Neurologic and vascular complications of scoliosis surgery in patients with Ehlers-Danlos syndrome. A case report

Spinal Deformity in Ehlers-Danlos Syndrome: Focus on Musculocontractural Type

Spinal deformity in Ehlers-Danlos syndrome (EDS) is an important symptom that can lead to trunk balance deterioration, respiratory dysfunction, and digestive disorders as the deformity progresses, thereby reducing a patient's quality of life and activities of daily living. The severity of the deformity varies widely, with treatment depending on the extent and the presence of associated complications. The present review addressed the current state of clinical research and treatment of spinal deformities in EDS with a specific focus on the musculocontractural type. Further studies are needed to better understand the underlying mechanisms of spinal deformity in EDS.

Spinal manifestations of Ehlers-Danlos syndrome: a scoping review

OBJECTIVE

Since its initial description, the definition of Ehlers-Danlos syndrome (EDS) has notably changed. At present, it broadly refers to disorders of the connective tissue that are heritable and have similar features including joint hypermobility, dermal dysplasia, and vascular as well as internal organ fragility. There has been no comprehensive review of spinal manifestations of EDS in the recent literature. That has led to controversies in management protocols of this so-called orphan disease.

METHODS

The authors used the latest version of the EDS classification from 2017, in which 13 subtypes were recognized. EDS has 19 different causal genes, mainly associated with collagen synthesis. Of these, 5 subtypes have associated spinal manifestations.

RESULTS

Some of the spinal pathologies associated with EDS include Chiari malformation, craniocervical instability, kyphoscoliosis, segmental instability and kyphosis, spontaneous CSF leaks, Tarlov cyst syndrome, tethered cord, and problems associated with wound healing. Here, the authors briefly discuss the demographics, etiology, pathophysiology, clinical features, management strategies, and directions for further research for each of these manifestations.

CONCLUSIONS

EDS belongs to the group of orphan diseases, with the total patient population being below 200,000. Further research on spinal manifestations of EDS is the need of the hour to establish clinical practice guidelines and close the significant knowledge gaps that currently exist.

Orthopaedic Conditions Associated with Aneurysms

Orthopaedic surgeons are sometimes the first specialists encountered by patients with inherited conditions that predispose them to aneurysms. The skeletal features are evident, but the aneurysm is silent. Early recognition of the conditions associated with aneurysms can lead to effective treatment and minimize risks of morbidity and death. Marfan syndrome is characterized by abnormal fibrillin-1 protein and has a broad range of skeletal manifestations, including scoliosis, hindfoot deformity, arachnodactyly, pectus excavatum or carinatum deformity, dural ectasia, and acetabular protrusio. Aneurysm-associated complications are the leading cause of early morbidity and death in patients with Marfan syndrome. Ehlers-Danlos syndrome is caused by a disturbance in collagen biosynthesis most commonly resulting in joint hypermobility and skin abnormalities. Among the types of Ehlers-Danlos syndrome, vascular Ehlers-Danlos syndrome presents the highest risk of vascular complications. Clubfoot and joint dislocations are common presenting symptoms in vascular Ehlers-Danlos syndrome. Loeys-Dietz syndrome is a connective tissue disorder resulting in aortic root dilation and several skeletal manifestations, including scoliosis, cervical malformations, joint contractures, and foot deformities.

Posterior Spinal Fusion for Severe Spinal Deformities in Musculocontractural Ehlers-Danlos Syndrome: Detailed Observation of a Novel Case and Review of 2 Reported Cases

BACKGROUND

Musculocontractural Ehlers-Danlos syndrome caused by pathogenic variants in CHST14 (mcEDS-CHST14) is a recently delineated connective tissue disorder characterized by multisystem congenital malformations and progressive connective tissue fragility-related manifestations. With only 2 cases of mcEDS-CHST14 containing precise information on surgical spinal correction being reported to date, there remains no consensus on treatment standards. This study describes the detailed clinical and radiologic outcomes of the third known patient with mcEDS-CHST14 who successfully underwent surgery for severe kyphoscoliosis.

