Anomalies of vertebrae and ribs: Jarcho Levin syndrome. Description of a case and literature review

Spondylocostal dysostosis with type II split cord malformation: A report of a rare case and brief review of the literature

Spondylocostal dysostosis (Jarcho Levin syndrome) is a rare costovertebral malformation syndrome that will result in restrictive pulmonary physiology. It manifests its major components at birth. Split cord malformation, together with spondylocostal dysostosis, is even rarer. We hereby report our experience with diagnosing 1 infant with spondylocostal dysostosis and type II split cord malformation using computed tomography and magnetic resonance imaging. We also present a concise summary of previously published case reports and case series involving patients with concurrent spondylocostal dysostosis and split cord malformations.

Identification of a Novel Nonsense Variant in the DLL3 Gene Underlying Spondylocostal Dysostosis in a Consanguineous Pakistani Family

Introduction

Spondylocostal dysostosis (SCD) is characterized by multiple vertebral abnormalities associated with abnormalities of the ribs. Five genes causative for the disease have been identified. These include DLL3 (OMIM *602768), MESP2 (OMIM #608681), LFNG (OMIM #609813), TBX6 (OMIM *602427), and HES7 (OMIM *608059).

Methods

In the current study, we investigated a Pakistani consanguineous family segregating spondylocostal dysotosis. Whole-exome sequencing (WES) followed by Sanger sequencing was performed using DNA of affected and unaffected individuals to identify pathogenic variant(s). The identified variant was interpreted using ACMG classification. Literature review was performed to summarize currently known mutated alleles of DLL3 and the underlying clinical phenotypes.

Results

Clinical examination using anthropometric measurements and radiographs diagnosed the patients to be afflicted with SCD. Pedigree analysis of the affected family showed an autosomal recessive inheritance pattern of the disease. WES followed by Sanger sequencing identified a novel homozygous nonsense variant (DLL3(NM_016941.4): c.535G>T; p.Glu179Ter) in the DLL3 gene located on chromosome 19q13.2.

Conclusion

The study will be helpful in carrier testing and genetic counseling to prevent segregation of the disease to the next generations within this family. It also provides knowledge for clinicians and researchers in search of a better understanding of SCD anomalies.

Effect of ApoE ε4 gene polymorphism on the correlation between serum uric acid and left ventricular hypertrophy remodeling in patients with coronary heart disease

Background

Hyperuricemia and dyslipidemia are associated with left ventricular hypertrophy (LVH), while the effect of ApoE gene polymorphism on the correlation between serum uric acid (UA) level and severity of LVH in patients with coronary heart disease (CHD) has not been clarified.

Methods

This was a retrospective observational study of patients with CHD. Patients were divided into groups of ε4 carriers and non-ε4 carriers based on sanger sequencing. The association of ApoE ε4 gene polymorphism, serum UA level, and LVH, determined by cardiac color Doppler ultrasound, was evaluated by multivariate analysis.

Results

A total of 989 CHD patients who underwent ApoE genotyping were enrolled and analyzed. Among them, the frequency of the ApoE ε4 genotype was 17.9% (15.7% for E3/4, 1.1% for E4/4, and 1.1% for E2/4). There were 159 patients with LVH, 262 with end-diastolic LV internal diameter (LVEDD) enlargement, 160 with left ventricular ejection fraction (LVEF) reduction, and 154 with heart failure. Multivariate analysis showed that for every increase of 10 μmol/L in serum UA level, the risk of LVH decreased in ε4 carriers (odds ratio (OR) = 0.94, 95% confidence interval (CI): 0.890-0.992, P = 0.025) and increased in non-ε4 carriers (OR = 1.03, 95% CI: 1.005-1.049, P = 0.016). The risk of LVEDD enlargement tended to decrease in ε4 carriers (OR = 0.98, 95% CI: 0.943-1.023, P = 0.391) and increased in non-ε4 carriers (OR = 1.03, 95% CI: 1.009-1.048, P = 0.003). The risk of LVEF reduction was reduced in ε4 carriers (OR = 0.996, 95% CI: 0.949-1.046, P = 0.872) and increased in non-ε4 carriers (OR = 1.02, 95% CI: 0.994-1.037, P = 0.17). The risk of LVEDD enlargement decreased in ε4 carriers (OR = 0.98, 95% CI: 0.931-1.036, P = 0.508) and increased in non-ε4 carriers (OR = 1.02, 95% CI: 0.998-1.042, P = 0.07).

