What is the management approach for a 65-year-old female with a diagnosis of spina bifida occulta found on X-ray?

Management of Incidentally Discovered Spina Bifida Occulta in a 65-Year-Old Female

In an asymptomatic 65-year-old female with incidentally discovered spina bifida occulta on X-ray, no specific treatment is required, but focused evaluation for urological and neurological symptoms is warranted to identify any occult dysfunction that could impact quality of life.

Initial Assessment Approach

The discovery of spina bifida occulta in an older adult requires a targeted evaluation rather than routine intervention, as most cases remain asymptomatic throughout life. However, occult spinal dysraphism can present with urinary symptoms as the sole initial complaint, even in the absence of obvious neurological abnormalities 1.

Key Clinical Evaluation Points

Urological symptom assessment is critical, as patients with spina bifida occulta can develop:

• Urinary incontinence or urgency 1
• Incomplete bladder emptying with significant post-void residuals 1
• Recurrent urinary tract infections 2
• These urological issues represent a significant source of morbidity and can lead to chronic kidney disease if unrecognized 2

Neurological examination should focus on:

• Lower extremity motor function, particularly looking for upper motor neuron signs which predominate in the occult form 1
• Bulbocavernosus and anal reflexes, which may be absent in 56-57% of occult cases 1
• Foot deformities or gait abnormalities 3
• Lumbosacral skin findings (dimpling, masses, angiomas) 3

Bowel function inquiry should assess for fecal incontinence, which has an even greater impact on quality of life than urinary incontinence 4.

Diagnostic Workup Based on Symptoms

If Symptomatic (Urological, Neurological, or Bowel Symptoms)

MRI of the spine is essential to characterize intraspinal and perispinal abnormalities, identify tethered cord syndrome, and determine conus medullaris position 5. The conus may be low-placed (below L2) in symptomatic cases 3.

Urodynamic testing should be performed if any urinary symptoms are present, as there is no correlation between neurological findings and urodynamic abnormalities 1. Common findings in occult spina bifida include:

• Detrusor hyperreflexia (42% of cases) 1
• Low compliance detrusor (67% of cases) 1
• Detrusor-sphincter dyssynergia (27% of cases) 1

If Asymptomatic

No immediate intervention is required for truly asymptomatic spina bifida occulta discovered incidentally 3. However, the patient should be educated about potential symptoms to monitor.

Management Algorithm

For Asymptomatic Patients

• Reassurance and education about the condition
• Symptom monitoring with instructions to report urinary changes, bowel dysfunction, or progressive lower extremity weakness
• No routine surveillance imaging or urodynamic testing is indicated in the absence of symptoms

For Symptomatic Patients

Urological dysfunction management:

• Clean intermittent catheterization (CIC) with or without pharmacotherapy as first-line treatment 2
• Regular urodynamic surveillance to detect bladder dysfunction before upper tract deterioration develops 2
• Surgical intervention (bladder augmentation, bladder neck procedures) is reserved for those at risk for renal deterioration or who fail medical management 2

Tethered cord syndrome:

• Surgical untethering is indicated when neurological symptoms are confirmed, particularly if progressive 3
• Nineteen of 26 surgically treated patients in one series demonstrated urological and neurological improvement 3

Bowel management (if fecal incontinence present):

• Stepwise approach: dietary modifications and laxatives (50% success rate) → retrograde enemas (75% success rate) → antegrade continence enema procedure (77% continence rate) → colostomy as definitive management 4, 6

Critical Pitfalls to Avoid

Do not dismiss chronic lower back pain in patients with known spina bifida occulta without thorough evaluation, as it may represent symptomatic tethered cord or nerve compression requiring decompression 5.

Do not assume normal urological function based on absence of obvious symptoms—four patients in one series presented with urinary symptoms as their sole initial complaint 1.

Avoid performing spinal anesthesia without pre-procedural MRI imaging to identify conus position and intraspinal abnormalities 7.

Recognize that urological complications are a major source of long-term morbidity and mortality in spina bifida patients, with chronic kidney disease being a serious complication of poor bladder dynamics 2.