CASE DESCRIPTION

The patient was a 19-year-old girl with mcEDS-CHST14 who suffered from low back pain and decreased daily activities caused by progressive kyphoscoliosis. She underwent posterior spinal fusion with an all-pedicle screw construct from T4 to L4 for a preoperative main curve Cobb angle of 69 degrees and kyphotic angle of 27 degrees. Postoperative Cobb angle of the main curve and kyphotic angle were 26 and 6 degrees, respectively. Although sufficient correction was achieved without disseminated intravascular coagulation or other serious sequelae, a large amount of blood (2600 g) was lost due to tissue fragility. Her low back pain was decreased at 1 year after surgery.

CONCLUSIONS

On the basis of the present and 2 earlier reported cases, posterior spinal fusion may be a reasonable surgical option for severe progressive spinal deformities in patients with mcEDS-CHST14. However, careful attention is needed for possible massive blood loss from tissue fragility.

Complications in Children with Ehlers-Danlos Syndrome Following Spine Surgery: Analysis of the Pediatric National Surgery Quality Improvement Program Database

BACKGROUND

Ehlers-Danlos syndrome (EDS) is a group of rare congenital disorders of connective tissue that result in tissue fragility and joint hyperextensibility. Owing to its rarity, outcomes of pediatric spine surgery in patients with EDS are poorly characterized. Although it has been suggested that complication rates are high, few studies have characterized these complications.

METHODS

Pediatric National Surgery Quality Improvement Program data from 2012-2016 were analyzed. Patients with EDS undergoing spine surgery were identified along with patients without EDS undergoing the same surgeries using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes.

RESULTS

Of 369,176 total patients, 279 were determined to have EDS. Of these, 56 patients underwent spine surgery; 46% were male and 54% were female (P = 0.108). Mean age at surgery was 11.59 years (P = 0.888) with a range of 1.77-17.33 years. The most common procedure was arthrodesis (n = 37). There were no differences in unplanned reoperations (n = 4, P = 0.119), wound infections or disruptions (n = 2, P = 0.670), or overall complications (n = 25, P = 0.751). Blood transfusions were required in 41% of patients with EDS, but this was not significant compared with patients without EDS undergoing the same procedures (n = 23, P = 0.580). The total amount of blood transfused (P = 0.508), length of hospital stay (P = 0.396), and total operative time (P = 0.357) were not different from control subjects.

CONCLUSIONS

Pediatric patients with EDS do not appear to be at a higher risk of bleeding or other complications during spine surgery as reported in past case series. This is the largest retrospective review of its kind that has been performed in this patient population.

Spinal manifestations in 12 patients with musculocontractural Ehlers-Danlos syndrome caused by CHST14/D4ST1 deficiency (mcEDS-CHST14)

Musculocontractural Ehlers-Danlos syndrome caused by mutations in CHST14 (mcEDS-CHST14) is a recently delineated disorder, characterized by craniofacial, skeletal, visceral, and ocular malformations; and progressive cutaneous, skeletal, vascular, and visceral fragility-related manifestations. Spinal lesions, though one of the most serious complications, have not been investigated systematically. In this study, we report detailed and comprehensive information about spinal lesions of 12 patients with a mean age at the first visit of 13.4 years. Eight patients (66.7%) had scoliosis with a Cobb angle ≥10°, including one with severe scoliosis with a Cobb angle ≥45°. Five patients (41.7%) had kyphosis at the thoracolumbar junction with a kyphotic angle ≥20°. Three patients (25%) developed severe thoracolumbar kyphosis with a kyphotic angle ≥50° accompanied by thoracic lordosis with a wedge-like vertebral deformity and anterior vertebral osteophyte at the thoracolumbar junction, and two of them underwent surgical correction: complicated by fistula formation in one and performed safely and effectively through two-staged operation in the other. Six patients (50.0%) had cervical kyphosis, all of whom except one had kyphosis ≥20° at the thoracolumbar level. Two patients (16.7%) had atlantoaxial subluxation, and 10 patients (83.3%) had cervical vertebral malformations. Patients with mcEDS-CHST14 are susceptible to develop scoliosis, thoracolumbar kyphosis, and cervical kyphosis; and are recommended to have regular surveillance including total spine radiology. The present findings also suggest the critical role of dermatan sulfate in the development and maintenance of the spine.

Musculoskeletal Conditions in a Pediatric Population with Ehlers-Danlos Syndrome

OBJECTIVE

To describe musculoskeletal conditions in children with Ehlers-Danlos syndrome (EDS).