Conclusion

High serum UA levels decreased the risk of LVH in ApoE ε4 carriers with CHD, while increased the risk of LVH in non-ε4 carriers.

Genetics of non-isolated hemivertebra: A systematic review of fetal, neonatal, and infant cases

Hemivertebra is a congenital vertebral malformation caused by unilateral failure of formation during embryogenesis that may be associated with additional abnormalities. A systematic review was conducted to investigate genetic etiologies of non-isolated hemivertebra identified in the fetal, neonatal, and infant periods using PubMed, Cochrane database, Ovid Medline, and ClinicalTrials.gov from inception through May 2022 (PROSPERO ID CRD42021229576). The Human Phenotype Ontology database was accessed May 2022. Studies were deemed eligible for inclusion if they addressed non-isolated hemivertebra or genetic causes of non-isolated hemivertebra identified in the fetal, neonatal, or infant periods. Cases diagnosed clinically without molecular confirmation were included. Systematic review identified 23 cases of non-isolated hemivertebra with karyotypic abnormalities, 2 cases due to microdeletions, 59 cases attributed to single gene disorders, 18 syndromic cases without known genetic etiology, and 14 cases without a known syndromic association. The Human Phenotype Ontology search identified 49 genes associated with hemivertebra. Non-isolated hemivertebra is associated with a diverse spectrum of cytogenetic abnormalities and single gene disorders. Genetic syndromes were notably common. Frequently affected organ systems include musculoskeletal, cardiovascular, central nervous system, genitourinary, gastrointestinal, and facial dysmorphisms. When non-isolated hemivertebra is identified on prenatal ultrasound, the fetus must be assessed for associated anomalies and genetic counseling is recommended.

The role of radiography in the study of spinal disorders

Despite the growing use of computed tomography (CT) and magnetic resonance imaging (MRI) in the study of spinal disorders, radiography still plays an important role in many conditions affecting the spine. However, the study and interpretation of spine radiograph is receiving less attention and radiologists are increasingly unfamiliar with the typical findings in normal and pathologic conditions of the spine. The aim of this article is to review the radiologic indications of radiograph in different pathologic conditions that affect the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumour disorders, as well as their main radiographic manifestations.

Structured MRI reporting in spinal dysraphism

Magnetic resonance evaluation of spinal dysraphism can be confusing for inexperienced radiologists and a detailed, step-by-step evaluation of the normal and abnormal imaging findings can help garner the diagnosis. The purpose of this article is to review the existing literature and to provide a comprehensive, structured, template checklist-style format for reporting spinal dysraphism that can help inexperienced radiologists to systematically analyze and report all the significant and ancillary findings in cases of spinal dysraphism and efficiently communicate the findings to the treating physician/surgeon.

Butterfly Vertebrae: A Systematic Review of the Literature and Analysis

STUDY DESIGN

Systematic review (Level 4).

OBJECTIVE

To summarize the demographics, clinical presentations, and conditions associated with butterfly vertebrae.

METHODS

A systematic search was performed of multiple databases. A total of 279 articles were identified for screening. Case series or case reports of butterfly vertebrae with adequate clinical detail were complied.

RESULTS

Eighty-two total articles (109 patients) were selected for final inclusion. Sixty-one percent of patients presented with a single butterfly vertebra, while 39% were multiple. The most common location for butterfly vertebrae was T1. Fifty-six percent of cases were associated with a syndrome, the most common being spondylocostal dysostosis. The presence of multiple butterfly vertebra was strongly associated with a syndrome or additional anomalies (P < .001). Overall, the most common presenting complaint was low back pain. Seventy percent of patients had associated spinal disease. Other organ systems affected included musculoskeletal (43%), craniofacial (30%), neurologic (27%), cardiovascular (24%), genitourinary (23%), gastrointestinal (22%), laboratory abnormality (16%), and endocrine (9%).

