Seminar

Spina bida
Laura E Mitchell, N Scott Adzick, Jeanne Melchionne, Patrick S Pasquariello, Leslie N Sutton, Alexander S Whitehead
Lancet 2004; 364: 188595 Institute of Bioscience and Technology, The Texas A&M University System Health Science Center, TX, USA (L E Mitchell PhD);Department of Surgery, The University of Pennsylvania School of Medicine, PA, USA (Prof N S Adzick MD); Center for Fetal Diagnosis and Treatment, The Childrens Hospital of Philadelphia, PA, USA (Prof N S Adzick); Department of Pediatrics, The University of Pennsylvania School of Medicine, PA, USA (J Melchionne RN, Prof P S Pasquariello MD); Department of Neurosurgery, The University of Pennsylvania School of Medicine, PA, USA (Prof L N Sutton MD); Department of Pharmacology and Center for Pharmacogenetics, The University of Pennsylvania School of Medicine, PA, USA (Prof A S Whitehead DPhil) Correspondence to: Dr Laura E Mitchell, The Texas A&M University System, Health Science Center, Institute of Biosciences and Technology, 2121 W Holcombe Boulevard, Houston, Texas 77030-3303, USA lmitchell@ibt.tamhsc.edu

Spina bida results from failure of fusion of the caudal neural tube, and is one of the most common malformations of human structure. The causes of this disorder are heterogeneous and include chromosome abnormalities, single gene disorders, and teratogenic exposures. However, the cause is not known in most cases. Up to 70% of spina bida cases can be prevented by maternal, periconceptional folic acid supplementation. The mechanism underlying this protective effect is unknown, but it is likely to include genes that regulate folate transport and metabolism. Individuals with spina bida need both surgical and medical management. Although surgical closure of the malformation is generally done in the neonatal period, a randomised clinical trial to assess in utero closure of spina bida has been initiated in the USA. Medical management is a lifelong necessity for individuals with spina bida, and should be provided by a multidisciplinary team. Spina bida is a general term that encompasses a broad range of malformations. This review focuses on a subset of these malformations, which is characterised by caudal lesions affecting the spinal cord, vertebrae, and skin. These malformations are commonly referred to as spina bida, but are more accurately referred to as meningomyelocoeles. The neural tube (ie, the embryonic structure that develops into the spinal cord and brain) is formed by a sequence of events that is referred to as neurulation. The brain and most of the spinal cord are formed by primary neurulation, which involves the shaping, folding, and midline fusion of the neural plate. The number of fusion initiation sites in the human embryo has been debated.1,2 In man, primary neurulation extends caudally into the region of the future rst to fth sacral vertebrae (the exact location has not been rmly established),3,4 and is completed by about the 25th day post-conception. The most caudal portion of the spinal cord is formed by a distinct process called secondary neurulation, which does not include neural folding. Spina bida (meningomyelocoele) is a defect of primary neurulation that results from failure of fusion in the caudal region of the neural tube. Defects of primary neurulation that result from failure of fusion in the cranial region of the neural tube are called anencephaly. Data from animal models suggest that spina bida and anencephaly can result from disturbances in cell adhesion, or alterations in neural plate shaping or bending that prevent apposition of the neural folds.5 affected individuals do not have an underlying malformation syndrome. The list of variables that have been implicated as risk factors for the non-syndromic form of spina bida is long and varied, ranging from maternal consumption of blighted potatoes16 to a short inter-pregnancy interval.17 However, most of the associations that have been reported are weak and have not been replicated in subsequent studies. Consequently, only a few variables have been established, or are strongly suspected to be risk factors for spina bida (table 2).

Family history
A family history of spina bida or anencephaly is one of the strongest risk factors for these disorders. The risk for spina bida or anencephaly, or both, in the siblings of affected individuals ranges from 3% to 8% and is consistently higher than that of the general population.1822 An increase in the risk of spina bida has also been reported for second and third degree relatives of affected individuals.20,21,23,24 One study has suggested that the risk of having a child with spina bida or another type of neural tube defect might be increased in couples who have had a child with Downs syndrome, and the risk of having a child with this syndrome might be increased in couples who have had a child with a neural tube defect.25 However, these associations were not conrmed in a subsequent, independent study.26 Additional investigation is needed to conrm or rule out any potential link between these two disorders.

Epidemiology
Spina bida is one of the most common, serious malformations of human structure. At birth, it tends to be more common in girls than in boys. Additionally, the prevalence of spina bida varies across time, by region, and by both race and ethnicity (table 1). Since the early 1980s, estimation of the prevalence of spina bida in many industrialised countries has been complicated by the availability of prenatal diagnosis and the elective termination of some affected fetuses.1013 A recognised chromosomal, teratogenic, or Mendelian malformation syndrome can be identied in a small proportion of individuals with meningomyelocoeles.14,15 However, most
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Folic acid
It is generally accepted that inadequate intake of natural folate, or its synthetic form, folic acid, before and during

Search strategy and selection criteria This seminar is a personal overview and non-systematic synthesis of articles published in English over the past decade. Articles were selected from a MEDLINE search with the key words "spina bida","neural tube","folate","folic acid","meningomyelocoele".

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Time period

Prevalence (per 1000)

Variation across countries6 England and Wales 1996 031 Finland 1996 041 Norway 1996 057 Northern Netherlands 1996 063 Regional variation7 Northern China 199293 292 Southern China 199293 026 Temporal variation8 Eastern Ireland 1980 27 Eastern Ireland 1994 06 9 Ethnic and racial variation (California) Non-Hispanic White 199094 047 Hispanic 199094 042 African-American 199094 033 Asian 199094 020 Variation as a result of prenatal diagnosis and elective termination (England and Wales)6 Live and stillbirths only 1996 009 Live and stillbirths, plus terminations 1996 031

Table 1: Variation in spina bida prevalence

early pregnancy, is associated with an increased risk of spina bida and anencephaly. Case-control studies, randomised clinical trials, and community-based interventions with vitamin supplements have shown that the failure to consume folic acid supplements or folic acid-containing multivitamins increases the risk of having an affected child by two-fold to eight-fold.27 Moreover, the risk of having a child affected by a neural tube defect is indirectly related to both maternal folate and folic acid intake (from dietary sources and supplements)28 and maternal folate status.29,30 The mechanism underlying the association between neural tube defects and folate has not been established. However, folate participates in two metabolic pathways that, if disrupted, could have an adverse effect on the development of the embryo. One of these pathways is important for nucleic acid synthesis, and the other for a range of methylation reactions. Disruptions in folate metabolism can also result in raised homocysteine concentrations, which are teratogenic to the neural tube in some animal models.31 Nutrients other than folate, in particular vitamin B12, might also be associated with neural tube defects.32 A population-based, case-control study in Mexican-American women reported a three-fold increase in the risk of neural tube defects in the offspring of women with postpartum vitamin B12 concentrations in the lowest quintile, relative to the offspring of women with B12 concentrations in the highest quintile. This association remained after adjustment for dietary folate intake, red blood cell folate level, and other potential risk factors.33 Moreover, a systematic review of studies published before November, 2002, provided support for a moderate association between low maternal vitamin B12 concentrations and the risk of neural tube defects.34

defects (ie, diabetic embryopathy). In these women the risk of having a child with a malformation of the central nervous system, including spina bida, is two-fold to tenfold higher than the risk in the general population.35 The mechanism underlying this teratogenic effect has not been established, but it is clearly related to the degree of maternal metabolic control. Indeed, there is evidence that the risk of congenital malformations in the offspring of diabetic women is associated with rst-trimester blood glucose concentrations (assessed by glycosylated haemoglobin concentrations).35 Whether raised glucose concentrations are directly teratogenic, or whether they serve as a marker for another teratogenic agent (eg, ketone bodies, free oxygen radicals) is unclear.36 However, data from mouse models suggest that glucose has a direct teratogenic effect, and indicate that excess glucose might alter the expression of genes involved in embryonic development.37,38 The risk of congenital malformations in the offspring of women who develop gestational diabetes is lower than the risk to offspring of women with pregestational diabetes, but might not be as low as in the general population.39,40 The range of birth defects noted in the offspring of women who develop gestational diabetes seems to be similar to the diabetic embryopathy associated with pregestational diabetes.40,41 However, precise estimates of risk for specic malformations (eg, spina bida) are not available.

