Surgery to repair a baby's spinal defect has traditionally been performed after birth. In a major advance in foetal and paediatric neurosurgery, a team of multi-disciplinary doctors from AIIMS, New Delhi, have taken this intervention into the womb, performing India's first open foetal repair of myelomeningocele, a severe form of spina bifida.
In a six-hour operation at 25 weeks of pregnancy, the aim was to limit neurological damage before birth.
The procedure, performed on November 12, involved repairing a defect in the lower spine through which the spinal cord and its coverings had protruded, leaving the delicate neural tissue exposed to injury. The surgery aimed to prevent further damage before birth, potentially improving the child's neurological outcomes.
Traditionally, myelomeningocele is repaired after birth. However, exposure of the spinal cord to the surrounding amniotic fluid during pregnancy can cause progressive neurological injury. Foetal surgery offers an opportunity to intervene before birth, although it does not reverse all existing damage or cure the condition.
The landmark operation followed more than five weeks of multidisciplinary preparation involving detailed foetal imaging, counselling of the parents, anaesthetic planning and surgical simulations. It was performed at the Neurosciences Centre of AIIMS using high-end microscopy and continuous ultrasound guidance.
The neurosurgical component was led by Professor Deepak Gupta, while the maternal-foetal medicine and obstetric teams were headed by Professor Neena Malhotra and Professor K. Aparna Sharma. The obstetric anaesthesia and neuroanaesthesia teams included Prof Vimi Rewari, Prof Mihir Pandia, Dr Rashmi Ramachandran and Dr Gyanendra Pal Singh. Dr Shashank Chauhan led the plastic surgery team, while neonatology support was provided by Dr Ramesh Agarwal and Dr Deepika Kainth.
The patient was initially screened and counselled by Professor K Aparna Sharma, along with Dr Anubhuti Rana, Dr Deepali Garg and Dr Saloni Kamboj. Preoperative imaging and planning were supported by Dr Smita Manchanda of the Department of Radiodiagnosis and Interventional Radiology.
More than 30 doctors, specialists and nursing personnel from obstetrics and gynaecology, maternal-foetal medicine, neurosurgery, anaesthesia, plastic surgery, radiodiagnosis and neonatology participated in the procedure.
Professor Deepak Gupta, president of the Indian Society for Paediatric Neurosurgery, said the achievement establishes an important new capability for foetal care and paediatric neurosurgery in the country.
"In carefully selected cases, prenatal repair aims to limit ongoing injury to exposed neural tissue, reduce the subsequent need for cerebrospinal-fluid diversion for hydrocephalus and improve certain neurological outcomes. It is not a cure, and long-term multidisciplinary care remains essential," he said.
Professor Neena Malhotra said the accomplishment reflected the collective commitment and coordinated efforts of an exceptional multidisciplinary team.
Professor Aparna Sharma said the decision to undertake foetal intervention was based on careful assessment of the potential benefits and risks to both the mother and the baby.
"Foetal intervention in this case is a well-reasoned and carefully planned decision to optimise outcomes for both. The safety of the mother and foetus depends on detailed counselling, high-quality anaesthesia and coordinated monitoring before and after surgery," she said.
The decision to undertake prenatal repair is supported by international clinical evidence. The landmark Management of Myelomeningocele Study (MOMS) found that the proportion of children requiring cerebrospinal-fluid shunt placement by 12 months was 40% among those who underwent prenatal surgery, compared with 82% among those operated on after birth. The study also reported better motor outcomes and reduced Chiari II-associated hindbrain herniation following prenatal repair.
However, foetal surgery is a complex intervention and carries risks, including premature delivery and complications related to the uterine scar, which can affect future pregnancies. It is therefore recommended only for carefully selected pregnancies and in specialised centres equipped to provide comprehensive maternal and foetal care.
Myelomeningocele is an open neural tube defect in which the developing spinal cord and its protective coverings protrude through an opening in the spine. Depending on the severity and location of the defect, affected children may experience lower-limb weakness or paralysis, bladder and bowel dysfunction, hydrocephalus and other lifelong complications.
India continues to bear a substantial burden of neural tube defects, although prevalence varies across regions. A 2024 systematic review of 27 Indian studies estimated their pooled prevalence at 9.46 per 1,000 births, underscoring the need for stronger national surveillance and prevention efforts.
The AIIMS procedure was performed free of cost under the Government of India's Janani Shishu Suraksha Karyakram (JSSK). The cost of comparable comprehensive maternal and infant care, including foetal surgery, high-risk obstetric management, delivery and neonatal treatment, in the US can exceed Rs 1 crore, depending on the institution and clinical course.
While foetal surgery offers hope to selected families, doctors stressed that prevention remains equally important. Neural tube closure occurs within about 28 days of conception, often before a woman realises she is pregnant. Adequate folic acid intake before conception and during early pregnancy, food fortification with folic acid and stronger surveillance are essential to reducing the burden of these birth defects.
The mother and foetus will remain under close multidisciplinary observation through the remainder of the pregnancy, delivery and newborn period.
"Fourteen years ago, we spoke about the possibility of foetal spinal surgery at AIIMS. Today, that possibility has become a reality. Our next responsibility is to make it safe and accessible to Indian families who may benefit from it," the team said.