CONCLUSIONS

This study is the largest collection of butterfly vertebrae cases to date. Butterfly vertebrae are associated with spinal deformity and multiple butterfly vertebrae may indicate a syndromic illness. Low back pain or disc herniation may occur with lumbar butterfly vertebrae however the etiology of this phenomena has not been rigorously explained. Many diseases and syndromes are associated with butterfly vertebrae.

Butterfly vertebra: a case report

Background and importance: Butterfly vertebra is an uncommon congenital spinal anomaly, which can be easily mistaken for vertebral fracture, infection or tumor.

Clinical presentation: We report the case of a 20-year-old male patient with a 3-year history of intermittent mid-thoracic spinal pain. Local examination showed a mild thoracic kyphoscoliosis. Neurological examination was normal. Computer tomography revealed the presence of a T6 butterfly vertebra associated with morphological anomalies in adjacent vertebral bodies and T6-T9 Schmorl’s nodes. MRI scan confirmed the diagnosis and additionally showed a mild spinal stenosis caused by apparent posterior epidural fat hypertrophy. The patient was treated with painkillers and physical therapy.

Conclusion: Butterfly vertebra is a benign condition. Once diagnosed, additional diagnostic procedures are not necessary. Neurosurgeons must be aware of this congenital anomaly that should not be confused with a vertebral fracture.

A Single-Center Experience of CNS Anomalies or Neural Tube Defects in Patients With Jarcho-Levin Syndrome

Jarcho-Levin syndrome (JLS) is a genetic disorder characterized by distinct malformations of the ribs and vertebrae, and/or other associated abnormalities such as neural tube defect, Arnold-Chiari malformation, renal and urinary abnormalities, hydrocephalus, congenital cardiac abnormalities, and extremity malformations. The study included 12 cases at 37-42 weeks of gestation and diagnosed to have had Jarcho-Levin syndrome, Arnold-Chiari malformation, and meningmyelocele. All cases of Jarcho-Levin syndrome had Arnold-Chiari type 2 malformation; there was corpus callosum dysgenesis in 6, lumbosacral meningmyelocele in 6, lumbal meningmyelocele in 3, thoracal meningmyelocele in 3, and holoprosencephaly in 1 of the cases. With this article, the authors underline the neurologic abnormalities accompanying Jarcho-Levin syndrome and that each of these abnormalities is a component of Jarcho-Levin syndrome.

Spondylocostal dysostosis (Jarcho-Levine syndrome) associated with occult spinal dysraphism: Report of two cases

Spondylocostal dysostosis, also known as Jarcho-Levine syndrome, is a rare disorder characterized by multiple vertebral and rib anomalies at birth. The association of occult spinal dysraphic lesions with this entity is rare. Two patients with spondylocostal dysostosis and occult spinal dysraphic lesions, one with type I split cord malformation and another with spinal dermal sinus are being reported. A 7-month-old female child who was operated at birth for imperforate anus was noted to have a dimple at the low back with altered skin color around the dimple. Examination revealed the right lower extremity was slightly thinner than the left. Plain radiographs showed features of spondylocostal dysostosis with scoliosis. Magnetic resonance imaging (MRI) showed a type I split cord malformation at the lumbosacral junction with low-lying conus and terminal syringomyelia. Patient underwent excision of the bony spur uneventfully. A 14-month-old male child was noted to have a small swelling in the low back along with deformity of the right lower chest since birth. Plain radiographs revealed features of spondylocostal dysostosis. MRI showed a spinal dermal sinus at the lumbosacral junction with a low-lying conus. The patient underwent excision of the spinal dermal sinus and untethering of the cord uneventfully. Although rare, spondylocostal dysostosis can be associated with occult spinal dysraphic lesions like type I split cord malformations or spinal dermal sinus. Physicians should be aware about the possibility of children with spondylocostal dysostosis harboring occult spinal dysraphic lesions so that these patients receive appropriate treatment.

