Spina Bifida and medical marijuana

Spina Bifida

Spina bifida  is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube.  Some vertebrae overlying the spinal cord are not fully formed and remain unfused and open.  If the opening is large enough, this allows a portion of the spinal cord to protrude through the opening in the bones. There may or may not be a fluid-filled sac surrounding the spinal cord.  Other neural tube defects include anencephaly, a condition in which the portion of the neural tube that will become the cerebrum does not close, and encephalocele, which results when other parts of the brain remain unfused.

Spina bifida malformations fall into three categories: spina bifida occulta, spina bifida cystica with meningocele, and spina bifida cystica with myelomeningocele.

The most common location of the malformations is the lumbar and sacral areas. Myelomeningocele is the most significant form and it is this that leads to disability in most affected individuals. The terms spina bifida and myelomeningocele are usually used interchangeably.

Spina bifida can be surgically closed after birth, but this does not restore normal function to the affected part of the spinal cord. Intrauterine surgery for spina bifida has also been performed and the safety and efficacy of this procedure is currently being investigated. The incidence of spina bifida can be decreased by up to 70% when daily folic acid supplements are taken prior to conception.

Spina bifida occulta

Occulta is Latin for "hidden". This is the mildest form of spina bifida.
In occulta, the outer part of some of the vertebrae are not completely closed.  The split in the vertebrae is so small that the spinal cord does not protrude.  The skin at the site of the lesion may be normal, or it may have some hair growing from it; there may be a dimple in the skin, or a birthmark.

Many people with this type of spina bifida do not even know they have it, as the condition is asymptomatic in most cases.  The incidence of spina bifida occulta is approximately 10% of the population,  and most people are diagnosed incidentally from spinal X-rays.  A systematic review of radiographic research studies found no relationship between spina bifida occulta and back pain.  More recent studies not included in the review support the negative findings.

However, other studies suggest spina bifida occulta is not always harmless. One study found that, among patients with back pain, severity is worse if spina bifida occulta is present.

Meningocele

The least common form of spina bifida is a posterior meningocele (or meningeal cyst).
In a posterior meningocele, the vertebrae develop normally, however the meninges are forced into the gaps between the vertebrae.  As the nervous system remains undamaged, individuals with meningocele are unlikely to suffer long-term health problems, although there are reports of tethered cord.  Causes of meningocele include teratoma and other tumors of the sacrococcyx and of the presacral space, and Currarino syndrome.

A meningocele may also form through dehiscences in the base of skull. These may be classified by their localisation to occipital, frontoethmoidal, or nasal. Endonasal meningoceles lie at the roof of the nasal cavity and may be mistaken for a nasal polyp. They are treated surgically. Encephalomeningoceles are classified in the same way and also contain brain tissue.

Myelomeningocele

This type of spina bifida is the most common and often results in the most severe complications.  In individuals with myelomeningocele, the unfused portion of the spinal column allows the spinal cord to protrude through an opening. The meningeal membranes that cover the spinal cord form a sac enclosing the spinal elements. Spina bifida with myeloschisis is the most severe form of myelomeningocele.  In this type, the involved area is represented by a flattened, plate-like mass of nervous tissue with no overlying membrane. The exposure of these nerves and tissues make the baby more prone to life-threatening infections.

The protruded portion of the spinal cord and the nerves that originate at that level of the cord are damaged or not properly developed.  As a result, there is usually some degree of paralysis and loss of sensation below the level of the spinal cord defect. Thus, the higher the level of the defect the more severe the associated nerve dysfunction and resultant paralysis. People may have ambulatory problems, loss of sensation, deformities of the hips, knees or feet, and loss of muscle tone.  Depending on the location of the lesion, intense pain may occur originating in the lower back, and continuing down the leg to the back of the knee.

