Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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X-rays are not necessary in evaluating any type of cervical, lumbar, or sacral dimple; ultrasound is beneficial for young patients and MRI is the gold standard for older patients — Francesco Mangano, Management of neural tube defects: prevention, embryology, and surgical approaches · 9:41
Diffusion tensor imaging in children following prenatal myelomeningocele repair and its predictive value for the need and timing of subsequent CSF diversion surgery for hydrocephalus.
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The aim of this study was to investigate diffusion tensor imaging (DTI), an objective and noninvasive neuroimaging technique, for its potential as an imaging biomarker to predict the need and timing of CSF diversion surgery in patients afte
article · Nov 2026
Abnormal anisotropic diffusion properties in pediatric myelomeningocele patients treated with fetal surgery: an initial DTI study
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Purpose: To investigate white matter microstructural abnormality based on diffusion tensor imaging (DTI) in pediatric patients with fetal repair for myelomeningocele (MMC). Methods: This was a retrospective analysis of DTI data from 8 pedia
article · Nov 2026
Management of neural tube defects: prevention, embryology, and surgical approaches
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presentation by Dr. Francesco Mangano
video44:57 · Nov 2026
Diffusion Tensor Imaging of Fetuses With Congenital Diaphragmatic Hernia
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Objective: To evaluate differences in diffusion tensor imaging (DTI) parameters in the brain between fetuses with congenital diaphragmatic hernia (CDH) and age-matched controls. Method: This retrospective IRB-approved study included fetal M
article · Nov 2026
Pediatric Spinal Ultrasound: Neonatal and Intraoperative Applications
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The purpose of this article is to review the use of ultrasound as a screening tool for spinal diseases in neonates and infants and its intraoperative value in selected pediatric neurosurgical disorders. A review of spinal embryology followe
article · Nov 2026
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Management of neural tube defects: prevention, embryology, and surgical approaches
Global prevalence of neural tube defects is roughly 20 per 10,000 live births, with US incidence of 7 per 10,000 and some countries like Algeria reaching 96 per 10,000
epidemiologicalFrancesco Mangano2:23 ↗
Folate supplementation can have a significant reduction of the incidence of neural tube defects, and countries that have adopted fortification mandates have done much better than others in preventing this problem
clinicalFrancesco Mangano3:10 ↗
The conus medullaris above L2 or above is considered to be normal, and anything below that level is considered to be abnormal
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position5:15 ↗
Tethered cord syndrome has been described in patients that have a normal conus medullaris, with roughly 50% of patients with occult tethered cord having a normal conus position
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position5:38 ↗
Dr. Yamada's experiments demonstrated that the greatest effect of pathology from tethering was in the lower set of nerves, with the dentate ligaments providing some protection to the rostral cord
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position6:13 ↗
The pathophysiology of tethered cord is primarily related to a lack of blood flow and oxidative metabolism to the cord
clinicalFrancesco Mangano6:33 ↗
Benign sacral dimples in the intergluteal fold are relatively common in newborns and typically have no consequences; these patients typically do not have a tethered cord and do not have any reason to have any further imaging or workup
clinicalFrancesco Mangano7:08 ↗
Any lesions occurring above the gluteal fold should be considered to be potentially abnormal and warrant investigation
clinicalFrancesco Mangano7:41 ↗
X-rays are not necessary in evaluating any type of cervical, lumbar, or sacral dimple; ultrasound is beneficial for young patients and MRI is the gold standard for older patients
clinicalFrancesco Mangano9:41 ↗
Filum terminale lipomas have been reported in cadaveric studies to occur in as many as four to six percent of the population, with MRI prevalence up to four percent
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position11:34 ↗
In many parts of the world, patients that have a fatty filum as a tethered cord finding on imaging are just observed and do not undergo prophylactic detethering; this is more of a North American trend in some institutions
clinicalFrancesco Mangano11:44 ↗
Dr. Mangano does not typically detether patients that have an asymptomatic tethered cord, but follows them; the risk is that they could deteriorate at some point, but that is typically not the case
opinionFrancesco Mangano12:09 ↗
Patients that have a conus below at or below the level of L4 tend to be those that present with symptoms, while those patients between L2 and L4 are less likely to present with symptoms (50% threshold)
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position12:22 ↗
Lipomyelomeningoceles result from primary and secondary neurulation defects; patients usually present very early in life and prophylactic resection and detethering is typically recommended because they will become symptomatic
clinicalFrancesco Mangano13:45 ↗
Dr. Pang describes the ideal patient for lipomyelomeningocele repair as someone who is asymptomatic, less than two years of age, without a history of previous lipoma surgery
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position14:15 ↗
Three types of lipomyelomeningoceles: dorsal (lipoma not affecting the conus, easily dissected), transitional (lipoma extends into conus, difficult to achieve gross total resection), and chaotic (lipoma includes ventral roots, creating further difficulty in dissection)
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position14:33 ↗
In lipomyelomeningocele surgery, the dura typically is not normal, so the dural dissection is extended out as laterally as possible to enable watertight closure without a patch; it is rare to require a dural patch
clinicalFrancesco Mangano16:52 ↗
In type 1 diastematomyelia with a midline bony spur, the spur is the tethering lesion; prophylactic detethering occurs at the level of the bony spur, not necessarily at the bottom of the canal where the filum is located
clinicalFrancesco Mangano17:49 ↗
Myelomeningocele is a primary problem of primary neurulation, with most lesions in the thoracolumbar region and primarily more distal
clinicalFrancesco Mangano18:24 ↗
The majority of myelomeningoceles are associated with hydrocephalus requiring shunts when repaired postnatally, and more than 90% of patients have a Chiari 2 malformation
epidemiologicalFrancesco Mangano18:34 ↗
The morbidity associated with myelomeningocele is not typically related to the cord itself, but usually to the hindbrain issue and compression of the cervical medullary junction
clinicalFrancesco Mangano21:23 ↗
Most patients with postnatal myelomeningocele repair will have a relatively low normal IQ and can function in community quite well
clinicalFrancesco Mangano21:43 ↗
The MOMS trial was stopped early because there was a clear demonstration of efficacy shown in the prenatal repair group
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position22:14 ↗
Prenatal myelomeningocele repair showed reduced need for shunting (40% versus 82%), improved composite score for mental development and motor scores at 30 months, improved hindbrain herniation at 12 months, and improved ambulation at 30 months
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position22:51 ↗
The downside of prenatal repair are the associated maternal and fetal risks
clinicalFrancesco Mangano23:15 ↗
MOMS trial inclusion criteria required myelomeningocele between T1 and S1, grade 3 hindbrain herniation on MRI, gestational age between 19 and 27 weeks, normal fetal genome and echocardiography, and singleton pregnancy
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position23:29 ↗
Exclusion criteria for prenatal repair included significant fetal anomalies, lumbosacral kyphosis greater than 30 degrees, incompetent cervix, and significant morbid obesity by the mother
Host summaryFrancesco Mangano summarizing the discussion — not the host's own clinical position24:00 ↗
Fetoscopic myelomeningocele repair has become what is primarily done at Cincinnati in 2022
clinicalFrancesco Mangano18:06 ↗
Adult tethered cord presentation is rare but when it happens with symptoms should be managed surgically; the clinical presentation can differ from the pediatric population, especially with incontinence
clinicalFrancesco Mangano30:09 ↗
Folate supplementation is the best resource to prevent neural tube defects and leads to better outcomes than surgical outcomes
clinicalFrancesco Mangano30:26 ↗
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