Fetal surgery for myelomeningocele: After the Management of Myelomeningocele Study (MOMS)

Myelomeningocele (MMC) is the most frequently occurring congenital abnormality of the central nervous system and leads to significant physical disabilities. Historically treatment involved postnatal closure with management of the associated sequelae including ventricular shunting. The mechanism of neurologic damage that begins with abnormal neurulation followed by continued injury over the course of gestation made MMC a plausible candidate for in-utero surgical repair. Animal and early human studies demonstrated the feasibility of fetal closure. The benefit of in-utero closure was debated until the results of the prospective randomized multicenter Management of Myelomeningocele Study (MOMS trial) were published, demonstrating a decreased need for shunting, reversal of hindbrain herniation, and better neurologic function in the prenatal repair group compared to postnatal repair with maternal complications and prematurity as a trade-off. As such, fetal MMC closure has become a standard of care option for prenatally diagnosed spina bifida. This paper reviews the MOMS trial and the journey of fetal MMC closure since that time.