Drugs
Many anticonvulsant drugs are known teratogens. However, different anticonvulsants are associated with different constellations of malformations. An increased risk of spina bida is associated with in-utero exposure to valproic acid or carbamazepine alone, or in combination with each other or other anticonvulsants.4244 In infants exposed to valproic acid or carbamazepine the risk of spina bida might be as high as 1%2%.45 Women who use these drugs for indications other than epilepsy (eg, bipolar
Relative risk Established risk factors History of previous affected pregnancy with same partner Inadequate maternal intake of folic acid Pregestational maternal diabetes Valproic acid and carbamazepine Suspected risk factors Maternal vitamin B12 status Maternal obesity Maternal hyperthermia Maternal diarrhoea Gestational diabetes Fumonisins Paternal exposure to Agent Orange Chlorination disinfection by-products in drinking water Electromagnetic elds Hazardous waste sites Pesticides
NE=not established.

30 28 210 1020 3 1535 2 34 NE NE NE NE NE NE NE

Maternal diabetes
Women with pregestational diabetes are at increased risk of having a child with spina bida and other types of birth
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Table 2: Established and suspected risk factors for spina bida

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disease, migraine, chronic pain) are also at increased risk of having a child with spina bida if they become pregnant while taking these drugs. The mechanisms by which valproic acid and carbamazepine increase the risk of spina bida have not been established. Free radicals formed as byproducts of drug metabolism might damage the developing embryonic tissues. However, although free radicals are formed during the metabolism of valproic acid, they are not formed during the metabolism of carbamazepine.46 Another potential mechanism for the teratogenicity of these drugs could be their effects on folate metabolism. Other folate antagonists with known teratogenic effects include aminopterin and methotrexate, and possibly trimethoprim.43 Whether periconceptional folic acid supplementation can reduce the risk of spina bida and other birth defects in the offspring of women taking valproic acid, carbamezepine, or other drugs with antifolate properties has not been established. The data suggest that maternal use of folic acid might reduce the risk of birth defects associated with some, but not all, such drugs.43,47,48 Additional investigation is needed to establish which of these drug-related birth defects can be prevented by maternal use of folic acid, and to establish the best dose of folic acid for women taking these drugs.

Other risk factors

Many additional variables have been implicated as risk factors for spina bida in one or more studies.49 However, many of the reported associations with spina bida are weak and have not been consistently replicated across studies. There is substantial evidence that the risk of having a child with spina bida is increased in obese women. This risk seems to increase with increasing body mass index; women in the highest category (usually dened as a prepregnancy body mass index 29 kg/m2) have a 15-fold to 35-fold higher risk than women with lower body mass indices.5056 Data from one study suggest that the increased risk of spina bida in the offspring of obese women might be attributable to hyperinsulinaemia.55 Since hyperinsulinaemia might precede or coexist with obesity and diabetes this metabolic state provides a potential link between these two maternal risk factors. In women who have undergone surgical procedures for the treatment of morbid obesity, the risk of having a child with spina bida seems to be increased in those who have undergone gastric bypass surgery,57,58 but not in those who have undergone intestinal bypass surgery.59 The reported association between maternal gastric bypass and spina bida could be attributable to reduced absorption of nutrients (which is less of a difculty after intestinal bypass than it is after gastric bypass) rather than the underlying obesity. There is substantial evidence that hyperthermia as a result of maternal fever or febrile illness in early pregnancy may increase the risk of having a child with spina bida or anencephaly by up to two-fold.6063 Based
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on epidemiological studies, it is difcult to determine whether this association is attributable to raised body temperature or the underlying disorder. However, there is evidence that other causes of maternal hyperthermia, such as the use of saunas, hot tubs,60 and tanning beds,64 might be associated with increased risk. Moreover, studies in animals have shown the teratogenic potential of maternal hyperthermia.65 A potential link between the risk of having a child with a neural tube defect and maternal exposure to fumonisins (a class of myocotoxins associated with equine leucoencephalomalacia and porcine pulmonary oedema) was suggested by the occurrence of a cluster of anencephalic births in South Texas, after a period when high levels of fumonisins were detected in corn-based feed products in that state.66 Although fumonisins can produce neural tube defects in animal models,67 a denitive link between this class of mycotoxins and neural tube defects in human beings has not been established. Maternal diarrhoea has been implicated as a risk factor for neural tube defects.68 This association was independent of maternal fever and multivitamin intake and might, therefore, indicate a loss of nutrients to the embryo after the transient impairment of the absorptive capacity of the maternal gastrointestinal tract. The National Academy of Sciences Institute of Medicine in the USA has concluded that there is limited or suggestive6971 evidence that the risk of spina bida is increased in the offspring of men who were exposed to the herbicide Agent Orange during the Vietnam war. This conclusion was, however, based on only three published studies,7274 the largest of which included only three cases of spina bida and one case of anencephaly.74 The risk of having a child with spina bida has also been associated with maternal exposure to chlorination disinfection byproducts in drinking water,75,76 electromagnetic elds,77 hazardous waste sites,78,79 and pesticides.80

Genetics
Although spina bida aggregates within families, the reported familial recurrence patterns are unlikely to be attributable to the effects of a single genetic locus. Rather, spina bida seems to be a complex trait determined by many genes and environmental factors that might affect susceptibility independently or via interactions. Recognition of the association between spina bida and maternal use of folic acid occurred when genetic studies of complex, non-Mendelian disorders, such as spina bida, were becoming increasingly feasible. Moreover, this association provided a strong rationale for considering the genes involved in folate-homocysteine metabolism and transport as potential risk factors for spina bida (panel).

Folate-homocysteine pathway genes

Genetic variants of several genes implicated in folatehomocysteine metabolism have been assessed as risk factors for spina bida in human beings (panel).97
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Variants of several of these genes are signicantly associated with the risk of spina bida in one or more studies (for example, MTHFR;98100 MTR;101 MTRR;95,101 MTHFD1102). Additionally, several studies have provided evidence that the risk of spina bida might be affected by interactions between different folate pathway genes (for example, MTHFR and MTRR;103 MTR and MTRR;104 MTHFR and RFC105), variants within the same gene (for example, MTHFR C677T and A1298C106), and folate pathway genes and environmental factors (for example, MTHFR and maternal folic acid intake;107 and RFC1 and maternal vitamin intake108). Furthermore, there is evidence that some of these genes might exert their effect on spina bida risk via the maternal genotype,101 whereas others might exert their risk via the embryonic genotype.109 In view of the number of published reports implicating folate pathway genes as risk factors for spina bida, it seems likely that variation in folatehomocysteine metabolism and transport affects the risk of this disorder. However, the reports about specic variants are characterised by weak and imprecise estimates of association, and lack of consistent replication across studies. Moreover, it is often unclear whether the published associations show the effects of the maternal genotype, the embryonic genotype, or maternal-embryonic genotype interactions.101,110 Hence, denitive conclusions about the precise role of specic
Associated with spina bida? Genes implicated in metabolic pathways other than folate-homocysteine Apolipoproteins B and E*81 No Leptin82 Possible modest association Leptin receptor82 No Uncoupling protein 283 Yes Orthologues of mouse genes 84 Breast cancer 1 No c-src tyrosine kinase85 No MARCKS protein gene86 No MARCKS-like protein gene85,86 No Msh homeo box homolog 287 No 88 Nucleosome assembly protein-1-like 2 No Platelet-derived growth factor -receptor89 Yes Transcription factor activating enhancer binding No protein 2 85,87 Zinc nger protein of the cerebellum 390 No Genes involved in neural tube development 91 Bone morphogenetic protein 4 Yes Homeobox A, B, C, and D92 No NOG91,93 Missense mutations identied in two patients SLUG94 Missense mutation identied in one patient Sonic Hedgehog95 No Zinc nger protein of the cerebellum 296 Yes
*Apoliproteins B and E are associated with cholesterol levels. Leptin and leptin receptor are associated with obesity. Uncoupling protein 2 may be associated with non-insulin-dependent diabetes and obesity.

Panel: Folate-homocysteine pathway genes 5,10-methylenetetrahydrofolate reductase (MTHFR) Methionine synthase (MTR) Methionine synthase reductase (MTRR) Methylenetetrahydrofolate dehydrogenase/methylenetetrahydrofolate cyclohydrolase/formyltetrahydrofolate synthetase (MTHFD1) Cystathionine- -synthase (CBS) Reduced folate carrier (RFC1) Folate receptor (FR ) Folate receptor (FR ) Betaine-homocysteine methyltransferase (BHMT) Transcobalamin (TC) Serine hydroxymethyltransferase (SHMT) Glutamate carboxypeptidase II (GCPII)

folate pathway gene variants in causing spina bida cannot be made at this time.