Spondylocostal dysostosis with lipomyelomeningocele: Case report and review of the literature

Spondylocostal dysostosis (SCDO) is rare anomaly caused due to flawed embryological development of the axial skeleton during preliminary stages of gravidity, characterized by malformed vertebral column and ribs, abridged thorax and kyphoscoliosis. This entity was also reported as a "Jarcho-Levin syndrome" eponym by erstwhile authors, before the introduction of genetic based classification. A literature review showed only three cases of this clinical entity with lipomyelomeningocele. We report the fourth case report of an infant with SCDO with lipomyelomeningocele. His chest X-ray displayed absent left side 6(th)-8(th) ribs with peculiar fan like configuration, making the heart vulnerable to any direct injury. Special care has to be taken for such patients who need surgical procedure in the prone position.

Neural tube defects in Jarcho-Levin syndrome: study of twenty-eight cases

Jarcho-Levin syndrome (JLS) is a congenital disorder consisting of various vertebral and costal anomalies. Congenital heart defects, abdominal wall malformations, urogenital and anal abnormalities, multiple skeletal anomalies, upper limb anomalies, spina bifida, and inguinal, umbilical and diaphragmatic hernias can be seen as components of JLS. Spina bifida appears to be a common finding in reported JLS cases. We retrospectively reviewed the medical records, plain X-rays and MRIs of patients with spina bifida between 2010 and 2014 and discussed the results.

Two iniencephaly cases born the same day in the same hospital of Cali, Colombia. Iniencephaly cluster?

Two patients with short and hyperextended neck, cervical meningocele and other birth defects, were born the same day at the same hospital, both died. The autopsy report and X-rays show iniencephaly's classic findings. Revision of clinical histories did not show consanguinity between the parents, or exposure to environmental factors.

Value of 3-dimensional sonography for prenatal diagnosis of vertebral formation failure

OBJECTIVES

The purposes of this study were to explore the value of 3-dimensional sonography for diagnosis of vertebral formation failure in the developing fetus and to formulate antenatal sonographic diagnostic criteria for suspected vertebral formation failure based on a comparison of sonographic characteristics of the disorder with normal sonographic findings and other imaging data.

METHODS

This study included sonographic data from 30 healthy fetuses and 13 fetuses suspected to have vertebral formation failure. Three-dimensional reconstruction of sagittal sections of the physiologic curves of the cervicothoracic and lumbosacral regions of the healthy fetuses was performed, and reconstruction was also performed on selected areas of interest when vertebral malformation was suspected. Stored data were analyzed, and a comparison with other image data was performed using various methods.

RESULTS

Three-dimensional reconstruction was more suitable for fetal spinal sonography among the 30 healthy fetuses, and it was particularly superior in detecting the positions of spines with evident physiologic curvature. The images revealed suspected vertebral formation failure in 13 cases, and the confirmed findings included 7 cases of hemivertebrae, 2 cases of butterfly vertebrae, 2 cases of mixed malformations (butterfly vertebra and hemivertebra), and 1 case of a coronal cleft vertebra. One case was lost to follow-up. The sonographic characteristics were definite, and there were evident differences from the sonograms of spina bifida.

CONCLUSIONS

Three-dimensional sonography is helpful for detection of vertebral formation failure in the developing fetus and might provide prognostic information with the potential to ameliorate the progressive spinal deformities that can result from embryonic vertebral formation failure.

Molecular diagnosis of vertebral segmentation disorders in humans

BACKGROUND

Vertebral malformations contribute substantially to the pathophysiology of kyphosis and scoliosis, common health problems associated with back and neck pain, disability, cosmetic disfigurement and functional distress.

OBJECTIVE

To provide an overview of the current understanding of vertebral malformations, at both the clinical level and the molecular level, and factors that contribute to their occurrence.

METHODS

The literature related to the following was reviewed: recent advances in the understanding of the molecular embryology underlying vertebral development and relevance to elucidation of etiologies of several known human vertebral malformation syndromes; outcomes of molecular studies elucidating genetic contributions to congenital and sporadic vertebral malformations; and complex interrelationships between genetic and environmental factors that contribute to the pathogenesis of isolated syndromic and non-syndromic congenital vertebral malformations.

