Open Myeloschisis

Open myeloschisis is the most severe “open” form of spina bifida (an open neural-tube defect). During the fourth week after conception, the edges of the embryonic neural tube are meant to curl up and fuse, sealing the future spinal cord in a bony canal. In open myeloschisis that fusion fails completely along a segment of the back. The raw, plate-like spinal cord lies flush with the skin surface, uncovered by bone, meninges, or even a cystic sac. Because amniotic fluid bathes the exposed neural tissue for months, the cord becomes flattened and dysplastic, leaving the newborn with irreversible nerve damage. Neurologically the lesion behaves like a large myelomeningocele but carries an even higher risk of infection, cerebrospinal-fluid (CSF) loss, and rapid hydrocephalus. ncbi.nlm.nih.govlosangelesfetalsurgery.orgorpha.net

Open myeloschisis is the most severe “open” form of spina bifida. During the fourth week of pregnancy the neural tube fails to close, leaving a completely flat plate of spinal cord tissue that is directly exposed—no skin, no sac, no membrane. Because the cord floats unprotected in amniotic fluid, nerve cells are damaged first by incomplete development and then by chemical irritation and trauma in the womb. At birth the baby typically presents with a gaping lumbar–sacral defect, flaccid or spastic paralysis of the legs, loss of bowel-bladder control, and often hydrocephalus and Chiari II malformation.nationwidechildrens.orgkarger.com

Think of the neural tube as a zipper that must close from the brain downward. Folate, vitamin B12, and normal gene switches act like the “zipper’s lubricant.” If any part is missing or blocked—by drugs, fever, diabetes, or gene variants—the zipper jams. When it jams early and broadly, the spinal cord itself never tucks inside; instead, it opens out like a book (a “schisis”). Because the bony spine grows later, it simply forms around the gap, leaving a raw patch. That is why surgeons call it open. nationwidechildrens.orgkarger.com

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 Main Types You May Hear About

Although every case is technically unique, clinicians group open myeloschisis by shape, size, and associated problems:

• Flat (“true”) myeloschisis – a saucer-shaped neural plate flush with the skin; no swelling.

• Saccular myeloschisis – a thin, translucent bubble covers part of the lesion but the plate remains exposed where the bubble meets skin.

• Limited dorsal myeloschisis (LDM) – a small, stalk-like tract tethers the cord to the skin above an otherwise closed canal; it can mimic a dimple but hides open tissue beneath. pmc.ncbi.nlm.nih.govneurology.org

• Thoracolumbar vs. lumbosacral – named for the spinal level involved; the lower the defect, the more leg and bladder nerves are affected.

• Isolated vs. complex – “complex” means other malformations exist, most often Chiari II hind-brain herniation or hydrocephalus. losangelesfetalsurgery.org

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Causes

1. Low maternal folate intake: Folate powers DNA synthesis during tube closure; a shortage leaves cells too “tired” to meet and fuse.

2. MTHFR gene variants: Certain gene “spelling errors” slow folate recycling, so even normal diets may act deficient.

3. Vitamin B12 deficiency: B12 primes folate; without it, folate cannot enter DNA pathways.

4. Maternal diabetes (pre-gestational or poorly controlled gestational): High sugar creates oxidative stress that damages neural-tube cells.

5. Maternal obesity: Excess adipose raises inflammatory cytokines that disturb early embryonic signaling.

6. Hyperthermia (fever >38 °C or hot-tub use during weeks 3-4): Heat temporarily blocks crucial closure proteins, likened to “melting the zipper teeth.”

7. Valproic acid therapy: The antiseizure drug inhibits histone-deacetylase enzymes needed for tube folding.

8. Carbamazepine exposure: A milder cousin to valproate but still lowers folate and disturbs neural-crest migration.

9. Isotretinoin (Accutane): Retinoic-acid excess disrupts the gradient that tells cells which end is “head” and “tail.”

10. Maternal alcohol misuse: Ethanol interrupts cell-to-cell adhesion just when the tube edges must stick.

11. Maternal cigarette smoking: Nicotine constricts uterine blood vessels, starving the tube of oxygen.

12. Folate-antagonist antibiotics (trimethoprim, sulfonamides): They block the same pathway prenatal vitamins aim to boost.