Physical complications

Physical signs of spina bifida may include:

  • Leg weakness and paralysis
  •  Orthopedic abnormalities (i.e., club foot, hip dislocation, scoliosis)
  •  Bladder and bowel control problems, including incontinence, urinary tract infections, and poor renal function
  •  Latex allergy
  •  Pressure sores and skin irritations
  •  Abnormal eye movement

According to the Spina Bifida Association of America (SBAA), over 73 percent of people with spina bifida develop an allergy to latex, ranging from mild to life-threatening. The common use of latex in medical facilities makes this a particularly serious concern.  The most common approach to avoid developing an allergy is to avoid contact with latex-containing products such as examination gloves, condoms, catheters, and many of the products used by dentists.
The spinal cord lesion or the scarring due to surgery may result in a tethered spinal cord.  In some individuals, this causes significant traction and stress on the spinal cord and can lead to a worsening of associated paralysis, scoliosis, back pain, and worsening bowel and/or bladder function.

Neurological complications

Many individuals with spina bifida will have an associated abnormality of the cerebellum, called the Arnold Chiari II malformation.  In affected individuals, the back portion of the brain is displaced from the back of the skull down into the upper neck.  In approximately 90 percent of the people with myelomeningocele, hydrocephalus will also occur because the displaced cerebellum interferes with the normal flow of cerebrospinal fluid, causing an excess of the fluid to accumulate.  In fact, the cerebellum also tends to be smaller in individuals with spina bifida, especially for those with higher lesion levels.

The corpus callosum is abnormally developed in 70-90% of individuals with spina bifida myelomeningocele; this impacts the communication processes between the left and right brain hemispheres.  Further, white matter tracts connecting posterior brain regions with anterior regions appear less-organized.  White matter tracts between frontal regions have also been found to be impaired.

Cortex abnormalities may also be present. For example, frontal regions of the brain tend to be thicker than expected while posterior and parietal regions are thinner.  Thinner sections of the brain are also associated with increased cortical folding.  Neurons within the cortex may also be displaced.

Executive function

Several studies have demonstrated difficulties with executive functions in youth with spina bifida,  with greater deficits observed in youth with shunted hydrocephalus. Unlike typically developing children, youth with spina bifida do not tend to improve in their executive functioning as they grow older.  Specific areas of difficulty in some individuals include planning, organizing, initiating, and working memory.  Problem-solving, abstraction, and visual planning may also be impaired.  Further, children with spina bifida may have poor cognitive flexibility.  Although executive functions are often attributed to the frontal lobes of the brain, individuals with spina bifida have intact frontal lobes; therefore, other areas of the brain may be implicated.

Individuals with spina bifida, especially those with shunted hydrocephalus, often have attention problems.  Children with spina bifida and shunted hydrocephalus have higher rates of ADHD than typically developing children (31% vs. 17%).  Deficits have been observed for selective attention and focused attention, although poor motor speed may contribute to poor scores on tests of attention.  Attention deficits may be evident at a very early age, as infants with spina bifida lag behind their peers in orienting to faces.

Academic skills

Individuals with spina bifida may struggle academically, especially in the subjects of mathematics and reading.  In one study, 60% of children with spina bifida were diagnosed with a learning disability.  In addition to brain abnormalities directly related to various academic skills, achievement is likely affected by impaired attentional control and executive functioning.  Children with spina bifida may perform well in elementary school, but begin to struggle as academic demands increase.

Children with spina bifida are more likely than their typically-developing peers to have dyscalculia.  Individuals with spina bifida have demonstrated stable difficulties with arithmetic accuracy and speed, mathematical problem-solving, and general use and understanding of numbers in everyday life.  Mathematics difficulties may be directly related to the thinning of the parietal lobes (regions implicated in mathematical functioning) and indirectly associated with deformities of the cerebellum and midbrain that affect other functions involved in mathematical skills.  Further, higher numbers of shunt revisions are associated with poorer mathematics abilities.  Working memory and inhibitory control deficiencies have been implicated for math difficulties,  although visual-spatial difficulties are not likely involved.  Early intervention to address mathematics difficulties and associated executive functions is crucial.

