The Unconventional Supine: Positioning an Infant with Giant Lumbosacral Meningocele during Cardiac Surgery

To the Editor, The incidence of congenital heart disease with neural tube defect (NTD) is 5–37%.1 Meningocele is a type of NTD in which there is a skin-covered cystic protrusion of the meninges through a posterior defect in the vertebrae.2 The transposition of great arteries (TGA) with meningocele has not been reported in the literature yet. We report the case of an infant in whom the co-occurrence of a large lumbosacral meningocele with D-TGA requiring arterial switch operation (ASO) presented a unique positioning conundrum. A 4-month-old child with TGA with a huge lumbosacral meningocele of size 8 × 10 cm Figure 1 had to undergo ASO before the corrective surgery for the meningocele. Transthoracic echocardiography revealed D-TGA with subpulmonary ventricular septal defect, atrial septal defect, and left ventricular outflow tract obstruction. Preoperative neurological examination revealed no overt motor or sensory deficits in the lower extremities, although definitive assessment was challenging due to age. There had been no existing literature up to date about how to position a patient with a huge lumbosacral meningocele in the supine position for prolonged hours for cardiac surgery.Figure 1: 18 × 10 cm lumbosacral meningoceleFor positioning the child for induction, we used two head rings (Medigel 20 × 10 × 4.5 cm) and covered them with five to six sterile dressing pads 15 × 10 cm in size to form a crater Figure 2 in which the meningocele fell freely without any pressure. The upper body and head were stabilized by placing operation towels beneath. The child was induced with an injection of ketamine 5 mg and rocuronium 5 mg, and intubated with a 3.5-mm cuffed endotracheal tube. After intubation, the meningocele was dressed in a 10 × 10 cm soft paraffin gauze and then covered with 20 × 20 cm sponges to form a soft cushion around the meningocele Figure 3 and was placed in position shown in Figure 4 for the insertion of invasive lines using a linear ultrasound probe (L15-7io with EPIC, Philips Ultrasound, Bothell, WA, USA).Figure 2: Two head rings covered them with five to six sterile dressing pads to form a craterFigure 3: Dressing of a meningoceleFigure 4: Final position of the child for surgeryThe final position for surgery is shown in Figure 4. In the ICU, the child was positioned the same way as shown in Figure 4. The child was extubated on postoperative day 2. After extubation, the child was kept in the same position as shown and sometimes in a lateral position with the meningocele covered with a dressing. The meningocele remained intact throughout the postoperative period. Neurological status remained unchanged. Children with meningocele lack the natural protective tissue barrier, predisposing the central nervous system to environmental exposure, trauma, and meningitis. Similar cases in the literature emphasize the importance of tailored positioning devices using gel doughnut rings and positioning blankets that are placed in such a position to remove pressure and reduce the likelihood of infection and further damage to the exposed, delicate neural tissue.3,4 To conclude, the challenge of maintaining adequate positioning of the child for induction, invasive lines placement, the surgical period, and in the ICU was overcome through innovative assembly using head rings and dressing pads and by covering the meningocele in a dressing while simultaneously avoiding rupture, infection, and discomfort. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.