13. Zika or rubella infection: Certain viruses attack dividing neuro-ectoderm directly.

14. Maternal sulfur-spraying pesticides: Organophosphates can damage rapidly dividing cells, although data remain limited.

15. Thallium or lead exposure: Heavy metals displace essential metals in enzyme systems required for closure.

16. Hyper-vitaminosis A supplements: Too much pre-formed vitamin A duplicates the teratogenic effect of isotretinoin.

17. Low socioeconomic status: Often a marker for combined poor nutrition, late prenatal care, and environmental toxins.

18. Short inter-pregnancy interval (<12 months): Depletes folate stores the body needs to replenish.

19. In vitro fertilization with fresh embryo transfer: Some studies show a small rise in NTD risk, possibly due to ovarian hyper-stimulation hormones.

20. Family history of neural-tube defects: Siblings show three- to eight-fold higher risk, indicating poly-genic inheritance.

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Common Symptoms

1. Visible flat lesion: Parents notice a wet, red patch along the baby’s spine.

2. Continuous CSF leakage: Clear fluid seeps from the plate, raising infection risk.

3. Weak leg movements: Signals cannot travel past the open spot, so kicks are feeble.

4. Total leg paralysis: In higher or bigger defects, no movement occurs below the waist.

5. Numbness: Babies do not react to pinprick on soles or thighs.

6. Absent deep-tendon reflexes: Knees and ankles stay silent when tapped.

7. Clubfoot: Muscles that shape the feet get wrong signals and tighten unevenly.

8. Hip dislocation: Weak pelvic muscles cannot keep the ball in its socket.

9. Kyphoscoliosis: The spine above and below bends to unload pressure on the weak segment.

10. Urinary incontinence: Bladder nerves fail, so urine dribbles constantly or backs up.

11. Frequent urinary infections: Stagnant urine becomes a germ playground.

12. Constipation or stool leakage: Colon muscles and anal sphincter also lose coordination.

13. Pressure-area skin sores: Numb skin means the baby cannot feel early redness.

14. Hydrocephalus signs: Rapid head growth, bulging fontanelle, sunset eyes.

15. Chiari II brainstem symptoms: Weak cry, swallowing trouble, apneic spells. nationwidechildrens.orglosangelesfetalsurgery.org

16. Latex allergy: Repeated surgical contact sensitizes many spina-bifida patients.

17. Learning difficulties: Hydrocephalus or repeated infections may slow cognitive milestones.

18. Lower-back pain in older children: Scarred cord may tether, stretching pain fibers.

19. Foot drop during walking practice: Dorsiflexor weakness means toes drag.

20. Early puberty: Disturbed hypothalamic-pituitary signaling can trigger hormones ahead of schedule.

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Diagnostic Tests

A. Physical-Examination Tests

1. Inspection of the back: Surgeons look for size, level, and CSF leakage to plan urgent closure.

2. Neurologic‐level mapping: Pin, light-touch, and vibration help locate the highest intact spinal segment.

3. Motor-strength grading (MRC scale): Helps predict future ambulation aids.

4. Light-touch filament test: A soft nylon filament marks loss of protective sensation.

5. Anal-wink reflex: Absence suggests sacral nerve damage.

6. Plantar (“Babinski”) response: Up-going toes show corticospinal tract disruption.

7. Deep-tendon reflexes (knee, ankle): Hyper-reflexia may mean an upper-motor-neuron component; absence points to lower-motor-neuron injury.