STUDY DESIGN

A retrospective medical record review was performed, which evaluated 205 patients with EDS (ages 6-19 years) seen in sports medicine or orthopedic clinic at a large pediatric hospital over a 5-year period.

RESULTS

Female (n = 147) and male (n = 57) patients were identified (mean age 12.7 years). The most common EDS subtype (55.6%) was hypermobility type. Patients had between 1 and 69 visits (median 4), and 764 diagnoses were recorded, most commonly laxity/instability, pain, subluxation, and scoliosis/spinal asymmetry. Nearly one-half of patients (46.8%) received a general diagnosis of pain because no more specific cause was identified, in addition to 8.3% who were diagnosed with chronic pain syndrome. The most common sites of presenting issue were knee (43.4%), back (32.2%), and shoulder (31.2%). Over three-fourths (77.1%) of patients had imaging. Most (88.1%) were prescribed physical therapy and/or other conservative measures, such as rest (40.5%), orthotics (35.6%), and medication (32.2%). Surgery was recommended to 28.8% of the study population.

CONCLUSIONS

Many pediatric and adolescent patients with EDS experience joint pain, instability, and scoliosis, along with other musculoskeletal issues. Despite extensive workup, the etiology of pain may not be identified. Large numbers of office visits, imaging studies, treatment prescriptions, and specialist referrals indicate considerable use of medical resources and highlight a great need for injury prevention and additional study.

ELECTROMYOGRAPHY AND INSTRUMENTATION IN PATIENTS WITH IDIOPATHIC SCOLIOSIS

ABSTRACT Objective: The objective of this study is to relate the use of intraoperative electromyography with surgical time, proper placement of screws, type of curve and time spent per screw in idiopathic scoliosis correction surgery in a group of surgeons from Belo Horizonte. This study used the database of protocol evaluation of patients operated in the service, and separately analyzed the results of motor and somatosensory potentials. Methods: Retrospective study of 80 patients undergoing surgery for correction of idiopathic scoliosis between December 2008 and January 2015. A single group of Belo Horizonte spine surgeons performed the intraoperative electromyographic (EMG) monitoring. EMG was performed with stimulation of pedicle screws in patients undergoing instrumentation with pedicle screws as fixation elements. Results: The sample consisted of 85% females (mean age 17 years) and 37.5% of cases had classification type 1AN of Lenke. Of the total surgical cases, 60% had EMG changes. Of the total cases analyzed, 66.3% were true positives for the result. Conclusion: Intraoperative monitoring with EMG is a very important tool for the surgical treatment of patients with scoliosis undergoing instrumentation with pedicle screws. It enables to check if the screw is located on the correct path, helping to decrease the error rate and providing corrections to the surgical approach through a change of strategies. Moreover, it contributes to decrease the time to screw positioning and the total surgical time.

Spontaneous Fatal Intraoperative Rupture of Great Vessel During Growing Rod Lengthening: Do Children With Ehlers-Danlos Syndrome Require the Availability of Vascular Expertise? A Case Report and Review of the Literature

BACKGROUND

Ehlers-Danlos syndrome (EDS) is a family of inherited connective tissue diseases. Kyphoscoliotic EDS (kEDS) is associated with severe and early spinal deformity. Very little has been reported regarding the orthopaedic surgical care of kEDS likely due to its rare incidence. A more common subtype is the vascular-type EDS (vEDS, previously labeled type IV), which is associated with reports of vascular complications in the literature.

METHODS

The case report of a single, fatal complication of spontaneous rupture of the superior vena cava, after extubation, subsequent to revision minimal growing rod lengthening in a child with kEDS. We additionally review prior reported cases of kEDS for pediatric spine surgery and the sentinel event of spontaneous vascular rupture in all EDS patients.

RESULTS

The anterior thoracoabdominal approach in children with kEDS has been associated with severe intravascular complications, with no deaths reported to date. Posterior spinal procedures were associated with frequent overall complications, but no events of perioperative or spontaneous vascular injury were identified before our case.Reports of spontaneous vessel rupture (n=39) appear more frequently in vEDS, but have been documented in patients with EDS type I (classic EDS or cEDS) and kEDS disease. The 30-day mortality in these patients was 59%. The majority of the deaths occurred on the day of the vascular event. Surviving patients overwhelmingly received intraoperative consultation and treatment from either general or vascular surgeons at their respective institutions for assistance.

