Spina bifida is one of the most common pediatric congenital malformations and is more common in Asia, with an incidence of 0.6% of newborns in some parts of China [1]. Cerebrospinal bulge is a type of dominant spina bifida with a high disability rate, which seriously threatens the health and quality of life of children. Approximately 30% to 90% of children with spina bifida have hydrocephalus, and the majority of them require repair of the bulging meninges and cerebrospinal fluid shunts [2]. In the past, both surgeries were performed in stages. With the advancement of surgical techniques and the improvement of anesthesia, 11 children with cerebrospinal bulge combined with hydrocephalus were treated in one stage from January 2008 to December 2011 in our hospital, and satisfactory results were obtained, as reported below. Data and methods General data The 11 cases in this group were 5 males and 6 females, aged 5 days to 5 years, with an average of 16 months, including 3 newborns, 5 cases aged 1 month to 1 year, and the remaining 3 cases aged 3 to 5 years; 4 cases of meningeal (cerebral) bulge, 5 cases of spinal cord bulge, 2 cases of spinal cord ectasia, and 1 case with spinal cord longitudinal fissure; 3 cases of meningeal bulge were located in the parieto-occipital region, and only 1 case of 7 cases of spinal bulge was located in the The remaining 6 cases were all located in the lumbosacral segment. All children underwent CT or MRI examination before surgery to understand the enlargement of the ventricles and the specific type of cerebrospinal bulge, and the hydrocephalus was moderate to severe; the follow-up period was 1-5 years. After general anesthesia, the child was placed flat on his back and the hydrocephalus surgery was performed first. The left parieto-occipital posterior ventricular horn puncture was preferred, and for asymmetrical enlargement of one ventricle, the enlarged side puncture was chosen, and the valve was placed under the skin behind the ear, and the distal canal was led subcutaneously to the small subxiphoid incision into the abdomen via a passageway. After closing each incision, the child is placed prone, re-sterilized and toweled, and microscopic repair of cerebrospinal bulge is performed, along with spinal cord embolism release surgery if necessary. During the surgery of cerebrospinal bulge, attention was paid to hemostasis, and cerebral cotton was used to protect the operative area and avoid the entry of bloody cerebrospinal fluid into the ventricles. In 11 children, there were no surgical deaths or complications, all wounds healed in one stage, and there was no central infection or shunt infection in 1-5 years of follow-up. 1 child improved after reoperation for shunt obstruction at the ventral end 8 months after surgery, and there was no abnormality in 2 years of follow-up. 1 abandoned child with spinal cord ectasia at 6 months of age had a shunt reset 1 month after surgery for shunt ectasia into the thoracic cavity, and 5 months later had a shunt obstruction at the cephalic end. The case improved after reoperation 5 months later due to cephalic shunt obstruction, and was followed up for 8 months without abnormality. Discussion Cerebrospinal bulge is a dominant spina bifida that occurs in the midline of the body and is a congenital malformation with multiple causes, the cause of which is still unclear and may be related to early pregnancy folic acid deficiency and certain genes. The incidence of spina bifida combined with hydrocephalus is as high as 90% [2], with close to 80-90% of cases requiring hydrocephalic shunt surgery sooner or later [3]. As a comorbid malformation, the severity of hydrocephalus may also vary. Although most children present with progressive moderate-to-severe hydrocephalus and require shunt surgery, 20% to 30% have only mild or moderate hydrocephalus, with near-normal head circumference growth and brain tissue development at late follow-up, referred to as “resting hydrocephalus”. Iborra et al. performed continuous ICP (intracranial pressure) monitoring in 14 children with spina bifida who did not undergo shunt surgery and found that most of the children (11/14) had varying degrees of increased intracranial pressure and eventually underwent shunt surgery, with only three children meeting the diagnosis of hydrostatic hydrocephalus [4]. Therefore, it has been suggested that the diagnosis of hydrostatic hydrocephalus needs to be made with caution, otherwise delayed surgery will cause irreversible neurological damage to the child. Indian scholars applied noninvasive cranial ultrasound to screen for concomitant hydrocephalus and select children requiring surgery. The likelihood of hydrocephalus was predicted by measuring the maximum transverse diameter of the bilateral frontal horns, the distance between the centers of the bilateral caudate nuclei and the maximum transverse diameter of the lateral ventricular bodies by ultrasound and after statistical analysis, the bifrontal diameter >26 mm, binuclear diameter >20 mm and ventricular body diameter >26 mm were considered as indications for hydrocephalic shunt surgery [5]. In our group of children with moderate to severe hydrocephalus, all underwent shunt surgery along with cerebrospinal bulge repair. The incidence of postoperative complications of cerebrospinal bulge with hydrocephalus was higher than that of children with a single disease, with the main complications being shunt obstruction and infection, regardless of whether the surgery was performed in one stage or not. Statistically, the hazard ratio for requiring shunt replacement after cerebrospinal bulge with hydrocephalus versus hydrocephalus alone is 1.95, and approximately 50% occur within 1 year after shunt surgery, of which 73% are mechanical obstructions and 27% are infections [6]. This higher complication may be related to the young age of the child, the presence of a spinal or cranial defect and the long duration of the operation, and also the altered biochemical nature of the cerebrospinal fluid after the repair of a cerebrospinal bulge may cause obstruction of the duct. The obstruction of the shunt occurred in 2 cases in this group, accounting for about 18% of the cases, which is not significantly higher than that reported abroad, but much higher than the rate of obstruction in another group of children with simple hydrocephalus shunts in China [7]. 