Individuals with spina bifida tend to have better reading skills than mathematics skills.  Children and adults with spina bifida have stronger abilities in reading accuracy compared to reading comprehension.  Comprehension may be especially impaired for text that requires an abstract synthesis of information rather than a more literal understanding.  Individuals with spina bifida may have difficulty with writing due to deficits in fine motor control and working memory.

Social complications

Compared to typically developing children, youth with spina bifida may have fewer friends and spend less time with peers.  They may be more socially immature and more passive in social situations.  Children with spina bifida have also reported feeling less close to their friends and feel they do not receive as much emotional support from their friendships.  Many social difficulties tend to be stable, lasting into adulthood.  Youth encountering the most social difficulties tend to have lower executive functioning and shunted hydrocephalus.  However, not all studies have found social difficulties in these youth compared with their typically developing peers.

Pathophysiology

Spina bifida is caused by the failure of the neural tube to close during the first month of embryonic development (often before the mother knows she is pregnant).

Under normal circumstances, the closure of the neural tube occurs around the 23rd (rostral closure) and 27th (caudal closure) day after fertilization.  However, if something interferes and the tube fails to close properly, a neural tube defect will occur.  Medications such as some anticonvulsants, diabetes, having a relative with spina bifida, obesity, and an increased body temperature from fever or external sources such as hot tubs and electric blankets may increase the chances of conception of a baby with a spina bifida. However, most women who give birth to babies with spina bifida have none of these risk factors, and, so, in spite of much research, it is still unknown as to what causes the majority of cases.

Extensive evidence from mouse strains with spina bifida indicates that there is sometimes a genetic basis for the condition.  In human spina bifida, as with other human diseases such as cancer, hypertension and atherosclerosis (coronary artery disease), spina bifida likely results from the interaction of multiple genes and environmental factors.

Research has shown that lack of folic acid (folate) is a contributing factor in the pathogenesis of neural tube defects, including spina bifida. Supplementation of the mother's diet with folate can reduce the incidence of neural tube defects by about 70 percent, and can also decrease the severity of these defects when they occur.  It is unknown how or why folic acid has this effect.

Spina bifida does not follow direct patterns of heredity like muscular dystrophy or hemophilia. Studies show that a woman having had one child with a neural tube defect such as spina bifida has about a three percent risk of having another child with a neural tube defect.   Risk can be reduced to about one percent if the woman takes high doses (4 mg/day) of folic acid before and during pregnancy.  For the general population, low-dose folic acid supplements are advised (0.4 mg/day.

Prevention

There is neither a single cause of spina bifida nor any known way to prevent it entirely.  However, dietary supplementation with folic acid has been shown to be helpful in preventing spina bifida.  Sources of folic acid include whole grains, fortified breakfast cereals, dried beans, leaf vegetables and fruits.

Folate fortification of enriched grain products has been mandatory in the United States since 1998.  The U.S. Food and Drug Administration, Public Health Agency of Canada and UK recommended amount of folic acid for women of childbearing age and women planning to become pregnant is at least 0.4 mg/day of folic acid from at least three months before conception, and continued for the first 12 weeks of pregnancy.  Women who have already had a baby with spina bifida or other type of neural tube defect, or are taking anticonvulsant medication should take a higher dose of 4–5 mg/day.

Certain mutations in the gene VANGL1 are implicated as a risk factor for spina bifida:  These mutations have been linked with spina bifida in some families with a history of spina bifida.

Treatment

There is no known cure for nerve damage due to spina bifida.  To prevent further damage of the nervous tissue and to prevent  infection, pediatric neurosurgeons operate to close the opening on the back. The spinal cord and its nerve roots are put back inside the spine and covered with  meninges.  In addition, a shunt may be surgically installed to provide a continuous drain for the excess cerebrospinal fluid produced in the brain, as happens with hydrocephalus.  Shunts most commonly drain into the abdomen or chest wall.  However, if spina bifida is detected during pregnancy, then open fetal surgery can be performed.

