Meningocele and meningocele with spinal cord

　　Meningocele and meningocele with spinal cord are caused by congenital factors leading to incomplete closure of the vertebral plates, with the meninges, spinal cord, and nerves prolapsing into the vertebral plate defect. The etiology of this disease is not yet clear. This condition is most common in the median line of the dorsal side of the spine, with the lumbar and sacral segment being the most common, and a few occur in the cervical or thoracic segment. In some cases, there may be prolapse from the paravertebral side through the expanded intervertebral foramen into the lateral side of the spinal canal, or the prolapsed sac extends to the posterior wall of the pharynx, the thoracic cavity, the abdominal cavity, and the pelvic cavity. Meningocele is generally solitary, and multiple occurrences are rare. Meningocele may coexist with congenital hydrocephalus.

　　The main complications after meningocele surgery are cerebrospinal fluid leakage and the resulting meningitis, etc. To prevent cerebrospinal fluid leakage, in addition to the strict suture of the dura mater, reinforcing the defect of the lumbar and sacral region with the lumbar and sacral fascia can significantly reduce the incidence of this complication. Postoperative application of antibiotics that can pass through the blood-cerebrospinal fluid barrier can reduce the incidence of meningitis.

　　The manifestations of meningocele and meningocele with spinal cord can be divided into the following three aspects

　　1. Local mass
　　At birth, a cystic mass can be seen at the neck, chest, or lumbosacral region along the median line of the back, with varying sizes from dates to giant. The mass is round or elliptical, most of which have a wide base, a few are strip-like, the surface skin is normal, and sometimes it shows scar-like changes or is thin. When the baby cries, the mass swells, and compressing the mass causes the anterior fontanelle to swell. In simple meningocele cases, the degree of translucency is high; for meningocele with spinal cord involvement, as it contains spinal cord and nerve roots, some shadows can be seen inside the mass; if it is a meningocele or meningocele with lipoma, due to the outer covering of fatty tissue and the deep meningocele sac, the degree of translucency is lower.

　　2. Neurological damage symptoms
　　Simple epidural hernia may not have symptoms of nervous system function. Those with myelomeningoceles and malformation or degeneration of the spinal cord end, forming a spinal cavity, have more severe symptoms, often with varying degrees of paralysis of the lower limbs and incontinence of urine and feces. Severe neurological damage symptoms caused by lumbar sacral lesions are much more than those caused by cervical and chest lesions, including malformation of the feet (such as inversion, eversion, and kyphosis of the foot), muscle atrophy, unequal length of the lower limbs, accompanied by numbness, weakness, and dysfunction of the autonomic nervous system, etc. The spinal cord tethering itself formed by the spinal cord and meninges can further worsen with age and growth in height, and the tethered cord syndrome can also worsen. The exposure of the spinal cord usually shows severe neurological symptoms and also depends on the degree of spinal cord malformation.

　　3. Other symptoms
　　A few cases of epidural hernia may extend to the lateral side of the spinal canal or the posterior wall of the pharynx, the thoracic and abdominal cavities, and the pelvic cavity, showing symptoms of the protruding sac compressing adjacent tissues and organs. Some children with myelomeningoceles may have other malformations such as hydrocephalus and scoliosis, and may appear corresponding symptoms.

　　To prevent epidural hernia and myelomeningoceles, pregnant women should avoid sitting for too long in front of computers, microwave ovens, and other places with strong magnetic fields in the early stages of pregnancy (before 3 months), as the fetus is not stable at this time, and all organs are in the stage of formation, which may cause congenital diseases in children. In addition, taking folic acid drugs or food fortification supplements for folic acid in the early stages of pregnancy can reduce the incidence of congenital spina bifida, myelomeningoceles, and meningocele.

　　The diagnosis of epidural hernia and myelomeningoceles, in addition to relying on clinical manifestations, also requires relevant auxiliary examinations. The main examinations are as follows:
　　1. Spinal X-ray film It can show the changes in the bony structure of the spinal bifida. For those protruding into the thoracic and abdominal cavities, there is often an enlargement of the intervertebral foramen; for those protruding into the pelvic cavity, there is often a significant enlargement of the sacrum.
　　2. CT, MRI scanning It can show pathological conditions such as malformations of the spine, spinal cord, and nerves, as well as local adhesions.

　　The health care and diet of patients with epidural hernia and myelomeningoceles should mainly pay attention to the following issues:
　　1. Vigorously promote the oral administration of folic acid drugs or food fortification supplements for folic acid in pregnant women in the early stages of pregnancy to reduce the incidence of congenital spina bifida, myelomeningoceles, and meningocele.
　　5. Do a good job of prenatal care and prenatal diagnosis, and induce labor in time for abnormal fetuses found, to reduce the birth of children with the disease.
　　4. Cooperate actively with the doctor's treatment, pay attention to diet and nutrition, strengthen physical exercise and functional training. Improve the quality of life of patients.

　　Epidural hernia and myelomeningoceles should be treated surgically in principle, and the earlier the surgery, the better the effect. The specific surgical methods are as follows:

　　I. Basic Points of Surgery
　　I. Excising the meningeal hernia sac and repairing soft tissue defects, for those with simple meningeal hernia, cure can be achieved through this surgery.
　　II. To explore the condition of the spinal cord and nerve roots herniating into the meningeal sac, it is advisable to free and dissect it under the operating microscope to return it to the spinal canal, and it should never be blindly excised.
　　III. For spinal and meningeal hernia surgery, it is usually necessary to expand the vertebral plate incision upwards and downwards to facilitate exploration and treatment of the intraspinal canal, which is conducive to the return of the herniated nerve tissue.
　　IV. For those with hydrocephalus and symptoms of increased intracranial pressure, cerebrospinal fluid diversion surgery should be performed first to relieve intracranial hypertension, and then the excision and repair of the meningeal hernia can be performed in the second step.
　　For herniated meningeal sacs extending to the posterior wall of the pharynx, thoracic cavity, abdominal cavity, and pelvic cavity, it is often necessary to perform vertebral plate incision and invite physicians from related disciplines to perform combined surgery in the posterior pharynx, thorax, abdomen, and pelvic cavity.

　　II. Anesthesia and Position Surgery is usually performed under local anesthesia with reinforced anesthesia, or general anesthesia can be adopted according to the situation. Generally, the prone position is adopted.

　　III. Surgical Incision Straight incisions or transverse incisions are adopted according to the size and shape of the mass. Straight incisions are more conducive to expanding the vertebral plate incision upwards and downwards for exploration.

　　IV. Surgical Steps The first step is to make a skin incision, free the meningeal sac to the area near the defect of the vertebral plate. If the herniated sac is too large, the needle should be used first to drain the fluid inside the sac to reduce its volume and explore the need to expand the vertebral plate incision; the second step is to explore the contents of the sac, free the nerve tissue and handle it according to different situations to achieve the requirement of returning the nerve tissue, and it is also possible to perform intraspinal exploration at the same time; the third step is to excise and repair the herniated sac, as well as strengthen the suture repair of the external muscular layer. Bone defects do not require repair.

　　V. Surgery for Infants and Young Children When performing spinal and meningeal hernia surgery on infants and young children, comprehensive consideration should be given to their overall condition and the tolerance for surgery. The infusion and blood transfusion during the operation should be guaranteed, which is very important to avoid hemorrhagic shock during the operation and the risk of life-threatening conditions.