{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T14:42:34Z","timestamp":1790347354615,"version":"4.1.0"},"reference-count":13,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["PED"],"published-print":{"date-parts":[[2015,12]]},"abstract":"<jats:sec>\n<jats:title>OBJECT<\/jats:title>\n<jats:p>The Management of Myelomeningocele Study (MOMS) was a multicenter randomized trial comparing the safety and efficacy of prenatal and postnatal closure of myelomeningocele. The trial was stopped early because of the demonstrated efficacy of prenatal surgery, and outcomes on 158 of 183 pregnancies were reported. Here, the authors update the 1-year outcomes for the complete trial, analyze the primary and related outcomes, and evaluate whether specific prerandomization risk factors are associated with prenatal surgery benefit.<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>The primary outcome was a composite of fetal loss or any of the following: infant death, CSF shunt placement, or meeting the prespecified criteria for shunt placement. Primary outcome, actual shunt placement, and shunt revision rates for prenatal versus postnatal repair were compared. The shunt criteria were reassessed to determine which were most concordant with practice, and a new composite outcome was created from the primary outcome by replacing the original criteria for CSF shunt placement with the revised criteria. The authors used logistic regression to estimate whether there were interactions between the type of surgery and known prenatal risk factors (lesion level, gestational age, degree of hindbrain herniation, and ventricle size) for shunt placement, and to determine which factors were associated with shunting among those infants who underwent prenatal surgery.<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>Ninety-one women were randomized to prenatal surgery and 92 to postnatal repair. The primary outcome occurred in 73% of infants in the prenatal surgery group and in 98% in the postnatal group (p &lt; 0.0001). Actual rates of shunt placement were only 44% and 84% in the 2 groups, respectively (p &lt; 0.0001). The authors revised the most commonly met criterion to require overt clinical signs of increased intracranial pressure, defined as split sutures, bulging fontanelle, or sunsetting eyes, in addition to increasing head circumference or hydrocephalus. Using these modified criteria, only 3 patients in each group met criteria but did not receive a shunt. For the revised composite outcome, there was a difference between the prenatal and postnatal surgery groups: 49.5% versus 87.0% (p &lt; 0.0001). There was also a significant reduction in the number of children who had a shunt placed and then required a revision by 1 year of age in the prenatal group (15.4% vs 40.2%, relative risk 0.38 [95% CI 0.22\u20130.66]). In the prenatal surgery group, 20% of those with ventricle size &lt; 10 mm at initial screening, 45.2% with ventricle size of 10 up to 15 mm, and 79.0% with ventricle size \u2265 15 mm received a shunt, whereas in the postnatal group, 79.4%, 86.0%, and 87.5%, respectively, received a shunt (p = 0.02). Lesion level and degree of hindbrain herniation appeared to have no effect on the eventual need for shunting (p = 0.19 and p = 0.13, respectively). Similar results were obtained for the revised outcome.<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>Larger ventricles at initial screening are associated with an increased need for shunting among those undergoing fetal surgery for myelomeningocele. During prenatal counseling, care should be exercised in recommending prenatal surgery when the ventricles are 15 mm or larger because prenatal surgery does not appear to improve outcome in this group. The revised criteria may be useful as guidelines for treating hydrocephalus in this group.<\/jats:p><\/jats:sec>","DOI":"10.3171\/2015.7.peds15336","type":"journal-article","created":{"date-parts":[[2015,9,15]],"date-time":"2015-09-15T08:01:12Z","timestamp":1442304072000},"page":"613-620","source":"Crossref","is-referenced-by-count":219,"title":["Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement"],"prefix":"10.3171","volume":"16","author":[{"given":"Noel","family":"Tulipan","sequence":"first","affiliation":[{"name":"Departments of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John C.","family":"Wellons","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth A.","family":"Thom","sequence":"additional","affiliation":[{"name":"The Biostatistics Center, George Washington University, Washington, DC;\u00a0"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nalin","family":"Gupta","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leslie