Genes included in other metabolic pathways

Although genes involved in folate-homocysteine metabolism and folate transport have received the most attention as candidate genes for spina bida, the risk of this disorder might also be determined by genetic variation in other metabolic pathways. Candidates include genes that affect metabolism in a manner that predisposes pregnant women to the development of known or suspected maternal risk factors for spina bida, including diabetes and obesity, genes that are involved in the metabolism of known teratogenic agents (eg, valproic acid), and genes that are involved in the metabolism of compounds needed for embryonic development (eg, cholesterol) (table 3). Genes in these pathways, like those involved in folate-homocysteine metabolism and transport, could affect the risk of spina bida through either the maternal or embryonic genotypes. Few genes in this category have been investigated as risk factors for spina bida, and no gene in this category has been denitively linked with the risk of this disorder.

Orthologues of mouse genes

In the mouse, more than 100 single gene mutations are associated with malformations of the neural tube.111 The human orthologues of only a few of these genes have been investigated (table 3), and variants of only two such genes, T-locus (brachyury) and PAX3, have been assessed as risk factors for human spina bida in several studies. The T-locus encodes a transcription factor needed for differentiation of mesoderm and normal axial development. In the mouse, embryos that are homozygous for a T-null allele have abnormalities of mesoderm-derived tissues and die in mid-gestation, whereas those that are heterozygous for a T-null allele survive but have shortened tails and, occasionally, malformations of the sacral vertebrae.112 An intronic
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Table 3: Candidate genes for spina bida that have been assessed in a small number of studies

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variant (TIVS7 T/C) of the human orthologue of the Tlocus has been investigated as a risk factor for human spina bida in several studies. Evidence in favour of an association between this variant and spina bida risk has been reported by one group,84,113 but was not found by two others.114,115 In an Irish population, the TIVS7 variant was associated with spina bida in individuals born before 1980 but not in those born later.116 This nding suggests that the effect of the T-locus on the risk of spina bida can be modied, at least in some populations, by an environmental factor that has changed over time. Mutations in the mouse transcription factor Pax3 give rise to the Splotch (Sp) phenotype, which is characterised by pigmentation defects in heterozygotes and defects of the neural tube in homozgyotes. In man, PAX3 mutations have been described in patients with Waardenburg syndrome type Ia disorder characterised by pigmentation defects similar to those found in Splotch heterozygotes and the occasional co-occurrence of spina bida. However, the studies published so far suggest that PAX3 and other members of the PAX gene family are not strongly associated with spina bida in human beings.114,117119 Folic acid supplementation protects against heat-induced neural tube defects in the mouse,120 and reduces the occurrence of neural tube defects in the Splotch,121 Cart1,122 Crooked tail,123 and Cited2124 mouse models. Although folate metabolism seems to be disturbed in some of these mouse models (eg, Splotch121), such disturbances have not been noted in others (eg, Cited2124). Hence, administration of high-dose folic acid to pregnant mice might compensate, at least in part, for developmental abnormalities that are outside the folate metabolic pathway.

Diagnosis and treatment

Prenatal diagnosis
Maternal serum -fetoprotein and ultrasound are now routinely used to identify fetuses that have or are likely to have either spina bida or anencephaly.127 Positive ndings from either of these two screens can be followed by amniocentesis or detailed sonography, or both. When amniocentesis is done, amniotic uid -fetoprotein and acetylcholinesterase concentrations can be used to conrm the presence of an open fetal malformation and differentiate between open ventral wall defects (ie, gastroschisis and omphalocoele) and open neural tube defects.128 Additionally, the fetal karyotype can be examined to rule out chromosomal anomalies. However, sonography can also be used to differentiate between ventral wall and neural tube defects,129 and to identify additional structural malformations that are characteristic of fetuses with chromosomal abnormalities.130 When a diagnosis of spina bida is conrmed, ultrasound is used to assess spontaneous leg and foot motion, leg and spine deformities, the presence of a Chiari II malformation and other physical defects.131 Prenatal MRI, with ultrafast T2-weighted sequences, can also be used to characterise the Chiari II and other malformations. Such prenatal imaging studies might help to predict neurological decit132 and ambulatory potential.133 Most fetuses with spina bida that are not electively terminated receive no treatment until after birth. Several studies have investigated whether method of delivery inuences the outcome for infants with the disorder. Based on a review of this work, Anteby and Yagel134 concluded that, in general, there is no conclusive evidence that caesarean section improves the outcome in children with spina bida relative to vaginal delivery. However, caesarean section might be justied for large lesions, to reduce the risk of trauma,134 and is done after inutero treatment of spina bida because the forces of labour are likely to produce a dehiscence.

Genes related to neural tube development

Variants of genes that are members of developmental pathways known to be involved in neural tube formation are also candidate risk factors for spina bida. A small number of such genes have been assessed as risk factors for spina bida in human beings (table 3). In view of the complexity of the developmental process underlying neural tube closure, that the identication of genetic variants inuencing spina bida risk has proven to be a challenge is not especially surprising. Indeed, weak genetic associations and inconsistent ndings across studies are characteristic of many complex diseases.125 Although population differences in the distribution of risk factors might partly account for the recorded inconsistencies across studies, it is likely that false-negative, underpowered studies have probably also contributed to the differences.126 The challenge for the future is to design studies that address the complex causes of disorders such as spina bida, including genegene and gene-environment interactions and the potential role of the maternal genotype, and to assemble study samples that provide adequate power to address the hypotheses of interest.
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Surgical closure and in-utero treatment

Closure of the spinal lesion is usually done within 48 h of birth. However, there are data indicating that, with antibiotics, the risk of infection does not rise until a week after birth.135 If there are overt signs of hydrocephalus, and imaging studies conrm the presence of ventriculomegaly, a shunt is usually placed at the same time as the lesion is closed. However, in most cases hydrocephalus is not manifest until a few days after surgical closure. Spina bida is a disorder that might be suitable for in-utero treatment, since it is compatible with life, is associated with substantial morbidity, and is routinely detected before 20 weeks of gestation. Moreover, neurological deterioration of affected fetuses might occur during gestation. Specically, leg movement can be seen on sonograms of some affected fetuses before 17 to 20 weeks, whereas later in gestation and in neonates there is typically some degree of deformity and paralysis.136 The
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lower limb movements noted early in gestation could be secondary to spinal arc reexes. However, such movements could be of cerebral origin and their absence in later gestation may be the result of neural tissue damage caused by exposure to amniotic uid137,138 or trauma.139 Additionally, animal studies, in which a model for spina bida is created by laminectomy and exposure of the spinal cord to amniotic uid, show that function can be retained if the lesion is closed before birth.140,141 There is also evidence that the Chiari II malformation, which occurs in almost all individuals with spina bida, is acquired and could potentially be prevented by in-utero closure.142,143 Hence, in-utero treatment might lead to improved outcome for individuals with spina bida relative to conventional treatment strategies. The rst cases of in-utero spina bida repair were done in 1994 with an endoscopic technique144 that proved unsatisfactory and was abandoned. In 1998, in-utero repair of spina bida by hysterotomy was reported.145,146 Early experience suggested that infants treated by hysterotomy had improvement in hindbrain herniation,147,148 and possibly a diminished need for shunting relative to infants treated postnatally.149 It might be that in-utero treatment reduces the need for shunting by eliminating the leakage of spinal uid that puts back-pressure on the hindbrain, such treatment allows reduction of the hindbrain hernia and relieves the obstruction of the cerebrospinal uid outow from the fourth ventricle. More than 200 in-utero, spina bida closures are estimated to have been done, and eight infants have died from complications associated with uncontrolled labour and premature birth. (The risks, benets, and ethics of inutero surgery have been reviewed150153). Urodynamic154 and leg function155,156 seem to be similar in infants treated in utero and postnatally. However, many of those treated in utero already had lower limb paralysis at the time of surgery, which might have limited any possible benet. Compared with historical controls, infants treated in utero have a lower incidence of moderate to severe hindbrain herniation and hydrocephalus requiring shunting.155 In a series of 50 spina bida cases treated in utero at the Childrens Hospital of Philadelphia, reversal of hindbrain herniation was reported in all cases, and the proportion requiring shunting was less than that in historical controls (43% versus 85%).157 A similar proportion requiring shunting (54%) was also noted in a series of 116 spina bida cases treated in utero at Vanderbilt University Medical Center.158 Comparisons between infants with spina bida who were treated in utero and historical controls are however subject to substantial bias. Infants treated in utero represent a highly selected subset of affected individuals. Additionally, the medical management of such infants might differ from that of historical controls for reasons unrelated to the in-utero repair. For these reasons, a randomised, controlled clinical trial, comparing outcome after in-utero and postnatal surgery for spina bida, has
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been initiated. The primary study endpoints include the need for a shunt procedure at 1 year, and fetal and infant mortality. Secondary endpoints include neurological function, cognitive outcome, and maternal morbidity. Additional information about this trial can be obtained from the study website (www.spinabidamoms.com).