Medical Marijuana Symptom Treatment

Studies were done in the U. K. on cannabis based medicine with excellent results.
Preclinical research in the U. S. using cannabis extracts are ongoing.

Medical marijuana is proven effective in the treatment of:

  1. movement disorders
  2. chronic pain
  3. muscles spasms
  4. nerve damage
  5. THC reduces spasticity
  6. vomiting
  7. migraines

While there is no cure for the nerve damage caused by Spina Bifida only surgery and supportive care, there is help in relieving the above symptoms.  That help comes from medical marijuana.

Use a whole plant tincture made from an indica x sativa hybrid.  Start with two drops under the tongue and then increase the dosage if necessary.
Recommended strains include but not limited to:  Blueberry, Strawberry Cough, Train Wreck, Bubblegum, Chronic, Great White Shark.

References



"What Is Spina Bifida?". ASBAH. Retrieved 2009-02-14.
a b Foster, Mark R. "Spina Bifida". Retrieved 2008-05-17.
a b "Spina Bifida Occulta". ASBAH. Retrieved 2009-02-14.
Saluja PG (1988). "The incidence of spina bifida occulta in a historic and a modern London population". J Anat. 158: 91–93. PMC 1261979.PMID 3066791.
van Tulder MW, Assendelft WJ, Koes BW, Bouter LM (1997). "Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies". Spine 22 (4): 427–34. doi:10.1097/00007632-199702150-00015. PMID 9055372.
Iwamoto J, Abe H, Tsukimura Y, Wakano K (2005). "Relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school rugby players: a prospective study". Scandinavian journal of medicine & science in sports 15 (3): 163–8. doi:10.1111/j.1600-0838.2004.00414.x. PMID 15885037.
Iwamoto J, Abe H, Tsukimura Y, Wakano K (2004). "Relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school and college football players: a prospective study". The American journal of sports medicine 32 (3): 781–6.doi:10.1177/0363546503261721. PMID 15090397.
Steinberg EL, Luger E, Arbel R, Menachem A, Dekel S (2003). "A comparative roentgenographic analysis of the lumbar spine in male army recruits with and without lower back pain". Clinical radiology 58 (12): 985–9. doi:10.1016/S0009-9260(03)00296-4. PMID 14654032.
Taskaynatan MA, Izci Y, Ozgul A, Hazneci B, Dursun H, Kalyon TA (2005). "Clinical significance of congenital lumbosacral malformations in young male population with prolonged low back pain". Spine 30 (8): E210–3. doi:10.1097/01.brs.0000158950.84470.2a. PMID 15834319.
Avrahami E, Frishman E, Fridman Z, Azor M (1994). "Spina bifida occulta of S1 is not an innocent finding". Spine 19 (1): 12–5.doi:10.1097/00007632-199401000-00003. PMID 8153797.
"Myelomeningocele". NIH. Retrieved 2008-06-06.
Mayo Clinic
a b c d Mitchell, L. E.; Adzick, N. S., Melchionne, J., Pasquariello, P. S., Sutton, L. N., & Whitehead, A. S. (2004). "Spina bifida". Lancet 364 (9448): 1885–1895. doi:10.1016/S0140-6736(04)17445-X. PMID 15555669.
a b c d Juranek, J; Salman MS (2010). "Anomalous development of brain structure and function in spina bifida myelomeningocele". Developmental Disabilities. 1 16: 23–30.
"Tethered Spinal Cord Syndrome". AANS. Retrieved 2011-10-23.
a b "Chiari Malformation Fact Sheet: National Institute of Neurological Disorders and Stroke (NINDS)". Ninds.nih.gov. 2011-09-16. Retrieved 2011-10-23.
Barkovich, J (2005). Pediatric Neuroimaging. Philadelphia, PA: Lippincott, Williams & Wilkens.