N.","family":"Sutton","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pamela K.","family":"Burrows","sequence":"additional","affiliation":[{"name":"The Biostatistics Center, George Washington University, Washington, DC;\u00a0"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diana","family":"Farmer","sequence":"additional","affiliation":[{"name":"Surgery, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William","family":"Walsh","sequence":"additional","affiliation":[{"name":"Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark P.","family":"Johnson","sequence":"additional","affiliation":[{"name":"Center for Fetal Diagnosis and Treatment, The Children\u2019s Hospital of Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Larry","family":"Rand","sequence":"additional","affiliation":[{"name":"Obstetrics and Gynecology, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan","family":"Tolivaisa","sequence":"additional","affiliation":[{"name":"Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary E.","family":"D\u2019alton","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Columbia University, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"N. Scott","family":"Adzick","sequence":"additional","affiliation":[{"name":"Center for Fetal Diagnosis and Treatment, The Children\u2019s Hospital of Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1-peds15336","series-title":"N Engl J Med","doi-asserted-by":"publisher","first-page":"993","DOI":"10.1056\/NEJMoa1014379","article-title":"A randomized trial of prenatal versus postnatal repair of myelomeningocele","volume":"364","author":"Adzick","year":"2011"},{"key":"b2-peds15336","series-title":"Radiology","doi-asserted-by":"publisher","first-page":"703","DOI":"10.1148\/radiology.190.3.8115615","article-title":"Prevalence of ventriculomegaly in association with myelomeningocele: correlation with gestational age and severity of posterior fossa deformity","volume":"190","author":"Babcook","year":"1994"},{"key":"b3-peds15336","series-title":"Childs Nerv 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Trials","author":"Friedman","year":"2010"},{"key":"b7-peds15336","series-title":"J Neurosurg Pediatr","doi-asserted-by":"publisher","first-page":"145","DOI":"10.3171\/2013.11.PEDS13197","article-title":"Hydrocephalus research funding from the National Institutes of Health: a 10-year perspective","volume":"13","author":"Gross","year":"2014"},{"key":"b8-peds15336","series-title":"J Neurosurg Pediatr","doi-asserted-by":"publisher","first-page":"224","DOI":"10.3171\/2014.6.PEDS13492","article-title":"Endoscopic third ventriculostomy and choroid plexus cauterization in infants with hydrocephalus: a retrospective Hydrocephalus Clinical Research Network study","volume":"14","author":"Kulkarni","year":"2014"},{"key":"b9-peds15336","series-title":"Pediatr Neurosurg","doi-asserted-by":"publisher","first-page":"245","DOI":"10.1159\/000028730","article-title":"Frontal and occipital horn ratio: A linear estimate of ventricular size for multiple imaging modalities in pediatric hydrocephalus","volume":"29","author":"O\u2019Hayon","year":"1998"},{"key":"b10-peds15336","series-title":"Pediatrics","doi-asserted-by":"publisher","first-page":"409","DOI":"10.1542\/peds.109.3.409","article-title":"A new look at myelomeningoceles: functional level, vertebral level, shunting, and the implications for fetal intervention","volume":"109","author":"Rintoul","year":"2002"},{"key":"b11-peds15336","series-title":"J Neurosurg Pediatr","doi-asserted-by":"publisher","first-page":"473","DOI":"10.3171\/2012.1.PEDS11292","article-title":"Center effect and other factors influencing temporization and shunting of cerebrospinal fluid in preterm infants with intraventricular hemorrhage","volume":"9","author":"Riva-Cambrin","year":"2012"},{"key":"b12-peds15336","series-title":"J Neurosurg Pediatr","doi-asserted-by":"publisher","first-page":"439","DOI":"10.3171\/2014.7.PEDS14152","article-title":"Combined endoscopic third ventriculostomy and choroid plexus cauterization as primary treatment for infant hydrocephalus: a prospective North American series","volume":"14","author":"Stone","year":"2014"},{"key":"b13-peds15336","series-title":"J Neurosurg Pediatr","doi-asserted-by":"publisher","first-page":"12","DOI":"10.3171\/2012.10.PEDS12329","article-title":"The assessment of bulging fontanel and splitting of sutures in premature infants: an interrater reliability study by the Hydrocephalus Clinical Research Network","volume":"11","author":"Wellons","year":"2013"}],"container-title":["Journal of Neurosurgery: 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