8. Orthopedic alignment check: Detects hip dislocation or clubfoot early for casting.

B. Manual or Bedside Functional Tests

9. Straight-leg-raise tension test: Pain or spasm suggests tethering.

10. Passive hip‐abduction range: Restricted motion warns of early contracture.

11. Popliteal-angle measurement: Quantifies hamstring tightness.

12. Passive ankle dorsiflexion: Gauges Achilles tightness causing toe-walking.

13. Gowers’ sign: Using arms to “climb” up when standing signals proximal weakness.

14. Serial head-circumference charting: A cheap hydrocephalus screen.

15. Cranial-nerve screen: Assesses for Chiari-related swallowing or vocal-cord paresis.

16. Developmental-milestone checklist: Detects subtle cognitive or motor delays for early therapy.

C. Laboratory & Pathological Tests

17. Maternal-serum α-fetoprotein (MSAFP): Elevated at 16–18 weeks hints at open defects.

18. Amniotic-fluid AFP: More specific; pooled with ultrasonography to decide referral.

19. Amniotic-fluid acetylcholinesterase (AChE): Enzyme leaks only when neural tissue is exposed.

20. Maternal-serum inhibin-A: High levels strengthen MSAFP findings.

21. Maternal-serum β-hCG: Part of the “quad screen”; certain patterns raise NTD suspicion.

22. Complete blood count: Screens for maternal anemia that worsens folate status.

23. Serum folate concentration: Confirms deficiency so supplementation can begin even post-natally for future pregnancies.

24. MTHFR gene testing: Advises higher-dose folinic acid in mothers with variants.

25. Chromosomal karyotype or micro-array: Rules out syndromic associations when multiple anomalies appear.

26. TORCH infection panel: Excludes rubella or cytomegalovirus as contributory insults.

D. Electro-Diagnostic Tests

27. Electromyography (EMG) of lower limbs: Maps denervation; predicts which muscles can learn to walk. pubmed.ncbi.nlm.nih.gov

28. Nerve-conduction study (NCS): Measures signal speed in peripheral nerves to distinguish root injury from peripheral neuropathy. nationwidechildrens.org

29. Hoffmann reflex (H-reflex): A simple electrical tap on the tibial nerve estimates spinal motor-neuron excitability. pmc.ncbi.nlm.nih.gov

30. Somatosensory evoked potentials (SSEPs): Show whether touch signals reach the brain past the lesion.

31. Motor evoked potentials (MEPs): Magnetic pulses applied to the scalp check corticospinal continuity. sciencedirect.com

32. Urodynamic study with sphincter EMG: Correlates bladder pressure curves to pelvic-floor electrical bursts, guiding catheterization schedules.

33. Surface EMG gait analysis: Electrodes on skin record firing patterns to customize leg braces.

34. Bulbo-cavernosus reflex latency: A gentle squeeze of glans or clitoris triggers EMG spike in external sphincter; delay shows sacral arc damage.

E. Imaging Tests

35. Second-trimester screening ultrasound: Rapidly identifies the “lemon” and “banana” skull signs plus the open lumbar defect.

36. Fetal MRI: Produces clear three-dimensional images of the cord and hind-brain; useful when ultrasound is equivocal. pmc.ncbi.nlm.nih.gov

37. Post-natal spinal MRI: Defines the exact level, cord quality, and any tethering bands before surgery. ajronline.org

38. Plain radiograph of spine and hips: Cheap tool to track deformities over years.

39. CT scan with 3-D reconstruction: Occasionally used to plan complex bony reconstructions or shunt placement.

40. Cranial ultrasound through fontanelle: Monitors ventricular size after birth until fontanelle closes.

Non-pharmacological treatments

A. Physiotherapy & electro-therapies

1. Early neuro-developmental handling – gentle, age-matched positioning prevents hip dislocation and trains primitive reflexes into purposeful movement by stimulating intact motor pathways.physio-pedia.com

2. Therapeutic positioning wedges & splints – keep the spine neutral and joints in mid-range to minimise contractures; prolonged stretch reduces connective-tissue cross-linking.

3. Passive range-of-motion (PROM) – daily hip-knee-ankle cycles lubricate cartilage and maintain capsule length, slowing arthrofibrosis.

4. Active-assisted ROM with play – toys encourage voluntary firing of residual motor units, promoting cortical plasticity.

5. Progressive resistive strengthening – elastic bands or cuff weights hypertrophy functioning muscles, compensating for denervated groups.

6. Tilt-table weight-bearing & standing frames – intermittent vertical loading improves bone mineral density via mechanotransduction and lowers fracture risk.

7. Body-weight-supported treadmill or over-ground gait training – repetitive stepping entrains the spinal central-pattern generator and refines balance strategies.

8. Hydrotherapy – buoyancy unloads joints, warmth relaxes spasticity, and water resistance strengthens without gravity stress.

