What is the management of spina bifida in primary practice when suspected due to dimples on the back?

Management of Sacral Dimples in Primary Care

When a sacral dimple is identified in primary care, immediate referral for imaging and specialist evaluation is necessary if high-risk features are present, while low-risk dimples require only routine follow-up. 1

Assessment of Sacral Dimples

Initial Evaluation

• Determine if the dimple is high-risk or low-risk based on:
  • Location: Dimples above the gluteal cleft line are potentially pathologic, while those below are likely innocent 1
  • Depth: Deep dimples warrant further investigation
  • Associated cutaneous markers: Look specifically for:
    • Hypertrichosis (abnormal hair growth)
    • Infantile hemangioma
    • Subcutaneous lipoma
    • Caudal appendage (skin tag)
    • Deviated or forked gluteal cleft
    • Vascular anomalies

Neurological Assessment

• Perform a basic neurological examination to check for:
  • Lower extremity movement and strength
  • Reflexes
  • Bladder/bowel function abnormalities
  • Orthopedic deformities

Management Algorithm

For High-Risk Dimples (any of the following):

1. Located above the gluteal cleft
2. Deep dimple
3. Associated cutaneous markers
4. Neurological symptoms

Management steps:

• Refer immediately for imaging:
  • Ultrasound for infants <6 months of age
  • MRI for children >6 months of age
• Arrange neurosurgical consultation
• If spina bifida is confirmed, surgical closure should be performed within 24-72 hours to prevent complications 1

For Low-Risk Dimples:

1. Located below the gluteal cleft
2. Shallow dimple
3. No associated cutaneous markers
4. No neurological symptoms

Management steps:

• No imaging necessary
• Continue routine well-child care
• Reassure parents about the benign nature of the finding

Follow-up Care

For Confirmed Spina Bifida:

• Multidisciplinary approach including:
  • Neurosurgery follow-up
  • Regular urodynamic studies to assess bladder function
  • Consider clean intermittent catheterization (CIC) and anticholinergic medications for bladder management 2
  • Monitor for tethered cord syndrome (occurs in approximately 32% of patients) 3
  • Screen for latex allergy (affects approximately 1/3 of patients with spina bifida) 2, 3
  • Monitor for scoliosis (affects approximately 49% of patients) 3

For High-Risk Dimples with Normal Imaging:

• Yearly neurological assessment until age 3
• Monitor for late-developing symptoms

Important Considerations

Latex Precautions

• Patients with spina bifida should have all medical-surgical-dental procedures performed in a latex-safe environment 2
• A latex-safe environment means no latex gloves in the room and no latex accessories (catheters, adhesives, tourniquets) coming into contact with the patient 2

Long-term Outcomes

• With proper management, approximately 75% of children born with myelomeningocele can be expected to reach early adulthood 3
• Late deterioration is common, highlighting the importance of ongoing monitoring 3
• More than 80% of young adults can achieve social bladder continence with appropriate management 3

Preventive Measures

• For future pregnancies, counsel about periconceptional folic acid supplementation to reduce risk of neural tube defects 4

Remember that early detection and timely intervention are crucial for optimal outcomes in patients with spina bifida, with surgical intervention ideally occurring within 24-72 hours of identification to prevent complications 1.