{"id":5859,"date":"2015-12-28T09:52:20","date_gmt":"2015-12-28T09:52:20","guid":{"rendered":"http:\/\/biomedpharmajournal.org\/?p=5859"},"modified":"2016-02-27T05:34:52","modified_gmt":"2016-02-27T05:34:52","slug":"the-results-of-clinical-examination-of-children-about-one-year-with-spinal-hernia","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol8no2\/the-results-of-clinical-examination-of-children-about-one-year-with-spinal-hernia\/","title":{"rendered":"The Results of Clinical Examination of Children About One Year With Spinal Hernia"},"content":{"rendered":"

Introduction<\/strong><\/p>\n

Spinal hernia is one of the difficult and\u00a0poorly understood malformations of the central\u00a0nervous system. The problem of diagnosis and\u00a0surgical treatment of spinal hernias attracts the\u00a0attention of pediatric surgeons, neurosurgeons,\u00a0urologists, orthopedists, neurologists and other\u00a0doctors, but far from being solved [1, 2].<\/p>\n

The relatively high detection rate of spinal\u00a0hernia, clinical severity and poor treatment\u00a0outcomes of a number of its forms make the problem\u00a0of diagnosis and treatment to date and today [3, 4].\u00a0Polymorphism defeats as different strain, most\u00a0often, spine, and failure of segmental conductor\u00a0unit of the spinal cord, motor, sensory, autonomic\u00a0nerve roots of the spinal determine the clinical\u00a0manifestations of the disease. The combination of\u00a0various malformations are making significant\u00a0changes in the course of disease and transform\u00a0the clinical manifestations of spinal hernias, but the\u00a0origin of these combined, their clinical value
\nrequires further studies [5, 6].<\/p>\n

Objective: to study the main clinical\u00a0symptom of spinal hernias with different variants of\u00a0their location, shapes and combination of defects.<\/p>\n

Materials and Methods<\/strong><\/p>\n

The work is based on the results of clinical\u00a0examination of 30 children with spinal hernias\u00a0treated at the Department of Neurosurgery of the\u00a0regional children\u2019s hospital in Shymkent for 2013 –\u00a02015. The age of patients ranged from 1 day to 1\u00a0year. Of these, 12 were boys, girls – 18. Children\u00a0from birth to 1 month amounted to – 17 (56.6%),\u00a0from 1 month to 3 months – 8 (26.6%) from 3 months\u00a0to 6 months – 3 (10.0%), from 6 months to 1 year – 2\u00a01044\u00a0(6.7%). Among patients with spinal hernias\u00a0accounted for most of the children with\u00a0myelomeningocele (63.3%). Patients with\u00a0meningocoele was 4 (13.3%), with\u00a0meningoradiculocele 3 (10.0%), with myeloschisis\u00a0– 3 (10.0%), and a child with a terminal\u00a0myelocystocele (3.4%).<\/p>\n

By clinical and radiographic contrast\u00a0studies were isolated and studied mainly\u00a0meningocele, myelomeningocele and\u00a0menigoradiculocele. It is these forms of great interest\u00a0and are more promising in terms of postoperative\u00a0recovery and rehabilitation. [7]\n

Methods of examination\u00a0<\/strong><\/p>\n

In children with congenital spinal hernias\u00a0conducted physical and neurological examination,\u00a0intraskopic diagnostic methods. Pluricausal,\u00a0exceptional complexity of the pathogenesis and\u00a0clinical severity of malformations put forward\u00a0specific requirements for diagnostic procedures [8,9].<\/p>\n

Clinical examination in children with spinal\u00a0hernias include: identification of complaints,\u00a0anamnesis, external examination of the patient\u2019s\u00a0neurological examination data, evaluation results\u00a0of the study of the musculoskeletal system, urinary\u00a0system . For diagnosis it was necessary to collect a\u00a0good history. Inspection of local changes, largely\u00a0determined by the degree of urgency of the\u00a0operation, the need for toilets, disinfection and\u00a0surface treatment of a hernia. The facial expression,\u00a0body position and the nature of the Movement is in\u00a0itself important diagnostic indication. Skin\u00a0pigmentation, hypertrichosis, nevi indicated\u00a0meningocele or the presence of other\u00a0malformations. A very important point is the correct\u00a0assessment of the size of the head and its growth\u00a0rate, as well as the state of physiological\u00a0development.<\/p>\n

Neurological examination in children differ\u00a0from adults in connection with the anatomical and
\nphysiological characteristics of the growing\u00a0organism. Direct study of the nervous system\u00a0evolved from the study of reflex activity, cranial\u00a0nerves, motor activity, sensitivity. Neurological\u00a0examination of the child was preceded by a general\u00a0examination and the study of its physical\u00a0development. Identify disparities parts of the body,\u00a0changes in the size and shape of the skull, the\u00a0detection of congenital anomalies indicative of\u00a0current or adjourned disease of the nervous system.
\nA study of the musculoskeletal system\u00a0consisted of the evaluation of motor deficit, identify\u00a0deformities of the spine, extremities, clinical factors\u00a0contractures and deformities.<\/p>\n

