The cervical spine in Marfan syndrome

Cervical kyphosis correction in Marfan syndrome: our experience and literature review

BACKGROUND

Spinal deformities are common in Marfan syndrome (MFS). They usually involve the thoraco-lumbar spine but rarely involves the cervical spine. Kyphosis is the common spine deformity of the cervical spine and mandates surgical correction as they are at risk of neurological deterioration since they are refractory to conservative management. Few studies of surgical correction of spine deformity included cervical deformity.

OBJECTIVES

To analyze the challenges faced during surgery, clinical and radiological outcome, and complications following surgical correction for cervical kyphosis in Marfan syndrome.

METHODS

We identified that 5 patients with a diagnosis of MFS with cervical kyphosis who underwent fusion surgery between the years 2010 and 2022 were reviewed, retrospectively. We analyzed the demographic details, radiological parameters, operative variables (blood loss and nuances), perioperative complications, length of stay, clinical and radiological outcome, and complications following fusion surgery for cervical kyphosis in MFS.

RESULTS

The mean age of patients was 16.6 ± 4.72 years (range, 12-23 years). The average kyphotic vertebra involved is 3 ± 0.7 bodies (range 2-4) with 2 patients with thoracic deformity. All patients underwent surgical deformity correction. All patients improved clinically with Nurick grade (pre vs. post: 3.4 vs. 2.2) and mJOA (pre vs. post: 8.2 vs. 12.6). There was significant deformity correction from 37.48° to 9.1°. Mean blood loss encountered was 900 ± 173.2 ml. Perioperative complications: wound complication with CSF leak (1). Late complications: ventilator dependence (1) and junctional kyphosis (1). Mean length of hospital stay was 103 ± 178.9 days. All patients were doing symptomatically better after mean follow-up of 58 ± 28.32 months. One patient is bedridden and hospitalized.

CONCLUSION

Cervical kyphosis is a rare spine deformity in patients with MFS, and they usually present with neurological deterioration mandating surgical correction. Multidisciplinary approach (pediatrics, genetics and cardiology) is required for systematic evaluation of these patients. They should be evaluated with necessary imaging to rule out associated spinal deformity (atlanto-axial subluxation, scoliosis, and intraspinal pathology like ductal ectasia). Our results suggest better surgical outcome in terms of low operative complications with neurologic improvement in MFS patients. These patients require regular follow-up to identify late complications (instrument failure, non-union, and pseudarthrosis).

Back pain in adolescent athletes: a narrative review

Background

Back pain in young athletes is common. Adolescents are at an increased risk for back pain related to several factors including rapid growth. Traditionally, the conversation around back pain in the adolescent age group has been centered around diagnosis and treatment; however, there are emerging studies regarding prevention.

Objective

The purpose of the present investigation is to summarize sport-specific risk factors, to describe the growing emphasis on prevention/screening, and report results on minimally invasive and surgical options.

Methods

The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. The full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by at least 3 authors until an agreement was reached.

Results

Adolescent athletes have a higher risk of developing spondylolysis and spondylolisthesis than their non-athletic counterparts. Participation in athletic activity alone, increased body mass index, varsity status, and nationally/internationally competitive status are identified are demographic risk factors. Weightlifters, gymnasts, football players, and combat athletes may be at higher risks. Increased lumbar lordosis, abdominal muscle weakness, hip flexor tightness, hamstring tightness, thoracolumbar fascia tightness, femoral anteversion, genu recurvatum, and thoracic kyphosis also predispose. Recent cadaveric and kinematic studies have furthered our understanding of pathoanatomic. There is some evidence to suggest that isokinetic testing and electromyographic data may be able to identify at-risk individuals. Perturbation-based exercise interventions can reduce the incidence of adolescent athletic back pain. There is a large body of evidence to support the efficacy of physical therapy. There is some data to support minimally invasive treatments including external bone growth simulators, steroid injections, and chemonucleolysis for specific pathologies. Endoscopic surgery results for a limited subset of patients with certain disease processes are good.

Conclusions

Back pain in adolescent athletes is common and may not lead to appropriate alterations in athletes' level of participation. Athletes with a higher body mass index should be counseled regarding the benefits of losing weight. Isokinetic testing and electromyographic data have the potential as diagnostic and screening tools. Strength deficits and postural control could be used to identify patients requiring early intervention and thus reduce the incidence. External bone growth simulators, steroid injections, and chemonucleolysis could potentially become conservative options in the future. When surgery is indicated, the endoscopic intervention has the potential to decrease operative time, decrease cost, and promote healing.

Is gender a factor affecting long-term heterotopic ossification incidence after single-level cervical disc arthroplasty?

