USE OF LUMBAR PERIOSTEAL TURNOVER FLAPS IN MYELOMENINGOCELE CLOSURE

OBJECTIVE: We report our experience with a previously undescribed meth od of myelomeningocele closure, which is the use of bilateral lumbar p eriosteal flaps as an additional tissue layer in complex cases. These flaps reinforce the dural repair, act to protect the spinal cord, and may help to contain any potential cerebrospinal fluid leak from the pr imary repair of the cord, thereby preventing pseudomeningocele formati on. METHODS: The repair involves the development of bilateral thoracol umbar fascial flaps in conjunction with periosteal flaps, which are el evated from adjacent lumbar pedicles and transverse processes, thus fo rming a composite tissue flap. These periosteally based flaps may be c losed in a ''pants over vest'' fashion to completely cover the spinal defect, reinforcing the neurosurgical repair. The flap anatomy and dis section are detailed. RESULTS: Two representative cases in which the l umbar periosteal turnover flap procedure was used are reported. One pa tient was operated on during the early neonatal period for primary mye lomeningocele repair; the other was operated on at age 5 years after a tethered cord release. Durable, stable soft tissue coverage of the sp inal cord was obtained in both patients, with a postoperative follow-u p period of at least 12 months. There was no recurrence of the pseudom eningocele noted preoperatively in the second patient. CONCLUSION: The lumbar periosteal turnover flap may be used to reinforce tenuous spin al cord and dural repairs in the myelomeningocele patient. This method provides a secure and watertight closure over the primary repair of t he cord, may help to contain potential cerebrospinal fluid leaks, and adds an additional autologous tissue layer to standard skin or muscle flap repairs.