Use of lumbar periosteal turnover flaps in myelomeningocele closure

OBJECTIVE: We report our experience with a previously undescribed method of myelomeningocele closure, which is the use of bilateral lumbar periosteal 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 primary repair of the cord, thereby preventing pseudomeningocele formation. METHODS: The repair involves the development of bilateral thoracolumbar fascial flaps in conjunction with periosteal flaps, which are elevated from adjacent lumbar pedicles and transverse processes, thus forming a composite tissue flap. These periosteally based flaps may be closed in a ''pants over vest'' fashion to completely cover the spinal defect, reinforcing the neurosurgical repair. The flap anatomy and dissection are detailed. RESULTS: Two representative cases in which the lumbar periosteal turnover flap procedure was used are reported. One patient was operated on during the early neonatal period for primary myelomeningocele repair; the other was operated on at age 5 years after a tethered cord release. Durable, stable soft tissue coverage of the spinal cord was obtained in both patients, with a postoperative follow-up period of at least 12 months. There was no recurrence of the pseudomeningocele noted preoperatively in the second patient. CONCLUSION: The lumbar periosteal turnover flap may be used to reinforce tenuous spinal cord and dural repairs in the myelomeningocele patient. This method provides a secure and watertight closure over the primary repair of the cord, may help to contain potential cerebrospinal fluid leaks, and adds an additional autologous tissue layer to standard skin or muscle flap repairs.