Fetal myelomeningocele repair after the MOMS trial: a systematic review of neurosurgical outcomes and evolving techniques.

PURPOSE: To review current evidence on neurosurgical and obstetric outcomes following prenatal versus postnatal repair of myelomeningocele (MMC) after the landmark Management of Myelomeningocele Study (MOMS) trial, emphasizing evolving surgical techniques and long-term implications.

METHODS

A systematic review was performed according to PRISMA guidelines. PubMed/MEDLINE was searched from 2011 (MOMS publication) to the present for studies on fetal MMC repair. Eligible studies included randomized trials, cohort comparisons, technical series, and evidence-based guidelines. Primary outcomes were cerebrospinal fluid (CSF) shunt placement, reversal of hindbrain herniation, and motor/ambulation function; secondary outcomes included maternal morbidity, urological, and orthopedic endpoints.

RESULTS

Forty-three studies met the inclusion criteria. Prenatal repair reduced ventriculoperitoneal shunt requirements by approximately 50% (about 40% vs. 80%) and doubled the rate of independent walking (about 45% vs. 24%) compared with postnatal repair, consistent with MOMS findings. Hindbrain herniation reversal occurred in up to 75% of prenatal cases. However, prenatal surgery increased risks of preterm delivery (around 34 weeks), premature membrane rupture, and uterine dehiscence. Refinements such as mini-hysterotomy and fetoscopy achieved similar fetal benefits with improved maternal safety profiles, depending on surgical expertise and institutional experience.

CONCLUSION

Prenatal MMC repair is one of the most significant advances in fetal neurosurgery, providing durable neurological and functional benefits such as reduced reliance on ventriculoperitoneal shunts and improved motor functions. Continued improvements in surgical techniques, maternal-obstetric safety, and equitable access to experienced fetal centers are essential to establishing prenatal surgical repair as a key advancement in modern pediatric neurosurgery and fetal therapy.