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PubMed This is a summary of 19 peer-reviewed journal articles Updated
Neurosurgery

Surgical Options and Early Management

At a Glance

For babies with myelomeningocele, families may consider fetal repair between 19 weeks 0 days and 25 weeks 6 days or closure after birth, usually within 24–48 hours. Both approaches have risks, and hydrocephalus may require a shunt or an endoscopic procedure called ETV+CPC.

Once a diagnosis of myelomeningocele (the most severe form of spina bifida) is confirmed, one of the most significant decisions a family will face is the timing of the surgical repair. While both prenatal (before birth) and postnatal (after birth) surgeries are standard options, they offer different benefits and risks that must be carefully weighed with a specialized medical team [1][2].

Prenatal (Fetal) Surgery

Fetal surgery involves closing the opening in the baby’s spine while they are still in the womb. This is an elective procedure, not a cure, and is only available for carefully selected pregnancies [3][1].

Eligibility and Timing

To be considered for fetal surgery, the pregnancy must typically meet strict criteria originally based on the landmark MOMS (Management of Myelomeningocele Study) trial [3][1]:

  • Window of Opportunity: The surgery must occur between 19 weeks 0 days and 25 weeks 6 days of pregnancy [3].
  • Medical Screening: Factors such as maternal BMI, the absence of other fetal anomalies, and a healthy uterus (no prior history of preterm birth or certain uterine surgeries) are evaluated [3][1].
  • The “Why”: The primary goal is to protect the exposed nerves from amniotic fluid and to reduce “hindbrain herniation,” where the brain is pulled down toward the spinal canal [4][5]. Fetal surgery does not restore already injured nerves and does not guarantee independent walking.

Benefits and Risks

Benefit to the Child Risk to the Mother & Pregnancy
Reduced Shunting: Only about 40% of MOMS trial fetal surgery babies needed a shunt by age one, compared to over 80% of those repaired after birth [4]. Preterm Birth: There is a significant risk of early delivery. The MOMS trial reported a median delivery around 34 weeks.
Better Mobility: Children who had fetal surgery in the MOMS trial were more likely to walk independently or with less assistance later in life [5]. PPROM: Preterm premature rupture of membranes (the “water breaking” early) is a common complication [6][7].
Reversed Brain Sagging: The surgery can often reverse the downward pull on the brainstem [5]. Uterine Scarring: Open fetal hysterotomy creates a full-thickness uterine scar. A Cesarean delivery is generally required for the current and future pregnancies [6][8].

Postnatal Surgery (After Birth)

If fetal surgery is not possible or chosen, the baby will be delivered—usually at a hospital with a Level III or IV Neonatal Intensive Care Unit (NICU)—and the spine will be closed shortly after birth [9][10].

The First 48 Hours

The priority for a newborn with an open myelomeningocele is to protect the exposed nerves and prevent infection (meningitis) [9][11].

  1. Immediate Protection: The sac is covered with sterile, moist dressings, and the baby is positioned on their stomach or side to avoid pressure on the lesion [9][12].
  2. Surgical Closure: Pediatric neurosurgeons typically perform the repair within 24 to 48 hours of birth [9][11].
  3. Baseline Testing: Doctors will perform a head ultrasound or MRI to check for fluid buildup in the brain and a renal ultrasound to check kidney health [13][12].

Managing Hydrocephalus

Many children with spina bifida develop hydrocephalus, a buildup of cerebrospinal fluid (CSF) in the brain’s chambers (ventricles). If the fluid causes pressure, surgeons use one of two main methods to drain it [14][15].

Ventriculoperitoneal Shunt (VPS)

A shunt is a thin tube with a valve that is surgically placed into the brain. It drains excess fluid down into the abdomen, where the body absorbs it [16].

  • Pros: Highly effective at controlling pressure [17].
  • Cons: Shunts are implanted devices that can fail or become infected. Many children will need a “shunt revision” (surgery to fix or replace it), though some are eventually removed or become unnecessary over time [17].

ETV+CPC

Endoscopic Third Ventriculostomy (ETV) combined with Choroid Plexus Cauterization (CPC) is an alternative that aims to avoid a permanent shunt [14][15].

  • How it Works: The surgeon makes a tiny hole in the floor of the brain’s third ventricle (ETV) to allow fluid to flow and uses a heat probe to reduce the tissue that produces the fluid (CPC) [14][18].
  • Pros: If successful, the child does not have an implanted device [14].
  • Cons: Success rates depend heavily on age, anatomy, and center experience, and are often reported between 60-75% in specific myelomeningocele cohorts. If it fails, a shunt is usually required [14][15][19][18].