CONCLUSIONS

Providers should consider their proximity to available emergent consultation before operating on patients with EDS of any subtype.

LEVEL OF EVIDENCE

Level V-expert opinion.

Vertebral Column Resection for Kyphoscoliosis in a Patient with Ehlers-Danlos Syndrome: An Intraoperative Neurophysiological Monitoring Alert

A 16-year-old male patient with Ehler-Danlos syndrome (EDS) and a back deformity since birth presented with severe kyphoscoliosis. The patient was neurologically intact but had respiratory and cardiac insufficiencies. A two-stage vertebral column resection (VCR) at T9-T10 with multiple level fusion with multimodality intraoperative neurophysiological monitoring (IONM) was planned. 

During the first stage, pedicle screws were placed at multiple spinal levels above and below the VCR level. Upper and lower somatosensory evoked potentials (SSEP), transcranial electrical motor evoked potentials (TCeMEP), and electromyography were monitored continuously and showed no significant changes. The second stage was performed one week later. Baseline SSEP and TCeMEP responses were present in all extremities. The surgeon was informed of a sudden 70% amplitude drop in TCeMEP in the lower limbs with stable SSEP after ligating one of the left nerves/vessels fully stretching the spinal cord. The surgeon removed the ligation, and an improvement in motor responses followed. Surgery proceeded with the highest levels of caution. Later, there was a sudden loss of TCeMEP and SSEP in the lower limbs bilaterally. The correction was released, mean arterial pressure was increased, and intravenous dexamethasone was administered. The surgical correction was aborted, and the decision was made to close the site. Lower SSEP and TCeMEP responses remained absent until closing, while upper SSEP and TCeMEP responses remained stable.

A wake-up test was done after closing. The patient moved his upper limbs but was unable to move his lower limbs bilaterally. The patient was sent for a magnetic resonance imaging scan while intubated and then sent to the intensive care unit. At 24 hours and 36 hours post-operation, the patient had no sensory and motor function below the T8 level. Forty-eight hours post-operation, the patient started to feel sensory stimuli at the T10 level. At one week post-operation, the patient regained sphincter functions, and at four weeks postoperatively, the patient’s hip flexors started to recover.

VCR in patients with EDS has a very high risk of damaging the spinal cord due to the fragile vasculature of the spinal cord. Real-time IONM is useful in the early identification of spinal cord injury in cases of this nature. 

Complications of surgical treatment of pediatric spinal deformities

Surgery in a child with spinal deformity is challenging. Although current orthopedic practice ensures good long-term surgical results, complications occur. Idiopathic scoliosis represents the most extensively investigated deformity of the pediatric spine. Nonidiopathic deformities of the spine are at higher risk for perioperative and long-term complications, mainly because of underlying comorbidities. A multidisciplinary treatment strategy is helpful to assure optimization of medical conditions before surgery. Awareness of complications that occur during or after spine surgery is essential to avoid a poor outcome and for future surgical decision making. This article summarizes the complications of surgical treatment of the growing spine.

Posterior spinal fusion in patients with Ehlers-Danlos syndrome: a report of six cases

PURPOSE

There is a paucity of literature describing posterior spinal fusion (PSF) in the Ehlers-Danlos syndrome (EDS) patient. The vast majority of these studies diagnosed EDS clinically. The purpose of this study is to discuss the management and complications of EDS patients with scoliosis treated with PSF at a single institution.

METHODS

Clinical and radiographic data are presented describing six patients who had PSF for EDS. The diagnoses were confirmed by a geneticist.

RESULTS

All of the patients in the current cohort underwent posterior fusion only, with no anterior approach. Neuromonitoring was also used in the majority. Half of our patients experienced complications. One patient had a hemoperitoneum that was initially treated nonoperatively but, unfortunately, they expired 1 month after discharge from abdominal bleeding. Another patient suffered neuropathic pain attributed to the type of implant used. A third underwent a total of seven procedures beginning at the age of 3 years in a different era of spinal surgery. The mean major curve, percentage correction, and estimated blood loss of the current cohort are similar to previous studies.