Medical management
Short-term and long-term survival of individuals with spina bida has increased with improvements in medical and surgical management. The most recent populationbased data indicate that 1-year survival is about 87%, and that roughly 78% of all individuals with spina bida survive to the age of 17 years.159 Unfortunately, these individuals continue to be subject to excess morbidity and mortality into and throughout adulthood.160163 Whether treated in utero or postnatally, individuals with spina bida are at substantial risk for leg weakness and paralysis, sensory loss, bowel and bladder dysfunction, and orthopaedic abnormalities (eg, clubfoot, contractures, hip dislocation, scoliosis, kyphosis). In general, the functional level of the defect corresponds to the anatomical level of the bony spinal defect as determined by radiology. However, a retrospective study published in 2002, noted that functional level was higher (ie, worse) than the anatomic level in 48% of individuals with spina bida, and lower than the anatomic level in 14% of individuals.164 Individuals with spina bida are at risk for associated malformations of the nervous system, including hydrocephalus and Chiari II malformations. Almost all of those with thoracic level lesions need a shunt, whereas shunting is required in less than 70% of those with sacral level lesions.164 Radiographic evidence of Chiari II malformations is present in most (>75%) affected individuals.165 Clinically symptomatic Chiari II malformations (eg, apnea, swallowing difculties, and stridor in the newborn baby; headache, quadriparesis, scoliosis, and balance and coordination difculties in the older child) are present in up to a third of individuals with the disorder. Most individuals with spina bida have normal intelligence, but specic cognitive disabilities and language difculties are common and can adversely affect educational and occupational achievements and the ability to live independently.166,167 Neonates with spina bida should have baseline imaging studies of the central nervous system and subsequent serial head measurements to assess the velocity of head growth and the need for shunting. Orthopaedic deformities should also be treated shortly after birth, and ultrasonography and urodynamic studies should be done to assess the status of the urinary tract and provide a baseline for continuing assessment. At this age, bowel function is usually not a substantial difculty since affected infants have the gastrocolic reex and pass stools with most feedings. Medical care and monitoring of individuals with spina bida is best provided by regular assessments by a multidisciplinary team. This team
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should be under the direction of a skilled physician with training in the care of children who have multiple disabilities, and should include a coordinator who is responsible for patient follow-up. Additional team members should include a nurse specialising in the care of children with multiple handicaps, a paediatric neurosurgeon, urologist and orthopaedic surgeon, a physical therapist, and a social worker. Other subspecialists should be available on an as needed basis. Team members should be in direct communication with each other and with the patients primary care physician, who should provide routine medical care (eg, immunisations) and continuing emotional support for the family. After the neonatal period, the neurological, urological, and musculoskeletal systems need continued surveillance in individuals with spina bida. Routine measurements of head circumference should be taken, and patients should be monitored for symptoms of shunt malfunction and infection, and other neurological complications (eg, seizures, tethering of the cord). Patients should also be monitored for urological complications resulting from abnormal neurological bladder function (eg, urinary retention with overow, ureteric reux), which can lead to recurrent urinary tract infections and ultimately deterioration of renal function, and personalised continence programmes should be established.168,169 Bladder and urinary tract management might involve a combination of clean intermittent catheterisation, pharmacological agents, and surgical intervention.168,169 Additionally, bowel management might include the use of suppositories, enemas, or laxatives,170 and the use of antegrade colonic enemas.171 Continuous review is also needed to address orthopaedic abnormalities such as scoliosis, kyphosis, and hip dysplasia that, if untreated, could lead to progressive loss of mobility. Additional issues that should be addressed by the team include neuropsychological development, mobility and means of locomotion, weight maintenance, skin care, and latex sensitisation. The team should work with the young patient and his or her family and primary care physician to develop a plan for the patients future education, employment, and living arrangements. This process should be started before the patient reaches 14 years of age.172 By participating in individualised educational programmes, children with spina bida might be able to develop the skills necessary for autonomy in adulthood.166 Little is known about the additional health problems that will be encountered by adults with spina bida, but it seems that excess morbidity and mortality continue throughout adult life.162,163 The coordinated delivery of health services is, therefore, a life-long imperative.

anencephaly by up to 70%. Moreover, dose-response relations have been shown between the risk of having a pregnancy affected by a neural tube defect and both maternal folate intake28 and maternal folate status.29,30 Such studies have led to a general, although not unanimous,175,176 belief that improving the folate status of females of reproductive age will lower the prevalence of spina bida and other neural tube defects.177,178 Health agencies in several countries have established policies recommending the use of folic acid supplements to prevent neural tube defects.179,180 However, translating such policies into practice has proven very difcult. Despite many public health campaigns, a substantial proportion of women of reproductive age remain unaware of the need to take folic acid before and during pregnancy for the prevention of neural tube defects.181186 Because of the difculties inherent in public health efforts aimed at changing individual behaviour, mandatory folic acid fortication of the food supply might be a more effective strategy than recommendations aimed at individual supplementation for the prevention of neural tube defects. Whether, and to what extent, the food supply should be fortied with folic acid has been, and continues to be, a hotly debated topic. Reservations about folic acid fortication stem from concerns about the potential for masking vitamin B12 deciency and other possible adverse health effects in the non-target portion of the population (eg, children, elderly people). Consequently, government policies regarding folic acid fortication span a broad range. The UKs Food Standards Agency has recommended against universal folic acid fortication,187 the Netherlands Health Council has advised that fortication be limited to products aimed at women of reproductive age,188 and the USA, Canada, and Chile have implemented fortication programmes but at different concentrations. Data from the USA, Canada, and Chile provide preliminary evidence supporting the benecial effects of folic acid fortication. Specically, after mandatory fortication mean red blood cell folate concentrations in women of reproductive age more than doubled,189,190 and the birth prevalence of neural tube defects declined by 30%50%.191195 At this time, folic acid supplementation and fortication provide the only means of implementing population-based, primary prevention for spina bida and other neural tube defects. Population-based screening for genetic variants, such as the MTHFR C677T polymorphism, is not recommended because of inconsistent results across studies, the low proportion of cases that are likely to be attributable to any single genetic factor, and the fact that screening would not change either pre-conceptional advice regarding the utility of vitamin supplements or pregnancy management.196

Prevention
Randomised173 and community-based174 clinical trials have shown that maternal, periconceptional supplementation with folic acid alone, or with multivitamins containing folic acid, can reduce the risk of spina bida and
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Conclusion
Spina bida is the only birth defect for which there have been tremendous successes in both treatment and prevention. Continuing advances in our understanding of
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the human genome are providing new opportunities to understand the causes of this disorder, and offer the prospect of developing improved strategies for the prevention of spina bida. Moreover, in utero treatment, although unproven at this time, might improve quality of life for those individuals born with spina bida.
Conict of interest statement LEM and ASW are supported by grants from the National Institutes of Health (HD39195 and HD39081). NSA is supported by a grant from the March of Dimes. References 1 Van Allen MI, Kalousek DK, Chernoff GF, et al. Evidence for multisite closure of the neural tube in humans. Am J Med Genet 1993; 47: 72343. 2 ORahilly R, Muller F. The two sites of fusion of the neural folds and the two neuropores in the human embryo. Teratol 2002; 65: 16270. 3 Nievelstein RAJ, Hartwig NG, Vermeij-Keers C, Valk J. Embryonic development of the mammalian caudal neural tube. Teratol 1993; 48: 2131. 4 ORahilly R, Muller F. Summary of the initial development of the human nervous system. Teratol 1999; 60: 3941. 5 Copp AJ, Green NDE, Murdoch JN. The genetic basis of mammalian neurulation. Nat Rev Genet 2003; 4: 78493. 6 International Clearinghouse for Birth Defects Monitoring Systems. Annual report 1998 with data for 1996. Rome: International Centre for Birth Defects, 1998. 7 Moore CA, Li S, Hong S, et al. Elevated rates of severe neural tube defects in a high-prevalence area in northern China. Am J Med Genet 1997; 73: 11318. 8 McDonnell RJ, Johnson Z, Delaney V, Dack P. East Ireland 19801994: epidemiology of neural tube defects. J Epidemiol Community Health 1999; 53: 78288. 9 Feuchtbaum LB, Currier RJ, Riggle S, Roberson M, Lorey FW, Cunningham GC. Neural tube defect prevalence in California (1990-1994): eliciting patterns by type of defect and maternal race/ethnicity. Genet Test 1999; 3: 26572. 10 Chan A, Robertson EF, Haan EA, Keane RJ, Ranieri E, Carney A. Prevalence of neural tube defects in South Australia, 1966-91: effectiveness and impact of prenatal diagnosis. BMJ 1993; 307: 70306. 11 Centers for Disease Control. Surveillance for anencephaly and spina bida and the impact of prenatal diagnosisUnited States, 19851994. MMWR Morb Mortal Wkly Rep 1995; 44 (SS-4): 113. 12 Velie EM, Shaw GM. Impact of prenatal diagnosis and elective termination on prevalence and risk estimates of neural tube defects in California, 1989-1991. Am J Epidemiol 1996; 144: 47379. 13 Manseld C, Hopfer S, Marteau TM. Termination rates after prenatal diagnosis of Down syndrome, spina bida, anencephaly, and Turner and Klinefelter syndromes: a systematic literature review. Prenat Diag 1999; 19: 80812. 14 Kallen B, Robert E, Harris J. Associated malformations in infants and fetuses with upper or lower neural tube defects. Teratol 1998; 57: 5663. 15 Hall JG, Solehdin F. Genetics of neural tube defects. Ment Retard Dev Disabil Res Rev 1998; 4: 26981. 16 Renwick JH. Hypothesis: ancephaly and spina bida are usually preventable by avoidance of a specic but unidentied substance present in certain potato tubers. Br J Prev Soc Med 1972; 26: 6788. 17 Todoroff K, Shaw GM. Prior spontaneous abortion, prior elective termination, interpregnancy interval, and risk of neural tube defects. Am J Epidemiol 2000; 151: 50511. 18 Williamson EM. Incidence and familial aggregation of major congenital malformations of the central nervous system. J Med Genet 1965; 2: 16172. 19 Carter CO, David PA, Laurence KM. A family study of major congenital malformations of the nervous system in south Wales. J Med Genet 1968; 5: 81106. 20 Carter CO, Evans K. Spina bida and anencephaly in greater London. J Med Genet 1973; 10: 20934. 21 Hunter AGW. Neural tube defects in eastern Ontario and western