RESULTS/CONCLUSION

Expert opinions extend to discussion of the importance of establishing improved classification systems for vertebral malformation, future directions in molecular and genetic research approaches to vertebral malformation and translational value of research efforts to clinical management and genetic counseling of affected individuals and their families.

Interpedicular graft using a titanium mesh cage in a patient with lumbar scoliosis associated with a congenital butterfly vertebra

A butterfly vertebra is a congenital anomaly often associated with a series of syndromic diseases and is often recognized incidentally without any presenting symptoms. The authors report the case of a 13-year-old girl with lumbar scoliosis and mild spondylolisthesis associated with a butterfly vertebra at L-6 causing radiculopathy. The L-5 and L-6 nerve roots were entrapped at the intervertebral foramina between L-5 and the butterfly vertebra (L-6) and between L-6 and S-1 in the concave side. To decompress and preserve the two nerve roots, correct the deformity, and obtain a solid bone fusion, surgery involving the thorough removal of the facet joints between L-5 and L-6 and between L-6 and S-1 in the concave side was performed, with a partial resection of the butterfly vertebra and the placement of a titanium mesh cage between the L-5 and S-1 pedicles dorsal to the nerve roots. Complete pain relief and correction of the deformity with solid bone fusion was obtained after a 2-year follow-up period.

A case of Jarcho-Levin syndrome associated with bilateral cystic renal disease and wilms tumor: MR imaging findings

Jarcho-Levin syndrome (JLS) is a congenital disorder characterized by a variety of vertebral and costal anomalies that result in thoracic deformity. Hitherto, a plethora of associated anomalies have been described in several reports. In this report, the authors describe a case of JLS who has Wilms tumor and bilateral cystic renal disease. To the authors' knowledge, there is only a single case of JLS who presented with multiple renal cortical cysts, but none with an associated Wilms tumor in the literature. Additional anomalies seen in the present case that are related with this syndrome are also discussed.

Progress in the understanding of the genetic etiology of vertebral segmentation disorders in humans

Vertebral malformations contribute substantially to the pathophysiology of kyphosis and scoliosis, common health problems associated with back and neck pain, disability, cosmetic disfigurement, and functional distress. This review explores (1) recent advances in the understanding of the molecular embryology underlying vertebral development and relevance to elucidation of etiologies of several known human vertebral malformation syndromes; (2) outcomes of molecular studies elucidating genetic contributions to congenital and sporadic vertebral malformation; and (3) complex interrelationships between genetic and environmental factors that contribute to the pathogenesis of isolated syndromic and nonsyndromic congenital vertebral malformation. Discussion includes exploration of the importance of establishing improved classification systems for vertebral malformation, future directions in molecular and genetic research approaches to vertebral malformation, and translational value of research efforts to clinical management and genetic counseling of affected individuals and their families.

Defective somitogenesis and abnormal vertebral segmentation in man

In recent years molecular genetics has revolutionized the study of somitogenesis in developmental biology and advances that have taken place in animal models have been applied successfully to human disease. Abnormal segmentation in man is a relatively common birth defect and advances in understanding have come through the study of cases clustered in families using DNA linkage analysis and candidate gene approaches, the latter stemming directly from knowledge gained through the study of animal models. Only a minority of abnormal segmentation phenotypes appear to follow Mendelian inheritance but three genes--DLL3, MESP2 and LNFG--have now been identified for spondylocostal dysostosis (SCD), a spinal malformation characterized by extensive hemivertebrae, trunkal shortening and abnormally aligned ribs with points of fusion. In affected families autosomal recessive inheritance is followed. These genes are all important components of the Notch signaling pathway. Other genes within the pathway cause diverse phenotypes such as Alagille syndrome (AGS) and CADASIL, conditions that may have their origin in defective vasculogenesis. This review deals mainly with SCD, with some consideration of AGS. Significant future challenges lie in identifying causes of the many abnormal segmentation phenotypes in man but it is hoped that combined approaches in collaboration with developmental biologists will reap rewards.