a b Wills, KE (1993). "Neuropsychological functioning in children with spina bifida and/or hydrocephalus". Journal of Clinical Child Psychology 22(2): 247–265.
a b Burmeister, R; Hannay HJ, Copeland K, Fletcher JM, Boudousquie A, & Dennis M (2005). "Attention problems and executive functions in children with spina bifida and hydrocephalus". Child Neuropsychology 11 (3): 265–283. doi:10.1080/092970490911324. PMID 16036451.
a b Tarazi, RA; Zabel TA, & Mahone EM (2008). "Age-related changes in executive function among children with spina bifida/hydrocephalus based on parent behavior ratings". The Clinical Neuropsychologist 22 (4): 585–602. doi:10.1080/13854040701425940. PMC 2575658.PMID 17853154.
a b c Fletcher, JM, Brookshire BL, Landry SH, Bohan TP, Davidson KC et al (1996). "Attentional skills and executive functions in children with early hydrocephalus". Developmental Neuropsychology 12: 53–76. doi:10.1080/87565649609540640.
Snow, JH (1999). "Executive processes for children with spina bifida". Children's Health Care 28 (3): 241–253.doi:10.1207/s15326888chc2803_3.
Rose, BM; Holmbeck GN (2007). "Attention and executive functions in adolescents with spina bifida". Journal of Pediatric Psychology 32 (8): 983–994. doi:10.1093/jpepsy/jsm042. PMID 17556398.
Landry, SH; Robinson SS, Copeland D, & Garner PW (1993). "Goal-directed behavior and perception of self-competence in children with spina bifida". Journal of Pediatric Psychology 18 (3): 389–396. doi:10.1093/jpepsy/18.3.389. PMID 8340846.
Mayes, SD; Calhoun, SL (2006). "Frequency of reading, math, and writing disabilities in children with clinical disorders". Learning and Individual Differences 16 (2): 145–157.
a b Barnes, MA; Wilkinson, M, Khemani, E, Boudesquie, A, Dennis, M, & Fletcher, JM (2006). "Arithmetic processing in children with spina bifida: Calculation accuracy, strategy use, and fact retrieval fluency". Journal of Learning Disabilities 39 (2): 174–187.
Dennis, M; Barnes, M (2002). "Math and numeracy in young adults with spina bifida and hydrocephalus". Developmental Neuropsychology 21 (2): 141–155.
a b Hetherington, R; Dennis M, Barnes M, Drake J, & Gentili J (2006). "Functional outcome in young adults with spina bifida and hydrocephalus".Child’s Nervous System 22 (2): 117–124. doi:10.1007/s00381-005-1231-4.
a b English,, LH; Barnes, MA, Taylor, HB, Landry, SH (2009). "Mathematical developmental development in spina bifida". Developmental Disabilities Research Reviews 15 (1): 28–34.
a b Barnes, M; Dennis M, & Hetherington R (2004). "Reading and writing skills in young adults with spina bifida and hydrocephalus". Journal of the International Neuropsychological Society 10 (5): 655–663. doi:10.10170S1355617704105055.
Fletcher, JM; Dennis M, Northrup H, Barnes AM, Hannay HJ...Francis, DF (2004). "Spina bifida: Genes, brain, and development". International Review of Research in Mental Retardation 29: 63–117. doi:10.1016/S0074-7750(04)29003-6.
Ellerton, M. L.; Stewart, M. J., Ritchie, J. A., & Hirth, A. M. (1996). "Social support in children with a chronic illness". The Canadian Journal of Nursing Research 28 (4): 15–36. PMID 9128474.