22

23 24

25

26

27 28

29 30 31

32 33

34 35 36 37

38

39

40

41

42 43

44

45 46 47

48

Quebec: demographic and family data. Am J Med Genet 1984; 19: 4563. Demenais F, Le Merrer M, Briard ML, Elston RC. Neural tube defects in France: segregation analysis. Am J Med Genet 1982; 11: 28798. Janerich DT, Piper J. Shifting genetic patterns in anencephaly and spina bida. J Med Genet 1978; 15: 10105. Zackai EH, Spielman RS, Mellman WJ, et al. The risk of neural tube defects to rst cousins of affected individuals. In: Crandall BF, Brazier MAB, eds. The prevention of neural tube defects: the role of -fetoprotein. New York: Academic Press, 1978: 99100. Barkai G, Arbuzova SBM, Heifetz S, Cuckle H. Frequency of Downs syndrome and neural-tube defects in the same family. Lancet 2003; 361: 133135. Amorim MR, Castilla EE, Orioli IM. Is there a familial link between Downs syndrome and neural tube defects? Population and familial survey. BMJ 2004; 328: 84. Wald N. Folic acid and the prevention of neural tube defects. Ann NY Acad Sci 1993; 678: 11228. Moore LL, Bradlee ML, Singer MR, Rothman KJ, Milunsky A. Folate intake and the risk of neural tube defects: an estimation of dose-response. Epidemiology 2003; 14: 20005. Daly LE, Kirke PN, Molloy AM, Weir DG, Scott JM. Folate levels and neural tube defects. JAMA 1995; 21: 1698702. Wald NJ, Law MR, Morris JK, Wald DS. Quantifying the effect of folic acid. Lancet 2001; 358: 206973. Rosenquist TH, Ratashak SA, Selhub J. Homocysteine induces congenital defects of the heart and neural tube: effects of folic acid. Proc Natl Acad Sci 1996; 93: 1522732. Schorah CJ, Smithells RW. Maternal vitamin nutrition and malformations of the neural tube. Nutr Res Rev 1991; 4: 3349. Suarez L, Hendricks K, Felkner M, Gunter E. Maternal serum vitamin B12 levels and risk for neural tube defects in a Texas-Mexico border population. Epidemiology 2003; 13: 8188. Ray JG, Blom HJ. Vitamin B12 insufciency and the risk of fetal neural tube defects. QJM 2003; 96: 28995. McLeod L, Ray JG. Prevention and detection of diabetic embryopathy. Community Genet 2002; 5: 3339. Greene MF. Diabetic embryopathy 2001: moving beyond the diabetic milieu. Teratology 2001; 63: 11618. Fine E, Horal M, Chang TI, Fortin G, Loeken MR. Evidence that elevated glucose causes altered gene expression, apoptosis, and neural tube defects in a mouse model of diabetic embryopathy. Diabetes 1999; 48: 245462. Hiramatsu Y, Sekiguchi N, Hayashi M, et al. Diacylglycerol production and protein kinase C activity are increased in a mouse model of diabetic embryopathy. Diabetes 2002; 51: 280410. Janssen PA, Rothman I, Schwartz SM. Congenital malformations in newborns of women with established and gestational diabetes in Washington state, 1984-91. Paediatr Perinat Epidemiol 1996; 10: 5263. Aberg A, Westbom L, Kallen B. Congenital malformations among infants whose mothers had gestational diabetes or preexisting diabetes. Early Hum Dev 2001; 61: 8595. Shefeld JS, Butler-Koster EL, Casey BM, McIntire DD, Leveno KJ. Maternal diabetes and infant malformations. Obstet Gynecol 2002; 100: 92530. Lammer EJ, Sever LE, Oakley GP. Teratogen update: valproic acid. Teratology 1987; 35: 46573. Hernandez-Diaz S, Werler MM, Walker AH, Mitchell AA. Neural tube defects in relation to use of folic acid antagonists during pregnancy. Am J Epidemiology 2001; 153: 96168. Matalon S, Schechtman S, Goldzweig G, Ornoy A. The teratogenic effect of carbamazepine: a meta-analysis of 1255 exposures. Reprod Toxicol 2002; 16: 917. Koren G. Safe use of valproic acid during pregnancy. Can Fam Physician 1999; 45: 145153. Pippenger CE. Pharmacology of neural tube defects. Epilepsia 2003; 44 (suppl 3): 2432. Hernandez-Diaz S, Werler MM, Walker AH, Mitchell AA. Folic acid antagonists during pregnancy and the risk of birth defects. N Engl J Med 2000; 343: 160814. Nambisan M, Wyszynski DF, Holmes LB. No evidence of a