CONCLUSION

The fragility of the EDS patient population cannot be overlooked. Despite a conservative surgical approach, half of our patients experienced complications. The surgeon choosing to operate on EDS patients must do so with extreme caution.

Lumbar artificial disc replacement in Ehlers-Danlos syndrome: A case report and discussion of clinical management

Background

Ehlers-Danlos syndrome (EDS) is a heterogeneous collection of connective tissue disorders characterized by varying degrees of skin hyperextensibility, joint hypermobility, and tissue fragility. Surgical treatment of EDS patients is complicated by the extreme fragility of their vessels and tissues. The purpose of this case report is to present the management of an EDS patient with debilitating low-back pain.

Methods

A 52-year-old woman with a clinical diagnosis of EDS presented with degenerative disc disease at L4-5 that had not been alleviated by previous microdiscectomies. The clinical course, decision-making process, and treatment are discussed in this case report.

Results

The patient was referred for genetic evaluation, which classified her with type III EDS, or hypermobility type. We presented the patient with the risks and benefits of fusion versus artificial disc replacement (ADR), particularly with regard to her EDS diagnosis of the hypermobility subtype. Given the patient's lack of extreme spinal hypermobility on examination and the absence of clear contraindications regarding ADR in type III EDS, the decision was made to proceed with ADR. There were no surgical complications, and the patient's low-back pain and radicular symptoms resolved with no evidence of implant migration or hypermobility at 1 year postoperatively.

Conclusions

In this case report, the referral to a geneticist and consultation with a vascular surgeon were integral steps in the decision to proceed with surgery. Although the clarified diagnosis of type III EDS did not eliminate the potential risk for vascular compromise during surgery, it placed the patient at lower risk than patients with other subtypes of EDS. Similarly, her lack of extreme hypermobility made us more comfortable with pursuing ADR. Although we emphasize extreme caution when considering surgical treatment, this case report suggests that some patients with less severe forms of EDS may be able to successfully undergo anterior spine surgery, including ADR.

Natural history of spinal deformity in a patient with Ehlers-Danlos syndrome: case report with 20-year follow-up

BACKGROUND CONTEXT

Scoliosis can present in patients with Ehlers-Danlos syndrome (EDS) and can be surgically treated despite possible complications. The long-term natural history of the progression of spinal deformity, particularly scoliosis, and associated complications in EDS patients remains relatively unknown.

PURPOSE

To assess the progression of spinal deformity and associated complications in a patient with EDS, who was not surgically treated for her spine condition and was followed up for 20 years.

STUDY DESIGN

A case report.

METHODS

A 9-year-old female with EDS presented to the orthopedic clinic with scoliosis and mild thoracic hyperkyphosis. The patient was followed up for a 20-year period. Progression of her spinal deformity and associated complications were noted.

RESULTS

The patient's curve progressed rapidly in the initial follow-up period an 83° worsening from the age of 9 to 10 years. Because she refused surgical intervention, her spinal deformity continued to progress. As such, by the age of 29 years, she presented with 115° from T9 to L4 with severe hyperkyphosis. The patient eventually developed respiratory compromise and diminished functional capacity.

CONCLUSIONS

In patients with EDS, scoliosis may progress rapidly and unrelentingly, and if not treated early may lead to respiratory compromise. Close follow-up of such patients is imperative, and appropriate management should be sought to prevent potentially fatal morbidities.

Posterior spinal fusion for scoliosis in Ehlers-Danlos syndrome, kyphoscoliosis type

The Ehlers-Danlos syndromes comprise a clinically and genetically heterogeneous group of heritable connective tissue disorders characterized by articular hypermobility, skin extensibility, and tissue fragility. Surgical treatment of scoliosis associated with Ehlers-Danlos syndrome poses a challenge to spine surgeons because of the high risk of major complications. There is a paucity of evidence in the literature on surgical treatment for scoliosis in the Ehlers-Danlos syndrome patient.This article describes 3 adolescent patients diagnosed with Ehlers-Danlos syndrome, kyphoscoliosis type, which was treated by posterior spinal fusion only. After unsuccessful conservative treatment for at least 1 year, the patients underwent posterior spinal surgery for the correction of spinal deformity. A satisfactory correction in the spinal curve was achieved, with no obvious loss of correction during follow-up. No intra- or postoperative major complications were observed.Our experience supports that a satisfactory correction of scoliosis can be achieved by posterior spinal fusion only in patients with Ehlers-Danlos syndrome, kyphoscoliosis type.