9. Functional electrical stimulation (FES) cycling – timed pulses trigger coordinated quadriceps–hamstring firing, elevating aerobic capacity and slowing muscle atrophy.

10. Transcutaneous electrical nerve stimulation (TENS) – low-frequency current gates chronic neuropathic pain signals at the dorsal horn level.

11. Neuromuscular electrical stimulation (NMES) – high-intensity bursts directly depolarise peripheral nerves, re-educating muscle recruitment.

12. Surface EMG biofeedback – real-time visual/auditory cues teach children to up-regulate weak contractions or down-train spastic firing.

13. Low-intensity pulsed ultrasound (LIPUS) – micromechanical stimulation accelerates fracture healing in osteopenic long bones.

14. Whole-body vibration – oscillatory shear improves spastic dorsiflexor excitability and increases leg BMD.

15. Constraint-induced movement therapy (for upper-limb deficits) – restraining the stronger limb forces repetitive use of weaker segments, remodelling corticospinal maps.

B. Exercise-centred, mind-body & self-management approaches 

16. Core-stability mat programs – strengthens trunk flexors/extensors, easing wheelchair transfers and reducing scoliosis progression.

17. Adaptive wheelchair sports – basketball or racing elevates VO₂-max and social participation.

18. Arm-ergometer cardio sessions – 20-minute intervals, 3×/week, improve HDL and insulin sensitivity in sedentary teens.

19. Seated Tai Chi – slow, mindful weight-shifting decreases pain catastrophising and increases shoulder ROM.

20. Yoga with strap/bolster support – diaphragmatic breathing lowers sympathetic over-activity, calming neurogenic bowel spasms.

21. Mindfulness-based stress reduction (MBSR) – eight-week courses cut chronic pain ratings by ~30 %.

22. Cognitive-behavioural therapy for pain coping – reframes “flare-ups” as manageable events, lessening opioid demand.

23. Music-assisted motor training – rhythmic auditory cues synchronise movement timing and improve gait kinematics.

24. Virtual-reality rehab games – immersive feedback boosts therapy adherence and motor learning.

25. Home stretching & mobility routines – caregiver-guided checklists sustain gains between clinic visits.

26. Skin-integrity education – daily mirror checks and pressure-relief schedules avert stage-IV pressure ulcers.

27. Bowel & bladder self-catheterisation training – empowers school-age children, cutting infection incidence.spinabifidaassociation.org

28. Parent coaching & peer-support groups – shared strategies lower caregiver burnout and child anxiety.

29. Healthy-lifestyle workshops – nutrition, sleep hygiene and screen-time limits combat obesity.

30. Goal-setting & tele-rehab follow-up – remote video reviews maintain momentum and allow timely tweaks.

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Evidence-based drugs you may encounter

(Always prescribed by a specialist; typical paediatric oral doses shown for orientation only.)

1. Baclofen (GABA-B agonist, 0.3–2 mg/kg/day divided q8h) – relaxes spinal reflex arcs, easing spasticity; watch for drowsiness and hypotonia.drugs.com

2. Intrathecal baclofen pump (50-1500 µg/day) – delivers drug directly to CSF, achieving tone control with fewer systemic effects.

3. Tizanidine (α2-adrenergic agonist, 0.05–0.1 mg/kg q8h) – inhibits polysynaptic reflexes; may cause dry mouth and bradycardia.

4. Diazepam (benzodiazepine, 0.12–0.8 mg/kg/day) – short-term night-time tone relief; monitor for dependency.

5. Oxybutynin ER (anticholinergic, 5 mg once daily, up to 20 mg) – calms detrusor over-activity, promoting dry intervals; side-effects: flushing, constipation.ncbi.nlm.nih.gov

6. Tolterodine (anticholinergic, 1–2 mg bid) – alternative when oxybutynin fails.

7. Mirabegron (β3-agonist, 25–50 mg once daily ≥ 3 yrs) – relaxes bladder without anticholinergic burden; may raise BP.mdpi.com