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57 58 59 60

61

62

63

64 65

66 67

68

69

70 71 72 73

74

75

protective effect due to periconceptional folic acid (PCFA) intake on risk for congenital anomalies in the offspring of mothers exposed to antiepileptic drugs (AEDs). Birth Defects Research (Part A) 2003; 67: Abs P45. Little J, Elwood JM. Epidemiology of neural tube defects. In: Kiely M, ed. Reproductive and Perinatal Epidemiology. Boca Raton: CRC Press, 1991: 251336. Waller DK, Mills JL, Simpson JL, et al. Are obese women at higher risk for producing malformed offspring? Am J Obstet Gynecol 1994; 179: 54148. Shaw GM, Velie EM, Schaffer D. Risk of neural tube defect-affected pregnancies among obese women. JAMA 1996; 275: 109396. Watkins ML, Scanlon KS, Mulinare J, Khoury MJ. Is maternal obesity a risk factor for anencephaly and spina bida? Epidemiology 1996; 7: 50712. Werler MM, Louik C, Shapiro S, Mitchell AA. Prepregnant weight in relation to risk of neural tube defects. JAMA 1996; 275: 108992. Shaw GM, Todoroff K, Schaffer DM, Selvin S. Maternal height and prepregnancy body mass index as risk factors for selected congenital anomalies. Paediatr Perinat Epidemiol 2000; 14: 23439. Hendricks K, Nuno OM, Suarez L, Larsen R. Effects of hyperinsulinemia and obesity on risk of neural tube defects among Mexican Americans. Epidemiology 2001; 12: 63035. Watkins ML, Ratashak SA, Honein MA, Botto LD, Moore CA. Maternal obesity and risk for birth defects. Pediatrics 2003; 111: 115258. Haddow JE, Mitchell LE, Kloza EM, Thanhauser D. Neural tube defects after gastric bypass. Lancet 1986; 1: 1330. Martin L, Chavez GF, Adams MJ, et al. Gastric bypass surgery as maternal risk factor for neural tube defects. Lancet 1988; 1: 64041. Knudsen LB, Kallen B. Gastric bypass, pregnancy and neural tube defects. Lancet 1986; 2: 227. Milunsky A, Ulcickas M, Rothman KJ, Willet W, Jick SS, Jick H. Maternal heat exposure and neural tube defects. JAMA 1992; 268: 88285. Lynberg MC, Khoury MJ, Lu X, Cocian T. Maternal u, fever and risk of neural tube defects: a population-based case-control study. Am J Epidemiology 1994; 140: 24455. Chambers CD, Johnson KA, Dick LM, Felix RJ, Jones KL. Maternal fever and birth outcome: a prospective study. Teratol 1998; 58: 25157. Shaw GM, Todoroff K, Velie EM, Lammer EJ. Maternal illness, including fever, and medication use as risk factors for neural tube defects. Teratol 1998; 57: 17. Lapunzina P. Ultraviolet light-related neural tube defects? Am J Med Genet 1996; 67: 106. Shiota K. Neural tube defects and maternal hyperthermia in early pregnancy: epidemiology in a human embryo population. Am J Med Genet 1982; 12: 28188. Hendricks K. Fumonisins and neural tube defects in south Texas. Epidemiology 1999; 10: 198200. Sadler TW, Merrill AH, Stevens VL, Sullards MC, Wang E, Wang P. Prevention of fumonisin B1-induced neural tube defects by folic acid. Teratol 2002; 66: 16976. Felkner M, Hendricks K, Suarez L, Waller DK. Diarrhea: a new risk factor for neural tube defects? Birth Defects Res Part A Clin Mol Teratology 2003; 67: 50408. Institute of Medicine. Veterans and agent orange: health effects of herbicide used in Vietnam. Washington: National Academy Press, 1994. Institute of Medicine. Veterans and agent orange: update 1998. Washington: National Academy Press, 1999. Institute of Medicine. Veterans and agent orange: update 2000. Washington: National Academy of Sciences, 2001. Erickson JD, Mulinare J, McClain PW, et al. Vietnam veterans risks for fathering babies with birth defects. JAMA 1984; 252: 90312. Centers for Disease Control. Health status of Vietnam veterans. III. Reproductive outcomes and child health. The Centers for Disease Control Vietnam Experience Study. JAMA 1998; 259: 271519. Wolfe WH, Michalek JE, Miner JC, et al. Paternal serum dioxin and reproductive outcomes among veterans of Operation Ranch Hand. Epidemiology 1995; 6: 1722. Klotz JB, Pyrch LA. Neural tube defects and drinking water

76 77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97 98

disinfection by-products. Epidemiology 1999; 10: 38390. Dodds L, King WD. Relation between trihalomethane compounds and birth defects. Occup Environ Med 2001; 58: 44346. Blaasaas KG, Tynes T, Lie RT. Risk of birth defects by parental occupational exposure to 50 Hz electromagnetic elds: a population based study. Occup Environ Med 2002; 59: 9297. Orr M, Bove F, Kaye W, Stone M. Elevated birth defects in racial or ethnic minority children of women living near hazardous waste sites. Int J Hyg Environ Health 2002; 205: 1927. Dolk H, Vrijheid M, Armstrong B, et al. Risk of congenital anomalies near hazardous-waste landll sites in Europe: the EUROHAZCON study. Lancet 1998; 352: 42327. Shaw GM, Wasserman CR, OMalley CD, Nelson V, Jackson RJ. Maternal pesticide exposure from multiple sources and selected congenital anomalies. Epidemiology 1999; 10: 6066. Volcik KA, Zhu H, Shaw GM, Lammer EJ, Finnell RF. Apolipoprotein E and apolipoprotein B genotypes and risk for spina bida. Teratol 2002; 66: 25759. Shaw GM, Barber R, Todoroff K, Lammer EJ, Finnell RF. Microsatellites proximal to leptin and leptin receptor as risk factors for spina bida. Teratol 2000; 61: 23135. Volcik KA, Shaw GM, Zhu H, Lammer EJ, Finnell RH. Risk factors for neural tube defects: assocations between uncoupling protein 2 polymorphisms and spina bida. Birth Defects Res Part A Clin Mol Teratology 2003; 67: 92428. Morrison K, Papapetrou C, Hol FA, et al. Susceptibility to spina bida; an association study of ve candidate genes. Ann Hum Genet 1998; 62: 37996. Klootwijk R, Hol FA, Wu M, et al. Genetic variation analysis of MLP, TFAP2A, and CSK in patients with neural tube defects. J Med Genet 2003; 40: e43. Stumpo DJ, Eddy RL, Haley LL, et al. Promoter sequence, expression, and ne chromosomal mapping of the human gene (MLP) encoding the MARCKS-like protein: identication of neighboring and linked polymorphic loci for MLP and MACS and use in the evaluation of human neural tube defects. Genomics 1998; 49: 25364. Stegmann K, Boecker J, Richter B, et al. A screen for mutations in human homologues of mice exencephaly genes Tfap2a and Msx2 in patients with neural tube defects. Teratol 2001; 63: 16775. Rogner UC, Danoy P, Matsuda F, Moore GE, Stanier P, Avner P. SNPs in the CpG island of NAP1L2: A possible link between DNA methylation and neural tube defects? Am J Med Genet 2002; 110: 20814. Joosten PHLJ, Toepoel M, Mariman ECM, Van Zoelen EJJ. Promoter haplotype combinations of the platelet-derived growth factor alpha-receptor gene predispose to human neural tube defects. Nat Genet 2001; 27: 21517. Carrel T, Herman GE, Moore GE, Stanier P. Lack of mutations in ZIC3 in three families with neural tube defects. Am J Med Genet 2001; 98: 28385. Felder B, Stegmann K, Schultealbert A, et al. Evaluation of BMP4 and its specic inhibitor NOG as candidates in human neural tube defects (NTDs). Eur J Hum Genet 2002; 10: 75356. Volcik KA, Blanton SH, Kruzel MC, et al. Testing for genetic assocations in a spina bida population: analysis of HOX gene family and human candidate gene regions implicated by mouse models of neural tube defects. Am J Med Genet 2002; 110: 20307. Bauer KA, George TM, Enterline DS, et al. A novel mutation in the gene encoding Noggin is not causative in human neural tube defects. J Neurogenet 2002; 16: 6571. Stegmann K, Boecker J, Kosan C, Ermert A, Kunz J, Koch MC. Human transcription factor SLUG: mutation analysis in patients with neural tube defects and identication of a missense mutation (D119E) in the SLUG subfamily-dening region. Mutat Res 1999; 406: 6369. Zhu H, Barber R, Shaw GM, Lammer EJ, Finnell RF. Is sonic hedgehog (SHH) a candidate gene for spina bida? A pilot study. Am J Med Genet 2003; 117A: 8788. Brown LY, Hodge SE, Johnson WG, Guy SG, Nye JS. Possible association with NTDs with a polyhistidine tract polymorphism in the ZIC2 gene. Am J Med Genet 2002; 108: 12831. Finnell RH, Gould A, Spiegelstein O. Pathobiology and genetics of neural tube defects. Epilepsia 2003; 44 (suppl 3): 1423. Whitehead AS, Gallagher P, Mills JL, et al. A genetic defect