a b Holmbeck, G. N.; Westhoven, V. C., Phillips, W. S., Bowers, R., Gruse, C., Nikolopoulos, T.,...Davison, K. (2003). "A multimethod, multi-informant, and multidimensional perspective on psychosocial adjustment in preadolescents with spina bifida". Journal of Consulting and Clinical Psychology71 (4): 782–796. doi:10.1037/0022-006X.71.4.782. PMID 12924683.
Devine, K. A.; Gayes, L., Purnell, J., & Holmbeck, G. N. (in press). "Close friendships of children and adolescents with spina bifida: Reciprocity and social adjustment". Journal of Pediatric Psychology.
Holmbeck, G. N.; DeLucia, C., Essner, B., Kelly, L., Zebracki, K., Friedman, D., & Jandasek, B. (2010). "Trajectories of psychosocial adjustment in adolescents with spina bifida: A 6-year, four-wave longitudinal follow-up". Journal of Consulting and Clinical Psychology 78 (4): 511–525.doi:10.1037/a0019599. PMID 20658808.
Zukerman, J. N.; Devine, K. A., & Holmbeck, G. N. (2011). "Adolescent predictors of emerging adult milestones in youth with spina bifida". Journal of Pediatric Psychology 36 (3): 265–276. doi:10.1093/jpepsy/jsq075. PMC 3062284. PMID 20855288.
Hommeyer, J. S.; Holmbeck, G. N., Wills, K. E., & Coers, S. (1999). "Condition severity and psychosocial functioning in pre-adolescents with spina bifida: Disentangling proximal functional status and distal adjustment outcomes". Journal of Pediatric Psychology 24 (6): 499–509.doi:10.1093/jpepsy/24.6.499. PMID 10608101.
Coakley, R. M.; Holmbeck, G. N., & Bryant, F. B. (2006). "Constructing a prospective model of psychosocial adaptation in young adolescents with spina bifida: An application of optimal data analysis". Journal of Pediatric Psychology 31 (10): 1084–1099. doi:10.1093/jpepsy/jsj032.PMID 15888643.
a b c T. Lissauer, G. Clayden. Illustrated Textbook of Paediatrics (Second Edition). Mosby, 2003. ISBN 0-7234-3178-7
Holmes LB (1988). "Does taking vitamins at the time of conception prevent neural tube defects?". JAMA 260 (21): 3181.doi:10.1001/jama.260.21.3181. PMID 3184398.
Milunsky A, Jick H, Jick SS et al (1989). "Multivitamin/folic acid supplementation in early pregnancy reduces the prevalence of neural tube defects".JAMA 262 (20): 2847–52. doi:10.1001/jama.262.20.2847. PMID 2478730.
Mulinare J, Cordero JF, Erickson JD, Berry RJ (1988). "Periconceptional use of multivitamins and the occurrence of neural tube defects". JAMA 260(21): 3141–5. doi:10.1001/jama.260.21.3141. PMID 3184392.
"Folic Acid Fortification". FDA. February 1996.
"Folic Acid - Public Health Agency of Canada".
a b "Why do I need folic acid?". NHS Direct. 2006-04-27. Archived from the original on April 13, 2006. Retrieved 2006-08-19.
Kibar Z, Torban E, McDearmid JR, Reynolds A, Berghout J, Mathieu M, Kirillova I, De Marco P, Merello E, Hayes JM, Wallingford JB, Drapeau P, Capra V, Gros P (2007). "Mutations in VANGL1 associated with neural-tube defects" (–Scholar search). N. Engl. J. Med. 356 (14): 1432–7.doi:10.1056/NEJMoa060651. PMID 17409324.[dead link]
"Center for Spina Bifida: Specialists and Services". Gillette Children's Hospital Center for Spina Bifida. Gillette Children's Hospital. Retrieved 15 November 2011.
a b Binks, JA; Barden WS, Burke TA, & Young NL (2007). "What do we really know about the transition to adult-centered health care? A focus on cerebral palsy and spina bifida". Archives of Physical Medicine and Rehabilitation 88 (8): 1064–1073. doi:10.1016/j.apmr.2007.04.018.