BACKGROUND

Cervical disc diseases have been treated by means of cervical disc arthroplasty (CDA). Nevertheless, some patients will experience a mobility failure in their cervical prostheses over time because of heterotopic ossification (HO). Aim of this study is to investigate the role of gender in long-term outcomes after CDA.

MATERIALS AND METHODS

A retrospective, single-center study including patients who underwent single-level CDA with a Bryan prosthesis was performed, including a narrative review about gender differences in both structural and biomechanical features of the cervical spine.

RESULTS

Study patients (14M, 30F) had an average follow-up period of 9,8 ± 3,2 years. Significant differences emerged between genders for specific items in Neck Disability Index (NDI) preoperative evaluation, with females reporting worse pain scores (p=0.05). After stratification by age we report a higher preoperative overall NDI score for female patients under 36 years of age (p=0.03). In an intergender, BMI-specific comparison we also found a significant difference in NDI preoperative score with normal-weight male patients faring worse than overweight ones (p= 0.05). At a radiological level, we found a tendency towards a higher HO incidence in male patients (62% males, 17% females, p=0.06). Women's cervical spine has peculiar features including bone structure, muscular action, soft-tissue response, genetic and epigenetic response to osteoarthritis.

CONCLUSION

The incidence of mobility failure in our series of single-level CDA was lower in females. Several gender specific factors both in static and dynamic features may play a significant role in spinal pathology and CDA long-term radiological outcome.

Atlantooccipital Assimilation and Basilar Invagination Treated Successfully in a Young Male With Marfanoid Features: A Stitch in Time

Marfan syndrome is a spectrum of disorders caused by a genetic defect involving connective tissue and is heritable by the autosomal dominant mode of inheritance. Atlantooccipital assimilation is a partial or complete fusion of the atlas and the occiput base congenitally. Although primarily asymptomatic, some patients with atlantooccipital assimilation may present with neurological issues, including myelopathy. Here, we are discussing a case of an 18-year-old male who presented with bilateral paraesthesia, tingling and neck pain which, upon investigations, turned out to be a case of atlantooccipital assimilation along with basilar invagination with spinal cord compression. The patient also had marfanoid features like tall stature, reduced upper to lower segment ratio, and increased arm span to height with positive wrist and thumb signs. As myelopathy had already developed, the patient was treated surgically rather than with medical management with a favorable outcome.

The Musculoskeletal Manifestations of Marfan Syndrome: Diagnosis, Impact, and Management

Purpose of Review

Marfan syndrome (MFS) is an autosomal dominant heritable disorder of fibrillin-1 (FBN1) with predominantly ocular, cardiovascular, and musculoskeletal manifestations that has a population prevalence of approximately 1 in 5–10,000 (Chiu et al. Mayo Clin Proc. 89(1):34–42, 146, Dietz 3, Loeys et al. J Med Genet. 47(7):476–85, 4).

Recent Findings

The vascular complications of MFS still pose the greatest threat, but effective management options, such as regular cardiac monitoring and elective surgical intervention, have reduced the risk of life-threatening cardiovascular events, such as aortic dissection. Although cardiovascular morbidity and mortality remains high, these improvements in cardiovascular management have extended the life expectancy of those with MFS by perhaps 30–50 years from an estimated mean of 32 years in 1972 (Dietz 3, Gott et al. Eur J Cardio-thoracic Surg. 10(3):149–58, 147, Murdoch et al. N Engl J Med. 286(15):804–8, 148). The musculoskeletal manifestations of MFS, which to date have received less attention, can also have a significant impact on the quality of life and are likely to become more important as the age of the Marfan syndrome population increases (Hasan et al. Int J Clin Pract. 61(8):1308–1320, 127). In addition, musculoskeletal manifestations are often critically important in the diagnosis of MFS.

Summary

Here, we review the main clinically relevant and diagnostically useful musculoskeletal features of MFS, which together contribute to the “systemic features score” (referred to hereafter as systemic score), part of the revised Ghent nosology for MFS. We discuss current treatment strategies and highlight the need for a multidisciplinary approach to diagnosis and management. Finally, we review new pharmacological approaches that may be disease modifying and could help to improve the outcome for individuals with this syndrome.

Surgical Evaluation and Management of Spinal Pathology in Patients with Connective Tissue Disorders

Connective tissue disorders represent a varied spectrum of syndromes that have important implications for the spine deformity surgeon. Spine surgeons must be aware of these diverse and global manifestations of disease because they have significant impact on perioperative and postoperative outcomes.