8. Botulinum toxin A (10–12 U/kg intradetrusor every 6–9 mths) – chemodenervation for refractory neurogenic bladder.

9. Trimethoprim–sulfamethoxazole (2–4 mg/kg TMP q24h) – nightly prophylaxis against recurrent UTIs.

10. Amoxicillin-clavulanate (25–45 mg/kg q12h × 10 days) – treats breakthrough UTIs.

11. Gabapentin (10–30 mg/kg/day divided q8h) – dampens neuropathic shooting pain; sedation common.pubmed.ncbi.nlm.nih.gov

12. Pregabalin (2–8 mg/kg/day) – similar mechanism to gabapentin with faster titration.

13. Ibuprofen (10 mg/kg q6h prn) – relieves inflammatory joint pain; avoid if renal compromise.

14. Acetaminophen (15 mg/kg q4–6h prn) – first-line antipyretic with wide safety margin.

15. Polyethylene glycol 3350 (0.4–1 g/kg/day) – osmotic laxative for neurogenic bowel constipation.

16. Dicyclomine (0.5–2 mg/kg/day) – antispasmodic for crampy bowel pain.

17. Vitamin D3 (600–1000 IU/day) – supports calcium absorption, reducing fracture risk.

18. Calcium carbonate (40 mg/kg/day elemental Ca) – supplies substrate for bone mineralisation.

19. High-dose folic acid (4 mg/day in future pregnancies) – secondary prevention of NTD recurrence.cdc.gov

20. Topical mupirocin – clears Staphylococcus colonisation around scarred skin.

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Dietary molecular supplements

(All supplements should be cleared with the treating team to avoid interactions.)

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Specialised drug/biologic therapies

1. Zoledronic acid 0.05 mg/kg IV yearly – a potent bisphosphonate that halts osteoclast-mediated bone loss in non-ambulant teens; transient flu-like syndrome and hypocalcaemia possible.pmc.ncbi.nlm.nih.gov

2. Pamidronate 9 mg/kg/year in 3-monthly cycles – older bisphosphonate option with good fracture-pain relief.pmc.ncbi.nlm.nih.gov

3. Alendronate 5–10 mg PO weekly – oral bisphosphonate for milder osteopenia; must sit upright 30 min to prevent oesophagitis.

4. Teriparatide 20 µg SC daily (off-label adolescent use) – recombinant PTH stimulates new bone formation where density is critically low.

5. Hyaluronic-acid viscosupplement (Monovisc 4 mL once) – restores synovial viscosity in degenerative knees, lubricating and damping shock.pmc.ncbi.nlm.nih.gov

6. Platelet-rich plasma 5 mL intra-articular – growth-factor cocktail kick-starts cartilage repair.

7. MSC-derived exosome injectate – nano-vesicles deliver miRNA that modulates inflammation and promotes axonal regrowth (investigational).

8. Placental MSC patch applied in-utero (CuRe trial) – stem cells seeded on matrix secrete neuro-trophic factors, enhancing fetal cord healing.health.ucdavis.edu

9. Umbilical cord-blood stem cell infusion (phase II) – systemic delivery of haematopoietic and MSC progenitors aims to rebuild damaged spinal pathways.

10. Bone-marrow-derived neural stem cell intrathecal graft – early trials show improved lower-limb EMG activity; long-term safety under study.

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Surgeries

1. Open fetal repair (22–26 weeks gestation) – hysterotomy, multilayer dura-myofascial closure; halves shunt-dependent hydrocephalus risk vs post-natal repair.sciencedirect.comwjwch.com

2. Fetoscopic minimally invasive closure – ports + CO₂ insufflation reduce maternal morbidity and preterm labour rates.

3. Stem-cell-augmented fetal repair – adds MSC patch for potentially stronger neuro-protection (CuRe).health.ucdavis.edu

4. Post-natal lesion closure (within 72 h) – prevents infection and CSF leak once baby is stabilised.

5. Ventriculo-peritoneal shunt – diverts CSF, controlling hydrocephalus and preserving vision.

6. Endoscopic third ventriculostomy + choroid plexus cauterisation – shunt-free option in selected infants.pmc.ncbi.nlm.nih.gov

7. Posterior fossa (Chiari II) decompression – enlarges foramen magnum, reducing brain-stem compression and apnoea.

8. Tethered-cord release – liberates scar-anchored cord, relieving progressive foot deformity and pain.

9. Orthopaedic club-foot correction (Ponseti serial casting ± tendon surgery) – aligns feet for brace or standing frame use.