2 cases of obstruction occurred within 1 year after surgery and were mechanical obstruction, which improved after unblocking and did not require replacement of the tube. Due to the small number of cases in this group and the lack of data comparing with the second-stage surgery, it remains to be confirmed whether there is a statistically increased risk of obstruction. Children undergoing first-stage surgery have a prolonged operative time due to concurrent cerebrospinal bulge surgery, while cerebrospinal fluid exposure may increase postoperative infection. arslan et al. retrospectively analyzed 166 children for infection and found that the incidence of infection after staged surgery was significantly lower than in children undergoing first-stage surgery, and therefore recommended staged surgery for children with spinal bulge combined with hydrocephalus [8]. The optimal timing of staging surgery is 5 to 10 days after the repair of the bulging meninges, which reduces the risk of infection to one fifth [9]. The fact that no children in this group had postoperative infection may be related to the following points: (1) most of the cases were children with cerebrospinal bulge, and there were few cases of spinal cord exstrophy, so the spinal cord was not exposed and the chance of external infection entering the center was reduced; (2) anatomically, the ventricles were not directly connected to the subarachnoid cavity at a long distance from the vertebral cavity or to the bulging subarachnoid cavity, so the chance of infection flowing back up or spreading through the cerebrospinal fluid circulation was smaller; (3) Strict disinfection of the operating area, aseptic operation, intraoperative reduction of cerebrospinal fluid loss, prevention of hemorrhagic cerebrospinal fluid diffusion and reduction of operating time. It is controversial whether the surgery should be performed in one phase or in stages, and there are no reports in the literature in China. In developing countries, physicians tend to perform hydrocephalus shunts days or weeks after cerebrospinal repair surgery due to the requirements of surgery and anesthesia time. The more important reason may be based on the prevention and treatment of infections, the ability of cerebrospinal repair to close spinal or cranial defects, and the fact that a course of antimicrobial agents will reduce the rate of infection during shunt surgery. However, the disadvantages of staged surgery are obvious: the child must undergo two surgeries and two anesthetics, the hospital stay is longer, and the medical costs are relatively higher. Therefore, with the advancement of technology, more and more scholars are advocating for one-stage cerebrospinal bulge repair and hydrocephalus shunts. Miller et al. compared the results of 21 cases of one-stage surgery with 48 cases of staged surgery and found that the incidence of wound cerebrospinal fluid leakage was higher and the length of hospital stay was longer in staged cases, suggesting that one-stage surgery is more appropriate [10]. method for spina bifida and hydrocephalus simultaneously, which eliminated the need for position changes during surgery, shortened the overall operative time, and had a postoperative infection rate similar to that of staged surgery, and their findings are consistent with other reported results [11]. As for the sequence of cerebrospinal bulge repair and hydrocephalus shunt surgery, it does not seem to be important and has not been explored in the literature. Considering that hydrocephalus surgery is relatively cleaner and that there is a loss of cerebrospinal fluid in meningeal bulge repair, which may cause shrinkage of the ventricles and increase the difficulty of puncturing the ventricular end of the brain, all cases in this group were performed by first performing shunt surgery in the supine position and then performing meningeal bulge repair surgery in the prone position. The surgical approach is the same as the traditional single operation, with the valve mostly selected as a medium pressure valve. The high-pressure valve has poor shunting effect and can easily cause dorsal or occipital wound dehiscence, while the low-pressure valve may lead to premature closure of the cranial suture. Recently, an adjustable valve gate has also been used, which allows for more individualized adjustment. The recognized advantages of first-stage surgery are the ability to reduce cerebrospinal fluid leakage and protection from hydrocephalus damage to brain tissue. Its possible disadvantages include intraoperative problems due to prolonged operative time, hydrocephalus infection and diversion dysfunction. Therefore, in cases where preoperative central infection is clearly present or likely, such as spinal cord exstrophy and cerebrospinal fluid leak, it is still advisable to consider cerebrospinal bulge repair surgery first and then perform hydrocephalus shunt surgery in the second stage after the cerebrospinal fluid leak has healed and the central infection has been controlled.