Carreras E1, Maroto A1, Illescas T1, Meléndez M2, Arévalo S1, Peiró JL3, García-Fontecha CG4, Belfort M5 and Cuxart A2. 1Maternal-Foetal Medicine, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain 2 Physical Medicine and Rehabilitation. Hospital Universitari Vall d’Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain 3 Paediatric Surgery. Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona,Barcelona, Spain 4 Paediatric Orthopaedic Surgery, Hospital Universitari Vall d’Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain 5 Maternal-Foetal Medicine. Texas Children’s Hospital. Houston, TX, USA KEYWORDS: myelomeningocele, prenatal ultrasonography, neurological examination, fetal surgery.

ABSTRACT
Objectives To report our preliminary experience in the use of prenatal ultrasound to explore lower-limb movements in fetuses with myelomeningocele. We aim to determine the accuracy of this method to establish the segmental level of neurological lesion, since this is the best known predictor for the future ability to walk. Methods Preliminary, observational study including fetuses with myelomeningocele operated on prenatally. The patterns of movements present and absent in the affected fetuses’ lower limbs were systematically evaluated by ultrasound. According to the known nerve function associated to each muscle group, the segmental level of neurological lesion was therefore established before birth. The agreement for the segmental levels assigned, between this prenatal ultrasound technique and the classical neurological clinical examination after birth (gold standard), was tested using the weighed Kappa (wκ) index.
Results Seventy-one fetuses with myelomeningocele were evaluated at the Hospital Universitari Vall d’Hebron. After counselling, the parents opted for prenatal surgery (26 cases), termination of pregnancy (43 cases) or postnatal repair (2 cases). Five patients didn’t fulfil the inclusion criteria for prenatal surgery and 3 were excluded after birth. In the 18 operated fetuses finally evaluated, the agreement between prenatal and postnatal segmental levels assigned was 91.7% for the right limb (wκ=0.80) and 88.9% for the left limb (wκ=0.73).
Discussion The agreement found between prenatal and postnatal results in this preliminary study suggests that the neurological sonographic evaluation is feasible before birth. This may provide accurate individualized information about the motor function and future ambulation prognosis of fetuses with myelomeningocele.