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in 5,10-methylenetetrahydrofolate reductase in neural tube defects. QJM 1995; 88: 76366. van der Put NMJ, Steegers-Theunissen RPM, Frosst P, et al. Mutated 5,10-methylenetetrahydrofolate reductase as a risk factor for spina bida. Lancet 1995; 346: 107071. Botto LD, Yang Q. 5,10-methylenetetrahydrofolate reductase gene variants and congenital anomalies: a HuGE review. Am J Epidemiol 2000; 151: 86277. Doolin M-T, Barbaux SMM, Hoess K, Whitehead AS, Mitchell LE. Maternal genetic effects, exerted by genes involved in homocysteine remethylation, inuence the risk of spina bida. Am J Hum Genet 2002; 71: 122226. Brody LC, Conley M, Cox C, et al. A polymorphism, R653Q, in the trifunctional enzyme methylenetetrahydrofolate dehydrogenase/methenyltetrahydrofolate cyclohydrolase/formyltetrahydrofolate synthetase is a maternal genetic risk factor for neural tube defects: report of the birth defects research group. Am J Hum Genet 2002; 71: 120715. Wilson A, Platt R, Wu Q, et al. A common variant of methionine synthase reductase combined with low cobalamin (vitamin B12) increases risk for spina bida. Mol Genet Metab 1999; 67: 31723. Zhu H, Wicker NJ, Shaw GM, et al. Homocysteine remethylation enzyme polymorphisms and increased risk for neural tube defects. Mol Genet Metab 2003; 78: 21621. De Marco P, Calevo MG, Moroni A, et al. Reduced folate carrier polymorphism (80A-G) and neural tube defects. Eur J Hum Genet 2003; 11: 24552. van der Put NMJ, Gabreels F, Stevens EMB, et al. A second common mutation in the mutation in the methylenetetrahydrofolate reductase gene: an additional risk factor for neural-tube defects. Am J Hum Genet 1998; 62: 104451. Volcik KA, Shaw GM, Lammer EJ, Zhu H, Finnell RF. Evaluation of infant mehylenetetrahydrofolate reductase genotype, maternal vitamin use, and risk of high versus low level spina bida. Birth Defects Res Part A Clin Mol Teratol 2003; 67: 15457. Shaw GM, Lammer EJ, Zhu H, Baker MW, Neri E, Finnell RF. Maternal periconceptional vitamin use, genetic variation of infant reduced folate carrier (A80G), and risk of spina bida. Am J Med Genet 2002; 108: 16. Shields DC, Kirke PN, Mills JL, et al. The thermolabile variant of methylenetetrahydrofolate reductase and neural tube defects: an evaluation of genetic risk and the relative importance of the genotypes of the embryo and the mother. Am J Hum Genet 1999; 64: 104555. Posey DL, Khoury MJ, Mulinare J, Adams MJ, Ou CY. Is mutated MTHFR a risk factor for neural tube defects. Lancet 1996; 347: 68687. Harris MJ. Why are the genes that cause risk of human neural tube defects so hard to nd? Teratology 2001; 63: 16566. Wilson V, Rashbass P, Beddington RSP. Chimeric analysis of T (Brachyury) gene function. Development 1993; 117: 132131. Morrison K, Papapetrou C, Attwood J, et al. Genetic mapping of the human homologue (T) of the mouse T (Brachyury) and a search for allele association between human T and spina bida. Hum Mol Genet 1996; 5: 66974. Trembath D, Sherbondy AL, VanDyke DC, et al. Analysis of select folate pathway genes, PAX3, and human T in a midwestern neural tube defect population. Teratol 1999; 59: 33141. Speer MC, Melvin EC, Viles KD, et al. T locus shows no evidence for linkage disequilibrium or mutation in American caucasian neural tube defect families. Am J Med Genet 2002; 110: 21518. Shields DC, Ramsbottom D, Donoghue C, et al. Association between historically high frequencies of neural tube defects and the human T homologue of mouse T (Brachyury). Am J Med Genet 2000; 92: 20611. Chatkupt S, Hol FA, Shugart YY, et al. Absence of linkage between familial neural tube defects and PAX3 gene. J Med Genet 1995; 32: 20004. Hol FA, Geurds MPA, Shugart YY, et al. PAX genes and human neural tube defects: an amino acid substitution in PAX1 in a patient with spina bida. J Med Genet 1996; 33: 65560. Volcik KA, Blanton SH, Kruzel MC, et al. Testing for genetic associations with the PAX gene family in a spina bida population. Am J Med Genet 2002; 110: 195202.

120 Shin J-H, Shiota K. Folic acid supplementation of pregnant mice suppresses heat-induced neural tube defects in the offspring. J Nutr 1999; 129: 207073. 121 Fleming A, Copp AJ. Embryonic folate metabolism and mouse neural tube defects. Science 1998; 280: 210709. 122 Zhao Q, Behringer RR, de Crombrugghe B. Prenatal folic acid treatment suppresses acrania and meroanencephaly in mice mutant for the Cart1 homeobox gene. Nat Genet 1996; 13: 27583. 123 Carter M, Ulrich S, Oofuji Y, Williams DA, Ross ME. Crooked tail (Cd) models human folate-responsive neural tube defects. Hum Mol Genet 1999; 8: 2199204. 124 Martinez-Barbera JPM, Rodriguez TA, Greene NDE, et al. Folic acid prevents exencephaly in Cited2 decient mice. Hum Mol Genet 2002; 11: 28393. 125 Hirschhorn JN, Lohmueller K, Byrne E, Hirschhorn K. A comprehensive review of genetic association studies. Genet Med 2002; 4: 4561. 126 Lohmueller KE, Pearce CL, Pike M, Lander ES, Hirschhorn JN. Meta-analysis of genetic association studies supports a contribution of common variants to susceptibility to common disease. Nat Genet 2003; 33: 17782. 127 Drugan A, Weissman A, Evans MI. Screening for neural tube defects. Clin Perinatol 2001; 28: 27987. 128 Loft AG. Determination of amniotic uid acetylcholinesterase activity in the antenatal diagnosis of foetal malformations: the rst ten years. J Clin Chem Clin Biochem 1990; 28: 893911. 129 Lennon CA, Gray DL. Sensitivity and specicity of ultrasound for the detection of neural tube and ventral wall defects in a high-risk population. Obstet Gynecol 1999; 94: 56266. 130 Sepulveda W, Corral E, Ayala C, Be C, Gutierrez J, Vasquez P. Chromosomal abnormalities in fetuses with open neural tube defects: prenatal identication with ultrasound. Ultrasound Obstet Gynecol 2004; 23: 35256. 131 Mangels K, Tulipan N, Tsao L, Alarcon J, Bruner J. Fetal MRI in the evaluation of intrauterine myelomeningocele. Pediatr Neurosurg 2000; 32: 12431. 132 Cochrane DD, Wilson RD, Steinbok P, et al. Prenatal spinal evaluation and functional outcome of patients born with myelomeningocele: information for improved prenatal counseling and outcome prediction. Fetal Diagn Ther 1996; 11: 15968. 133 Biggio JR, Owen J, Wenstrom KD, Oakes WJ. Can prenatal ultrasound ndings predict ambulatory status in fetuses with open spina bida? Am J Obstet Gynecol 2001; 185: 101620. 134 Anteby EY, Yagel S. Route of delivery of fetuses with structural anomalies. Eur J Obstet Gynecol Reprod Biol 2003; 106: 59. 135 Charney EB, Weller SC, Sutton LN, Bruce DA, Schut LB. Management of the newborn with myelomeningocele: time for a decision-making process. Pediatrics 1985; 75: 5864. 136 Korenromp M, Good J, Bruinese H, Kriek R. Early fetal movements in myelomeningocele. Lancet 1986; 1: 91718. 137 Correia-Pinto J, Reis JL, Hutchins GM, et al. In utero meconium exposure increases spinal cord necrosis in a rat model of myelomeningocele. J Pediatr Surg 2002; 37: 48892. 138 Drewek M, Brunner J, Whetsell NT. Quantitative analysis of the toxicity of human amniotic uid to cultured rate spinal cord. Pediatr Neurosurg 1996; 27: 19093. 139 Hutchins G, Meuli M, Meuli-Simmen C, Jordan M, Heffez D, Blakemore K. Acquired spinal cord injury in human fetuses with myelomeningocele. Pediatr Pathol Lab Med 1996; 16: 70112. 140 Meuli M, Meuli-Simmen C, Hwang SH, et al. In utero surgery rescues neurological function at birth in sheep with spina bida. Nat Med 1995; 1: 34247. 141 Michejda M, Bacher J. Functional and anatomic recovery in the monkey brain following excision of fetal encephalocele. Pediatr Neurosci 1985; 12: 9095. 142 Osaka K, Tanimura T, Matsumoto S. Myelomeningocele before birth. Neurosurgery 1978; 49: 71124. 143 Paek BW, Farmer DL, Wilkinson CC, et al. Hindbrain herniation develops in surgically created myelomeningocele but is absent after repair in fetal lambs. Am J Public Health 2000; 183: 111923. 144 Bruner J, Richards W, Tulipan N, Arney T. Endoscopic coverage of fetal myelomeningocele in utero. Am J Obstet Gynecol 1999; 180: 15358.

