Surgical considerations in the initial repair of meningomyelocele and the introduction of a technical modification.

Tethering of the spinal cord has been increasingly recognized as a cause of late deterioration in the child with repaired meningomyelocele. Findings at reoperation include dense arachnoiditis, dermal inclusion cysts, fibrolipoma of the filum terminale, and, on occasion, foreign body granulomas. This article reviews four key steps in meningomyelocele repair and the guidelines for detection of surgically remediable lesions associated with this disorder. In addition, it proposes a modification of the standard dural closure that may reduce the incidence of contributory adhesive arachnoiditis by the creation of a capacious cerebrospinal fluid space about the neural plaque.