Davis, BE; Shurtleff DB, Walker WO, Seidel KD, & Duguay S (2006). "Acquisition of autonomy skills in adolescents with myelomeningocele".Developmental Medicine & Child Neurology 48 (4): 253–258.
Friedman, D; Holmbeck GN, DeLucia C, Jandasek B, & Zebracki K (2009). "Trajectories of autonomy development across the adolescent transition in children with spina bifida". Rehabilitation Psychology 54 (1): 16–27. doi:10.1037/a0014279.
Monsen, RB (1992). "Autonomy, coping, and self-care agency in healthy adolescents and in adolescents with spina bifida". Journal of Pediatric Nursing 7 (1): 9–13.
Holmbeck, GN; Devine KA (2010). "Psychosocial and family functioning in spina bifida". Developmental Disabilities Research Reviews 16 (1): 40–46. doi:10.1002/ddrr.90.
a b c Lemire RJ (1988). "Neural tube defects". JAMA 259 (4): 558–62. doi:10.1001/jama.259.4.558. PMID 3275817.
a b c Cotton P (1993). "Finding neural tube 'zippers' may let geneticists tailor prevention of defects". JAMA 270 (14): 1663–4.doi:10.1001/jama.270.14.1663. PMID 8411482.
Boulet, SL; Yang Q, Mai C, Kirby RS, Collins JS, Robbins JM,...Mulinare J (2008). "Trends in postfortification prevalence of spina bifida and ancephaly in the United States". Birth Defects Research (Part A) 82: 527–532.
MOMS website and MOMS summary on ClinicalTrials.gov
Adzick, NS; Thom, Elizabeth A.; Spong, Catherine Y.; Brock, John W.; Burrows, Pamela K.; Johnson, Mark P.; Howell, Lori J.; Farrell, Jody A. et al (February 9, 2011). "A Randomized Trial of Prenatal versus Postnatal Repair of Myelomeningocele". New England Journal of Medicine. Online First364 (11): 993–1004. doi:10.1056/NEJMoa1014379. PMID 21306277.
"Universitätsklinikum Giessen und Marburg - Offener Rücken/ Spina bifida aperta". Ukgm.de. Retrieved 2011-10-23.
Kohl T, Gembruch U, Thomas; Thomas Kohl, Ulrich Gembruch (October 3, 2008). "Current status and prospects of fetoscopic surgery for spina bifida in human fetuses". Fetal Diagnosis and Therapy 24: 318–320.
Verbeek, R; Heep A, Maurits N, et al. (15). "Does fetal endoscopic closure of the myelomeningocele prevent loss of neurologic function in spina bifida aperta?". Cerebrospinal Fluid Research 7 (1): S18-S18. doi:10.1186/1743-8454-7-S1-S18.
Farmer, DL; Cornelia S. von Koch, MD, PhD; Warwick J. Peacock, MD; Moise Danielpour, MD; Nalin Gupta, MD, PhD; Hanmin Lee, MD; Michael R. Harrison, MD (2003). "In utero repair of myelomeningocele: experimental pathophysiology, initial clinical experience, and outcomes". Arch Surg138 (8): 872–878.
"Current status and prospects of fetoscopic surgery for spina bifida in human fetuses". Fetal Diagn Ther 24: 318–320. 2008.doi:10.1159/000158549.
Shaffer, Beverly (1977). "I'll Find a Way". National Film Board of Canada Web site. Retrieved 2009-05-27.
The Telegraph - World of Tanni Grey-Thompson, former Paralympic champion
Martin, Dan (2008-06-14). "Dan Martin meets Blaine from the Mystery Jets". guardian.co.uk. Retrieved 2008-08-06.
"Interview with actress Sascha Knopf from Shallow Hal". Movies.about.com. 2009-12-17. Retrieved 2011-10-23.
"John Mellencamp bio". Yahoo! Music.
Gavin, Kara (2001). "U-M Neurosurgeon Urges Women to Protect their Children by Taking Folic Acid". Medicine at Michigan 3 (2). Retrieved 2008-07-03.
a b Lewine, Edward (March 1, 2009). "Domains: Country House". The New York Times: pp. MM17. Retrieved 2009-03-02.