Spine deformities in patients with Ehlers-Danlos syndrome, type IV - late results of surgical treatment

Background

Spinal deformities in Ehlers-Danlos syndrome are usually progressive and may require operative treatment. There is limited number of studies describing late results of surgery in this disease.

Methods

This is a retrospective study of the records of 11 patients with Ehlers-Danlos syndrome type IV, treated surgically between 1990 and 2007. All patients underwent surgical treatment for spinal deformity. Duration of operation, type of instrumentation, intraoperative blood loss, complications and number of additional surgeries were noted. Radiographic measurement was performed on standing AP and lateral radiographs acquired before surgery, just after and at final follow up.

Results

The mean follow up period was 5.5 ± 2.9 years (range 1-10 years). The mean preoperative thoracic and lumbar curve were 109.5 ± 19.9° (range 83° - 142°) and 75.6 ± 26.7° (range 40° - 108°) respectively. Posterior spine fusion alone was performed on 6 patients and combined anterior and posterior fusion (one- or two stage) on 5 cases. Posterior segmental spinal instrumentation was applied with use of hooks, screws and wires. The mean postoperative thoracic and lumbar curve improved to 79.3 ± 16.1° (range 56° - 105°) and 58.5 ± 27.7° (range 10° - 95°) respectively, with a slight loss of correction during follow up. The average thoracic and lumbar correction was 26.4 ± 14.9% (range 5.3 - 50.4%) and 26.3 ± 21.2% (range 7.9 - 75%). Postoperatively, the mean kyphosis was 79.5 ± 40.3° (range 21° -170°), and lordosis was 50.8 ± 18.6° (range 20° -79°). Hyperkyphosis increased during follow up while lordosis remained stable. Mean Th12-L2 angle was -3.5 ±9.9° (range -19° - 15°) postoperatively and did not change significantly during follow up.

Conclusions

Huge spinal deformities in patients with Ehlers-Danlos syndrome require complex and extensive surgery. There is a big risk of sagittal imbalance in this group.

Rupture of abdominal aortic aneurysm after spine surgery in the patient with Ehlers-Danlos syndrome -A case report-

Ehlers-Danlos syndrome (EDS) is a rare inherited disorder of the connective tissue that is characterized by hyperextensible skin, hypermobile joints and abnormalities of the cardiovascular system. A 15-year-old girl with Ehlers-Danlos syndrome underwent thoracolumbar surgery for deformity correction. After surgery, an abdominal aortic rupture occurred, and she complained of abdominal distension had an abdominal circumference of 80 cm. Abdominal computed tomography revealed a pseudoaneurysm and a large hematoma at the retroperitoneum. She died of a massive hemorrhage during subsequent abdominal aortic surgery.

Comparação entre o teste de despertar e a monitoração neurofisiológica intra-operatória com potencial evocado somato-sensitivo nas cirurgias de escoliose

OBJETIVO: comparar a incidência de lesões neurológicas em cirurgias corretivas de curvas rígidas de escoliose idiopática, utilizando-se somente o teste do despertar e utilizando-se a monitoração neurofisiológica intra-operatória por meio dos Potenciais Evocados Somato-Sensitivo (PESS). MÉTODOS: foram realizadas 111 cirurgias para correção de escoliose idiopática, com curvas rígidas por meio de instrumentação e artrodese pela via posterior, no período de janeiro de 1985 a maio de 2001. Os procedimentos foram divididos em dois grupos, sendo 80 pacientes operados sem a monitoração intra-operatória, utilizando somente o teste do despertar, no período de janeiro de 1985 a janeiro de 1998. A partir de maio de 1998, as cirurgias passaram a ser monitoradas com potencial evocado somato-sensitivo (PESS), para prevenção de lesão neurológica, formando um segundo grupo de 31 pacientes. RESULTADOS: no primeiro grupo, um paciente teve lesão neurológica irreversível e quatro pacientes tiveram lesão neurológica reversível. Entre os 31 pacientes do segundo grupo, com monitoração neurofisiológica sensitiva durante a cirurgia, oito apresentaram lesão neurológica reversível constatada no intra-operatório, sem nenhuma repercussão clínica após o procedimento. CONCLUSÃO: os resultados apresentados sugerem a eficácia da monitoração intra-operatória, com o potencial evocado somato-sensitivo, para a prevenção de lesões neurológicas, nas cirurgias corretivas de curvas rígidas na escoliose idiopática.