Instrumental methods of research<\/strong><\/p>\n

The practice of child neurocasualty\u00a0department implemented different methods of beam\u00a0diagnostics of a pathology of the spine and spinal\u00a0cord: ultra sound, spondylography, computed\u00a0tomography, magnetic resonance imaging.<\/p>\n

Results<\/strong><\/p>\n

Visually spinal hernia represented tumor\u00a0protrusion, round or oval in shape, and dorsal\u00a0midline. Hernias often have a wide base and a leg,\u00a0so that they hung down and were as if suspended.<\/p>\n

A number of children with spinal hernia\u00a0on the periphery of herniation within healthy skin\u00a0and pilosity observed vascular pattern (50%). Skin\u00a0markers are present at open neural tube defects\u00a0[10]. Half of patients with spina bifida occulta found
\nsome form of the dermal embryopathy [11]. These\u00a0symptoms are often the key to recognizing the\u00a0spinal dysraphie. In this connection it is necessary\u00a0to exercise great caution when examining a child\u00a0who discovered lipomas, skin stigma dermal sinus,
\nhemangioma at the average line, hypertrichosis and\u00a0asymmetric folds of the buttocks [12, 13].<\/p>\n

With the growth of the child\u2019s size increased\u00a0herniation. And some children slowly (6), others\u00a0more rapidly (24). Rapidly growing hernia is usually\u00a0stretched and combined with hydrocephalus\u00a0(93.3%).<\/p>\n

Dimensions herniation were very different.\u00a0Large size is achieved spinal herniation of the\u00a0lumbar spine (36.6%). Consistency protrusions\u00a0dependent on the contents of the hernial sac and\u00a0preceding inflammatory processes which remained\u00a0after scarring wall hernia (20%). As a result of the\u00a0presence of the bone defect of the rear wall of the\u00a0spinal canal under the influence of high pressure\u00a0cerebrospinal fluid in the subarachnoid space to\u00a0the spinal cord and membranes protrude roots,\u00a0forming a mass lesion partially or completely\u00a0covered with leather.<\/p>\n

Skin herniation in 93.3% of cases were as\u00a0thin as tissue paper, and had a tendency to break.\u00a0Sometimes there is a maceration of the skin due to\u00a0constant rubbing of clothing, joined inflammatory\u00a0changes (26.6%). Especially difficult the infected\u00a0spinal hernia lumbar, lumbosacral, and sacral\u00a0localization. The lower localized hernia, the more\u00a0happening inflammation of the skin, their\u00a0maceration and create more conditions to break\u00a0the hernia sac with subsequent formation of\u00a0cerebrospinal fluid fistula.<\/p>\n

Movement disorders ranged from flaccid\u00a0paralysis to subtle disturbances. With involvement\u00a0of the spinal cord and its roots in the hernial sac\u00a0arose paraplegic. The basis of neurological\u00a0disorders were the disorder mechanisms\u00a0innervation of the lower extremities and was seen\u00a0by us as a result of gross underdevelopment of the\u00a0spinal cord (myelodysplasia). But not completely\u00a0clear mechanisms responsible for progressive\u00a0neurological disorders in patients with spinal\u00a0hernias [14, 15]. In our study, lower flaccid\u00a0paraparesis occurred in 63.3% of cases, and\u00a0paraplegia occurred in 16.6% of cases.<\/p>\n

Discussion<\/strong><\/p>\n

More than 70% of patients with\u00a0myelomeningocele arose combined incontinence.\u00a0Violations of urodynamics of the lower urinary tract,\u00a0which arose at an early age, contribute to the\u00a0development ureterohydronephrosis,\u00a0vesicoureteral reflux, and often are the cause of\u00a0severe kidney damage (renal disease, reflux\u00a0nephropathy, etc..) Later in life. [7] Obstructive\u00a0uropathy (vesicoureteral reflux,\u00a0hydroureteronephrosis, pyelectasia) are observed\u00a0in 30-50% of patients with spinal hernias [16, 17].<\/p>\n

We have observed a combination of\u00a0functional disorders of the spinal cord with other\u00a0anomalies and malformations. Identified exotropia\u00a0(3), bilateral clubfoot (9), congenital dislocation of\u00a0the hip joint (4). Neuro-orthopedic syndromes\u00a0manifest bone deformities and muscle atrophy in\u00a0the lower limbs, unsteady gait, pain in the limbs\u00a0and scoliosis [18, 19]. The anomalies of the spine\u00a0occur in patients with spinal hernias include: spina\u00a0bifida, sacred aplasia, segmentation violation and
\ncan be detected in 75% – 95% of children [20, 21,\u00a022].<\/p>\n

Spinal hernia, especially in children under\u00a0one year, is often associated with disorders of the\u00a0flow of cerebrospinal fluid, which result in\u00a0hydrocephalus (93.3%). Postoperatively, these\u00a0patients in 60% of cases, there is an increase\u00a0hydrocephalic syndrome, cerebrospinal fluid fistula\u00a0occurred, liquorrhea discrepancy cranial sutures\u00a0with the accession of inflammatory complications.
\nThe success of the combination treatment of spinal\u00a0hernias with hydrocephalus is largely dependent\u00a0on the nature of the anatomical and functional\u00a0disorders, and early diagnosis of shunting\u00a0operations.<\/p>\n