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145 Adzick N, Sutton L, Crombleholme T, Flake A. Successful fetal surgery for spina bifdia. Lancet 1998; 352: 167576. 146 Tulipan N, Bruner J. Myelomeningocele repair in utero: a report of three cases. Pediatr Neurosurg 1998; 28: 17780. 147 Sutton L, Adzick N, Bilaniuk L, Johnson M, Crombleholme T, Flake A. Improvement in hindbrain herniation demonstrated by serial fetal magnetic imaging following fetal surgery for myelomeningocele. JAMA 1999; 282: 182613. 148 Tulipan N, Hernanz-Schulman M, Lowe LH, Bruner JP. Intrauterine myelomeningocele repair reverses hindbrain herniation. Pediatr Neurosurg 1999; 31: 13742. 149 Bruner JP, Tulipan N, Paschall RL, et al. Fetal surgery for myelomeningocele and the incidence of shunt-dependent hydrocephalus. JAMA 1999; 282: 181925. 150 Lyerly AD, Gates EA, Cefalo RC, Sugarman J. Toward the ethical evaluation and use of maternal-fetal surgery. Obstet Gynecol 2001; 98: 68997. 151 Howe EG. Ethical issues in fetal surgery. Semin Perinatol 2003; 27: 44657. 152 MacKenzie TC, Adzick NS. Advances in fetal surgery. J Intensive Care Med 2001; 16: 25162. 153 Cortes RA, Farmer DL. Recent advances in fetal surgery. Semin Perinatol 2004; 28: 199211. 154 Holmes N, Nguyen H, Farmer D, Baskin L. Fetal intervention for myelomeningocele: effect on postnatal bladder function. J Urol 2001; 166: 238386. 155 Tulipan N, Bruner JP, Hernanz-Schulman M, Lowe LHWWF, Nickolaus D, Oakes WJ. The effect of intrauterine myelomeningocele repair on the central nervous system structure and neurologic function. Pediatr Neurosurg 1999; 31: 18388. 156 Tubbs RS, Chambers MR, Smyth MD, et al. Late gestation intrauterine myelomeningocele repair does not improve lower extremity function. Pediatr Neurosurg 2003; 38: 12832. 157 Johnson MP, Sutton LN, Rintoul N, et al. Fetal myelomeningocele repair: short-term clinical outcomes. Obstetrics 2003; 189: 48287. 158 Bruner JP, Tulipan N, Reed G, et al. Intrauterine repair of spina bida: preoperative predictors of shunt-dependent hydrocephalus. Am J Obstet Gynecol 2004; 190: 130512. 159 Wong LC, Paulozzi LJ. Survival of infants with spina bida: a population study, 1979-1994. Paediatr Perinat Epidemiol 2001; 15: 37478. 160 Hunt GM. Non-selective intervention in newborn babies with open spina bida: the outcome 30 years on for the complete cohort. Eur J Pediatr Surg 1999; 9 (suppl I): 58. 161 Singhal B, Mathew KM. Factors affecting mortality and morbidity in adult spina bida. Eur J Pediatr Surg 1999; 9(suppl I): 3132. 162 McDonnell GV, McCann JP. Why do adults with spina bida and hydrocephalus die? A clinic-based study. Eur J Pediatr Surg 2000; 10 (suppl I): 3132. 163 Bowman RM, McLone DG, Grant JA, Tomita T, Jacobsen JS. Spina bida outcome: a 25-year prospective. Pediatr Neurosurg 2001; 34: 11420. 164 Rintoul NE, Sutton LN, Hubbard AM, et al. A new look at myelomeningceles: functional level, vertebral level, shunting and the implications for fetal intervention. Pediatrics 2002; 109: 40913. 165 Just M, Schwarz M, Ludwig B, Ermert J, Thelen M. Cerebral and spinal MR-ndings in patients with post repair myelomeningocele. Pediatr Radiol 1990; 20: 26266. 166 Northrup H, Volcik KA. Spina bida and other neural tube defects. Curr Probl Pediatr 2000; 30: 31332. 167 Vachha B, Adams R. Language differences in young children with myelomeningocele and shunted hydrocephalus. Pediatr Neurosurg 2003; 39: 18489. 168 Bolt J, Rawicki B, Donellan S. Urological management of spina bida. Aust Fam Physician 2001; 30 (suppl 2): 2124. 169 Bauer SB. The management of the myelodysplastic child: a paradigm shift. Br J Urol 2003; 92 (suppl 1): 2328. 170 Leibold S, Ekmark E, Adams RC. Decision making for a successful bowel continence program. Eur J Pediatr Surg 2000; 10: 2630. 171 Perez M, Lemelle JL, Barthelme H, Marquand D, Schmitt M. Bowel management with antegrade colonic enema using a malone or monti conduitclinical results. Eur J Pediatr Surg 2001; 11: 31518.

172 American Academy of Pediatrics Committee on Children with Disabilities. The role of the pediatrician in transitioning children and adolescents with developmental disabilities and chronic illness from school to work and college. Pediatrics 2000; 106: 85456. 173 Medical Research Council. Prevention of neural tube defects. Lancet 1991; 338: 13137. 174 Berry RJ, Li Z, Erickson JD, et al. Prevention of neural-tube defects with folic acid in China. N Engl J Med 1999; 341: 148590. 175 Kalter H. Folic acid and human malformations: a summary and evaluation. Reprod Toxicol 2000; 14: 46376. 176 Turner LA, Morrison H, Prabhakaran VM. Do we need another randomized controlled trial of folic acid alone? Epidemiology 2001; 12: 26265. 177 Lumley J, Watson L, Watson M, Bower C. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects (Cochrane Review). Cochrane Database Syst Rev 2001; 3: CD001056. 178 Moore LL. Is the jury still out on folic acid and congenital anomalies? Epidemiology 2001; 12: 14144. 179 Cornel MC, Erickson JD. Comparison of national policies on periconceptional use of folic acid to prevent spina bida and anencephaly (SBA). Teratol 1997; 55: 13437. 180 Rosano A, Smithells D, Cacciani L, et al. Time trends in neural tube defects prevalence in relation to preventive strategies: an international study. J Epidemiol Community Health 1999; 53: 63035. 181 de Walle HEK, de Jong-van den Berg LTW, Cornel MC. Periconceptional folic acid intake in northern Netherlands. Lancet 1999; 353: 1187. 182 Neimanis IM, Paterson JM, Bain E. Prevention neural tube defects. Survey of preconceptional use of folic acid. Can Fam Physician 1999; 45: 171722. 183 Petrini JR, Damus K, Johnston RB, Mattison DR. Knowledge and use of folic acid by women of childbearing age - United States, 19951998. MMWR Morb Mortal Wkly Rep 1999; 48: 32527. 184 Ringel S, Lahat E, Elizov T, et al. Awareness of folic acid for neural tube defect prevention among Israeli women. Teratol 1999; 60: 2932. 185 Watson M, Watson L, Bell R, Halliday J. The increasing knowledge of the role of periconceptional folate in Victorian women of childbearing age: follow-up of a randomized community intervention trial. Aust N Z J Public Health 2001; 25: 38995. 186 Braekke K, Staff AC. Periconceptional use of folic acid supplements in Oslo. Acta Obstet Gynecol Scand 2003; 82: 62027. 187 Food Standards Agency, UK. Board reaches conclusion of folic acid. 2002. www.food.gov.uk/news/newsarchive/2002/may/62488 (accessed Nov 8, 2004). 188 de Walle HEK, Cornel MC, de Jong-van den Berg LTW. Three years after the Dutch folic acid campaign: growing socioeconomic differences. Prev Med 2002; 35: 6569. 189 Centers for Disease Control. Folate status in women of childbearing ageUnited States, 1999. Morb Mortal Wkly Rep 2000; 49: 96265. 190 Hertrampf E, Cortes F, Erickson JD, et al. Consumption of folic acidfortied bread improves folate status in women of reproductive age in Chile. J Nutr 2003; 133: 316669. 191 Mersereau P, Kikler K, Carter H, et al. Spina bida and anencephaly before and after folic acid mandateUnited States, 19951996 and 19992000. MMWR Morb Mortal Wkly Rep 2004; 53: 36265. 192 Castilla EE, Orioli IM, Lopez-Camelo JS, da Graca Dutra M, Nazer-Herrera J. Preliminary data on changes in neural tube defect prevalence rates after folic acid fortication in South America. Am J Med Genet 2003; 123A: 12328. 193 Ray JG, Meier C, Vermeulen MJ, Boss S, Wyatt PR, Cole DE. Association of neural tube defects and folic acid food fortication in Canada. Lancet 2002; 360: 204748. 194 De Wals P, Rusen ID, Lee NS, Morin P, Niyonsenga T. Trend in prevalence of neural tube defects in Quebec. Birth Defects Res Part A Clin Mol Teratol 2003; 67: 91923. 195 Persad VL, Van den Hof MC, Dube JM, Zimmer P. Incidence of open neural tube defects in Nova Scotia after folic acid fortication. CMAJ 2002; 167: 24145. 196 Finnell RH, Shaw GM, Lammer EJ, Volcik KA. Does prenatal screening for 5,10-methylenetetrahydrofolate reductase (MTHFR) mutations in high-risk neural tube defect pregnancies make sense? Genet Test 2002; 6: 4752.

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