer to A.A Black lion hospital.

Radiograph and Radiology image of the neonate is not attached in this case report due
to absence of this document from the pt. chart.

There is no evidence for familial history rather than the mother and neonate history.

Hypothesis: In this case report we have hypothesized that the mother of the
neonate does not take folic acid in her pre-conception period ,so the defect may
be due to lack of folic acid deficiency or it may resulted from farther genetically
defect.

Conclusion: We presented a child born with a lumbosacral myelomeningocele, which

is a rare lesion. Usually, there is neurological deficit in most myelomeningocele, but
based on neurological sign chart there is no signs and symptoms of neurological
disorder in this case. Surgical treatment consists of resection of the sac, dissecting the

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tissue band running inside the sac, and transecting the adhesions at the base of the
cele in order to untether the spinal cord to prevent future deterioration.

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 15. Reference
1. Rendeli C.et.al;does locomotion improve the cognitive profile of children

with meningomyocele; childs nerv syst(2002)18:231-234

2. Journal of Clinical Case Report Ryan P Morton1*, Tanya Z Filardi1 and

Trent L Tredway2

3. Laurence K: A declining incidcncc of neural tube defects in the UK. Z Kinderchir

1989; 44(suppl 1):5 1.

4. Moore KL: The Developing Human. Clinically Oriented Embryology. Philadelphia,

Saunders, 1988.

5. Ersahin Y, Barcin E, Mutluer S: Is meningocele really an isolated lesion? Childs

Nerv Syst 2001; 17:487-490.

6. Doran PA, Guthkelch A: Studies in spinal bifi-da cystica. l. General survey and

reassessment of the problem. J Neurol Neurosurg Psychiatry