Common questions in this guide

When is fetal surgery for myelomeningocele an option?
Fetal repair is usually considered between 19 weeks 0 days and 25 weeks 6 days of pregnancy, and only for carefully selected pregnancies. Screening may include the mother’s BMI, fetal anatomy, uterine health, and history of preterm birth or certain uterine surgeries. The procedure is elective and does not restore nerves that were already injured.
What can fetal spina bifida surgery help with, and what are its risks?
The goal is to protect exposed nerves, reduce hindbrain herniation, lower the chance of needing a shunt, and potentially improve later mobility. It can also cause preterm delivery, early rupture of the membranes, and a uterine scar that generally requires Cesarean delivery in the current and future pregnancies. It does not cure myelomeningocele or guarantee independent walking.
What happens when a baby has myelomeningocele repair after birth?
After birth, the sac is covered with sterile, moist dressings and the baby is positioned on the stomach or side to protect the exposed nerves. Pediatric neurosurgeons usually close the spinal opening within 24 to 48 hours, often at a hospital with a specialized neonatal intensive care unit. Doctors commonly use head imaging and a kidney ultrasound as early baseline tests.
How do doctors treat hydrocephalus in a baby with spina bifida?
If cerebrospinal fluid builds up and creates pressure, doctors may place a ventriculoperitoneal shunt to drain fluid into the abdomen. Another option is ETV+CPC, which creates a pathway for fluid and reduces the tissue that makes it. The choice depends on the child’s age, anatomy, and the treatment center’s experience, and ETV+CPC may still need a shunt if it does not work.
What is the difference between a shunt and ETV+CPC?
A ventriculoperitoneal shunt uses a tube and valve to move extra fluid from the brain to the abdomen. ETV+CPC makes a small opening in the brain’s third ventricle and reduces the tissue that produces cerebrospinal fluid, with the aim of avoiding a permanent implant. ETV+CPC does not work for every child, and a shunt may be needed if it fails.
Does fetal surgery cure myelomeningocele or guarantee independent walking?
No. Fetal surgery may improve the chances of better mobility and can reduce the downward pull on the brain, but it cannot repair nerves that were already damaged and does not guarantee independent walking. Each child’s mobility and care needs must be assessed individually by the medical team.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Do I (or does the fetus) meet the strict criteria for fetal surgery, and at what gestational age must this decision be finalized?
  2. 2.What are the specific maternal risks for me, including the likelihood of preterm labor and the impact on my future pregnancies?
  3. 3.If we choose postnatal repair, what steps are taken in the first 24 hours to protect the exposed spinal nerves?
  4. 4.Based on the current size of the brain's ventricles, what is the likelihood that a shunt or ETV+CPC will be needed?
  5. 5.What is your center's experience and success rate with ETV+CPC compared to traditional shunting for infants with spina bifida?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (19)
  1. 1

    Committee Opinion No. 720 Summary: Maternal-Fetal Surgery for Myelomeningocele.

    Obstetrics and gynecology 2017; (130(3)):672-673 doi:10.1097/AOG.0000000000002294.

    PMID: 28832482
  2. 2

    Prenatal counseling for myelomeningocele in the era of fetal surgery: a shared decision-making approach.

    Ravindra VM, Aldave G, Weiner HL, et al.

    Journal of neurosurgery. Pediatrics 2020; (25(6)):640-647 doi:10.3171/2019.12.PEDS19449.

    PMID: 32109872
  3. 3

    Global Policy and Practice for Intrauterine Fetal Resuscitation During Fetal Surgery for Open Spina Bifida Repair.

    Gallagher K, Crombag N, Prashar K, et al.

    JAMA network open 2023; (6(4)):e239855 doi:10.1001/jamanetworkopen.2023.9855.

    PMID: 37097634
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    Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement.

    Tulipan N, Wellons JC, Thom EA, et al.

    Journal of neurosurgery. Pediatrics 2015; (16(6)):613-20 doi:10.3171/2015.7.PEDS15336.

    PMID: 26369371
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    Prenatal Repair and Physical Functioning Among Children With Myelomeningocele: A Secondary Analysis of a Randomized Clinical Trial.

    Houtrow AJ, MacPherson C, Jackson-Coty J, et al.

    JAMA pediatrics 2021; (175(4)):e205674 doi:10.1001/jamapediatrics.2020.5674.

    PMID: 33555337
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    Benefits and complications of fetal and postnatal surgery for open spina bifida: systematic review and proportional meta-analysis.

    Kunpalin Y, Karadjole VS, Medeiros ESB, et al.

    Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology 2025; (66(2)):135-146 doi:10.1002/uog.29240.

    PMID: 40492626
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    Experience of 300 cases of prenatal fetoscopic open spina bifida repair: report of the International Fetoscopic Neural Tube Defect Repair Consortium.

    Sanz Cortes M, Chmait RH, Lapa DA, et al.

    American journal of obstetrics and gynecology 2021; (225(6)):678.e1-678.e11 doi:10.1016/j.ajog.2021.05.044.

    PMID: 34089698
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    Reproductive outcomes following open maternal-fetal surgery for myelomeningocele closure: analysis of MOMS trial participants.

    Moldenhauer JS, MacPherson C, Thom EA, et al.

    American journal of obstetrics & gynecology MFM 2025; (7(11)):101765 doi:10.1016/j.ajogmf.2025.101765.

    PMID: 40886957
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    Care management and contemporary challenges in spina bifida: a practice preference survey of the American Society of Pediatric Neurosurgeons.

    Alford EN, Hopson BD, Safyanov F, et al.

    Journal of neurosurgery. Pediatrics 2019; (24(5)):539-548 doi:10.3171/2019.5.PEDS18738.

    PMID: 31470398
  10. 10

    A comparison of the accuracy of fetal MRI and prenatal ultrasonography at predicting lesion level and perinatal motor outcome in patients with myelomeningocele.

    Sherrod BA, Ho WS, Hedlund A, et al.

    Neurosurgical focus 2019; (47(4)):E4.

    PMID: 31574478
  11. 11

    Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Closure of Myelomeningocele Within 48 Hours to Decrease Infection Risk.

    Beier AD, Nikas DC, Assassi N, et al.

    Neurosurgery 2019; (85(3)):E412-E413 doi:10.1093/neuros/nyz264.

    PMID: 31418041
  12. 12

    From birth to beyond: predicting incidence and timing of CSF diversion in postnatal MMC closure.

    Daniels K, Chesney KM, O'Neill BE, et al.

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2026; (42(1)):53 doi:10.1007/s00381-025-07099-3.

    PMID: 41615491
  13. 13

    Baseline Urinary Tract Imaging in Infants Enrolled in the UMPIRE Protocol for Children with Spina Bifida.

    Tanaka ST, Paramsothy P, Thibadeau J, et al.

    The Journal of urology 2019; (201(6)):1193-1198 doi:10.1097/JU.0000000000000141.

    PMID: 30730412
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    Endoscopic third ventriculostomy with or without choroid plexus coagulation for myelomeningocele-associated hydrocephalus: systematic review and meta-analysis.

    Omar AT, Espiritu AI, Spears J

    Journal of neurosurgery. Pediatrics 2022; (29(4)):435-443 doi:10.3171/2021.11.PEDS21505.

    PMID: 35061994
  15. 15

    Early Outcome of Endoscopic Third Ventriculostomy With Choroid Plexus Cauterization Versus Ventriculoperitoneal Shunt as Primary Treatment of Hydrocephalus in Children With Myelomeningocele: A Prospective Cohort Study.

    Adebayo BO, Kanu OO, Bankole OB, et al.

    Operative neurosurgery (Hagerstown, Md.) 2021; (21(6)):461-466 doi:10.1093/ons/opab314.

    PMID: 34662909
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    To shunt or not to shunt when closing myelomeningocele? A systematic review and meta-analysis of simultaneous versus delayed ventriculoperitoneal shunt placement in neonates undergoing myelomeningocele closure.

    Saarinen O, Piironen S, Pokka T, et al.

    Journal of neurosurgery. Pediatrics 2024; (34(5)):452-461 doi:10.3171/2024.5.PEDS23600.

    PMID: 39126714
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    Time to shunt failure in children with myelomeningocele: an analysis of the National Spina Bifida Patient Registry.

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    PMID: 35986725
  18. 18

    Third Ventricle Floor Variations and Abnormalities in Myelomeningocele-Associated Hydrocephalus: Our Experience with 455 Endoscopic Third Ventriculostomy Procedures.

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  19. 19

    Endoscopic third ventriculostomy with choroid plexus cauterization: predictors of long-term success and comparison with shunt placement for primary treatment of infant hydrocephalus.

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    Journal of neurosurgery. Pediatrics 2023; (32(2)):201-213 doi:10.3171/2023.4.PEDS2310.

    PMID: 37178026

This page is for informational purposes only and does not constitute medical advice. A maternal-fetal medicine and pediatric neurosurgery team should help your family weigh fetal repair, postnatal closure, and hydrocephalus treatment.

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