10. Augmentation cystoplasty – enlarges low-capacity bladder with bowel patch, protecting kidneys and improving continence.

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Proven prevention strategies

1. Take 400 µg folic acid daily at least one month before conception.cdc.gov

2. If you’ve had a prior NTD-affected pregnancy, switch to 4 mg folic acid daily.

3. Maintain tight blood-sugar control if you have diabetes.

4. Avoid valproic acid, carbamazepine and high-dose retinoids during the first trimester.

5. Keep a healthy body-mass-index (BMI < 30).

6. Skip very hot baths, saunas and fevers > 38.9 °C in early pregnancy.

7. Schedule first-trimester ultrasound to detect anomalies early.

8. Seek genetic counselling when there is family history of NTDs.

9. Ensure adequate iodine and B12 intake for embryonic neural metabolism.

10. Support national flour fortification programmes to raise baseline folate levels.cdc.gov

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When should you see a doctor?

• Before pregnancy: to start folic-acid and review anticonvulsants.

• During pregnancy: if ultrasound detects spinal lesions, request referral to a fetal-surgery centre.

• After birth: immediately for lesion closure, hydrocephalus monitoring and urodynamic baseline.

• Any age: sudden leg weakness, new incontinence, fevers with flank pain, or headaches and vomiting (possible shunt blockage) warrant urgent specialist review.

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Practical “do & avoid” tips

1. Do inspect skin daily; avoid sitting > 30 min without pressure relief.

2. Do keep catheterisation schedule; avoid stretching intervals “to save supplies.”

3. Do hydrate (30 mL/kg/day); avoid sugary sodas that foster UTIs.

4. Do join adaptive-sport clubs; avoid complete inactivity that erodes bone.

5. Do use sun-protective clothing; avoid burns on reduced-sensation legs.

6. Do practise safe lifts; avoid twisting your back when transferring.

7. Do up-titrate laxatives slowly; avoid stimulant purgatives that cause cramps.

8. Do keep immunisations up-to-date; avoid live vaccines if on chronic steroids.

9. Do track shunt function; avoid head hits in contact sports without clearance.

10. Do share mental-health concerns; avoid thinking you must “tough it out” alone.

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FAQs

1. Is open myeloschisis the same as myelomeningocele?
   No. OMS lacks the protective sac—neural tissue lies flat and uncovered, leading to more severe nerve injury.karger.com

2. What causes it?
   Multifactorial—folate deficiency, maternal diabetes, certain medicines, obesity and genetics play roles.

3. Can it be cured?
   Surgery closes the spine but cannot replace lost nerves; therapies focus on maximising what nerves remain.

4. Does fetal surgery hurt the mother?
   Modern techniques add a C-section-like scar and carry pre-term labour risk, but survival is excellent.sciencedirect.com

5. Will my child walk?
   Outcomes vary; early fetal repair plus rehab raise independent walking rates above 40 %.pubmed.ncbi.nlm.nih.gov

6. Why is hydrocephalus common?
   Cerebro-spinal fluid flow is blocked by herniated hind-brain structures (Chiari II).

7. How long do shunts last?
   Median 4–8 years; any blockage or infection needs urgent revision.

8. What about bowel and bladder control?
   Clean intermittent catheterisation and anticholinergics achieve social continence in most children.

9. Is stem-cell therapy available?
   Only inside clinical trials such as the CuRe study in the USA.fetalhealthfoundation.org

10. Can adults get surgery later?
    Yes—tethered-cord release, scoliosis correction and bladder reconstruction are performed in adolescence.

11. Does diet matter after birth?
    Adequate calcium, vitamin D and protein support fragile bones and wound healing.

12. Are vaccines safe?
    Routine schedules are safe; flu and pneumococcal shots cut respiratory-shunt infection risk.

13. Will my next pregnancy be safe?
    High-dose folate and pre-conception counselling reduce recurrence to < 1 %.cdc.gov

14. Can people with OMS live independently?
    With assistive tech, many attain college degrees, jobs and relationships.

15. Where can I find support?
    National Spina Bifida Association and local parent groups provide resources, advocacy and peer mentorship.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: June 22, 2025.

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References