Hydrocephalus is one of the constituent\u00a0elements of the classic symptom complex\u00a0congenital spinal hernias (dysfunction of the lower\u00a0extremities, pelvic disorders, orthopedic\u00a0manifestations). Hydrocephalus occurs mainly in\u00a0open forms dysraphie (spina bifida aperta) and\u00a0before the introduction of shunting operations are\u00a0the leading cause of death and poor intellectual
\ndevelopment of children [23]. Surgical correction\u00a0(shunting operations) require 80-95% of patients\u00a0with spina bifida aperta [24, 25]. According Tulipan\u00a0N. et al. (2003), the frequency shunting operations\u00a0within a year of life of these patients is 93% of the\u00a0patients [26].<\/p>\n

We have conducted 18 operations for\u00a0progressive hydrocephalus after excision of spinal\u00a0hernias. Our research has shown that babies with\u00a0severe and progressive hydrocephalus require\u00a0emergency surgery, while moderately expressed\u00a0and not expressed ventri\u00f1ulodilatation signs of\u00a0increased intracranial pressure allow intervention\u00a0to delay or even postpone it. When the primary\u00a0bypass surgery efficiency was quite low (30%),\u00a0which is consistent with the world literature [27].\u00a0This is due mainly to the peculiarities of the\u00a0anatomical structure of III ventricle at\u00a0meningomyelocele – ventricle less it extended its\u00a0bottom denser and elastic. Therefore, urgent\u00a0interventions we did not use tactics of simultaneous\u00a0or prior shunting operations. On the one hand,\u00a0sought to minimize the duration of the operation,\u00a0and on the other side – there was no expressed\u00a0intracranial hypertension in the presence of\u00a0cerebrospinal fluid.<\/p>\n

Postpartum hydrocephalus stated\u00a0approximately 15-25% of cases of children with\u00a0meningomyelocele [28, 23]. Therefore, congenital\u00a0hydrocephalus congenital spinal hernias often not\u00a0diagnosed. Most hydrocephalus developed after\u00a0the \u201cclosing\u201d of the spinal defect. The need for\u00a0shunting interventions occurred in 10 of 15 infants\u00a0(75%) operated on urgent indications, operations\u00a0were carried out in 1-3 months after the initial\u00a0intervention.<\/p>\n

According to the literature of shunt\u00a0dysfunction occurs in 51-86% of children with\u00a0myelomeningocele who underwent shunt surgery\u00a0for hydrocephalus. Most complications develop\u00a0during the first year after bypass surgery [29, 30].\u00a0According to our data of 18 operated in 8 cases\u00a0was the dysfunction of the shunt system, and all the\u00a0cases developed within the first year after bypass\u00a0surgery.<\/p>\n

Conclusions<\/strong><\/p>\n

    \n
  1. The clinical picture of the disease in children\u00a0with spinal hernia depends on the location,\u00a0and the progression of the depth of the lesion\u00a0of the spinal cord and roots, the presence\u00a0and severity of associated malformations,\u00a0the child\u2019s age.<\/li>\n
  2. Children under 1 year with spinal hernias\u00a0observed neurological changes of the lower\u00a0extremities (paraparesis – 63.3%, paraplegia\u00a0– 16.6%), pelvic disorders (70.5%) and the\u00a0combination with other anomalies and\u00a0malformations (hydrocephalus – 93.3%,\u00a0bilateral clubfoot – 30.0%, congenital\u00a0dislocation of the hip joint -13.3%, exotropia\u00a0– 10,0%).<\/li>\n
  3. Disability of patients with spinal hernia is\u00a0mainly determined by the degree of\u00a0involvement in the pathological process of\u00a0the spinal cord and its roots\u00a0(myelomeningocele – 63.3%).<\/li>\n
  4. Hydrocephalus is a common and lifethreatening\u00a0brain injury combined with the\u00a0congenital malformations of the central\u00a0nervous system.<\/li>\n
  5. Better results of treatment of hydrocephalus\u00a0was the determining factor in long-term\u00a0positive results of treatment of spinal hernias\u00a0in children.<\/li>\n<\/ol>\n

    References<\/strong><\/p>\n

      \n
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    29. Caldarelli M., Di Rocco C., La Marca F. Shunt\u00a0complications in the first postoperative year\u00a0in children with meningomyelocele. Childs\u00a0Nerv. Syst. 12: 748-754 (1996).<\/li>\n
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      Introduction Spinal hernia is one of the difficult and\u00a0poorly understood […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[11],"tags":[],"class_list":["post-5859","post","type-post","status-publish","format-standard","hentry","category-vol8no2"],"_links":{"self":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/5859","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/comments?post=5859"}],"version-history":[{"count":6,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/5859\/revisions"}],"predecessor-version":[{"id":6500,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/5859\/revisions\/6500"}],"wp:attachment":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/media?parent=5859"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/categories?post=5859"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/tags?post=5859"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}