Vascular complications from anterior spine surgery in three patients with Ehlers-Danlos syndrome

STUDY DESIGN

A case report of vascular complications arising from anterior spine surgery in 3 patients with Ehlers-Danlos syndrome (EDS).

OBJECTIVE

The aim of the article is to describe complications of anterior spine surgery in 3 patients with EDS.

SUMMARY OF BACKGROUND DATA

Scoliosis can be a skeletal manifestation of EDS. Anterior approaches to the spine are sometimes used during scoliosis surgery to gain more correction than otherwise possible. A literature search revealed no published articles focusing on major vascular bleeding during anterior spine surgery in EDS patients as the specific topic.

METHODS

Review of records and radiographs.

RESULTS

Three patients with EDS and severe scoliosis underwent an anterior and posterior release followed by posterior fusion. Major bleeding was encountered during anterior surgery in all 3 patients. Sources of bleeding included a torn external iliac artery, avulsed segmental arteries, and the abdominal aorta. Blood loss ranged from 600 mL to 6 L. All vessels were repaired with sutures and synthetic grafts. In all 3 patients, posterior fusion was met with no complications and their curves were stable at follow-up.

CONCLUSION

These complications may be explained by the fragility of blood vessels secondary to the collagen defect in EDS. Though methods exist to decrease these complications, they may not be enough to prevent catastrophic bleeding. For EDS patients, risk of vascular complications during anterior surgery of the spine is high and surgeons should be aware of this when developing a surgical plan.

Coeliac axis thrombosis after surgical correction of spinal deformity in type VI Ehlers-Danlos syndrome: a case report and review of the literature

STUDY DESIGN

An unusual case of postoperative thrombosis of celiac artery in a patient of Type VI Ehlers-Danlos syndrome (EDS) with severe kyphotic deformity is reported.

OBJECTIVE

To describe an unusual complication of celiac artery thrombosis following surgical correction of kyphotic deformity in Type VI EDS.

SUMMARY OF BACKGROUND DATA

Neurologic deficit following surgical correction for kyphoscoliotic deformities in patients with Type VI has been reported in 4 cases previously. There has been no previous report of combined celiac artery thrombosis leading to infarction of major abdominal organs along with quadriparesis below C7-C8.

METHODS

Case report and literature review.

RESULTS

Subsequent to a 2-stage surgical correction with posterior instrumentation and fusion of spine, this patient with Type VI EDS developed celiac artery thrombosis leading to infarction of major abdominal organs. At laparotomy, he required hemihepatectomy, splenectomy, cholecystectomy, and a repair of gastric perforation. Following his abdominal catastrophe, he developed quadriparesis possibly due to anterior spinal artery ischemia.

CONCLUSION

Spine surgeons treating Type VI EDS with progressive kyphoscoliosis should be aware of such an unusual complication of celiac artery occlusion in late postoperative period. Preoperative antithrombotic medication should be monitored carefully to avoid such catastrophic complication. The prognosis remains poor following anterior spinal artery ischemia due to infarction or thrombosis.

Sibs affected with both Ehlers-Danlos syndrome type IV and cystic fibrosis

We report on the unprecedented combination of two recessively inherited disorders, the kyphoscoliosis type of Ehlers-Danlos syndrome (EDS type VI) and cystic fibrosis (CF), in two sibs born to consanguineous Turkish parents. Because of failure to thrive and bronchitis CF was diagnosed in the index patient early whereas EDS VI was recognized only very late. Both patients had marked muscular hypotonia at birth, delayed gross motor development, progressive kyphoscoliosis, joint dislocations, Marfanoid habitus, hypertrophic and atrophic scars, and osteopenia. EDS VI was proven by collagen studies and the pathognomonic pattern of urinary pyridinolines. Because the genes coding for the two disorders are located on different chromosomes and a chromosomal rearrangement was excluded, we conclude that their combination is a chance association. The cardiopulmonary impairment common to both diseases makes the prognosis dismal.