Interdisziplinäre Betreuung von Menschen mit Marfan-Syndrom – Pharmakologie, Schwangerschaft, Auge, Skelett und organisatorische Aspekte

Im ersten Teil des vorliegenden Beitrags wurde im Detail auf die Genetik, Diagnose, Differenzialdiagnose, die diagnostische Bildgebung, Follow-up, die kardiovaskulären Probleme sowie die Manifestation an Aorta und den großen Gefäßen bei Patienten mit dem Marfan-Syndrom (MFS) eingegangen. In diesem zweiten Teil werden die medikamentöse Therapie des MFS, seine Bedeutung im Zusammenhang mit einer Schwangerschaft, die Beteiligung von Augen und Wirbelsäule bei MFS-Patienten sowie die organisatorischen Aspekte einer Marfan-Sprechstunde erläutert. Das MFS ist mit einer Prävalenz von etwa 1–2:10.000 die häufigste hereditäre Bindegewebserkrankung mit vaskulärer Komponente. Ursache sind Mutationen im Gen, das für das extrazelluläre Matrixprotein Fibrillin‑1 kodiert. Die Erkrankung wird autosomal-dominant vererbt. Es handelt sich um eine Multisystemerkrankung mit Beteiligung der Aorta, der Mitralklappe, Augen- und Skelettveränderungen. Die Augen- und/oder die Wirbelsäulenbeteiligung sind nicht zu unterschätzen, da sowohl die Skoliose als auch die Linsendislokation etwa 60 % der Patienten mit MFS betreffen. Bis anhin konnte kein Wirkstoff einen klaren Vorteil hinsichtlich klinischer Ereignisse in MFS-Patienten zeigen. Es besteht jedoch der allgemeine Konsens, Patienten mit MFS einen β‑Rezeptoren- oder Angiotensinrezeptorblocker isoliert oder als Kombinationstherapie zu verabreichen. Bei bestehendem Kinderwunsch muss ein besonderes Augenmerk auf die Planung der Schwangerschaft gelegt werden. Im Fall eines Aortenwurzeldurchmessers > 4–4,5 cm empfiehlt sich, entweder einen prophylaktischen Aortenwurzelersatz zu erwägen oder von einer Schwangerschaft abzuraten. Eine strukturierte Langzeitbetreuung ist für Patienten mit MFS essenziell.

Perioperative management and considerations in pediatric patients with connective tissue disorders undergoing cardiac surgery

BACKGROUND

Marfan syndrome and Loeys-Dietz syndrome are connective tissue disorders associated with cardiac and vascular disease. Patients often require surgical repair, but limited data exist to describe their perioperative management.

AIMS

Our goals were to review the perioperative features of patients with Marfan and Loeys-Dietz syndrome that may affect anesthesia care and to describe the differences in preoperative clinical characteristics and intra-operative anesthetic management.

METHODS

We conducted a retrospective cohort study of patients with Marfan and Loeys-Dietz syndrome who underwent cardiac surgery at a single institution. We collected demographic and perioperative data from the electronic medical record and performed descriptive statistics to characterize the patient populations and describe their anesthetic management.

RESULTS

In 71 patients (40 Marfan, 31 Loeys-Dietz), we found significant differences between the Marfan and Loeys-Dietz patients in airway difficulty, preoperative weight, blood utilization, valvular disease, and age at first cardiac surgery. Patients with Loeys-Dietz syndrome had higher preoperative rates of severe noncardiac comorbidities, including gastroesophageal reflux and asthma that required chronic medical therapy.

CONCLUSIONS

Despite undergoing similar surgical procedures, patients with Marfan and Loeys-Dietz syndrome have different intrinsic patient characteristics and comorbidities that may affect their perioperative care. This retrospective cohort study identified some factors, but additional collection and reporting of patient data based on multicenter experience are essential for the ongoing optimization of perioperative care in these patient populations.

Weak Ligaments and Sloping Joints: A New Hypothesis for Development of Congenital Atlantoaxial Dislocation and Basilar Invagination

OBJECTIVE

Developmental bony craniovertebral junction (CVJ) anomalies seem to have a genetic basis and also abnormal joint morphology causing atlantoaxial dislocation (AAD) and basilar invagination (BI).

METHODS

DNA extracted polymerase chain reaction single-stranded conformation polymorphism (SSCP) performed for mutation screening of FBN1 gene (n = 50 cases+ 50 age/sex-matched normal; total: 100). Samples with a deviated pattern of bands in SSCP were sequenced to detect the type of variation. Computed tomography (CT) scans of 100 patients (15-45 years old) compared with an equal number of age/sex-matched controls (21.9 ± 8.2 years). Joint parameters studied: sagittal joint inclination (SI), craniocervical tilt (CCT), coronal joint inclination (CI).

RESULTS

Thirty-nine samples (78%) showed sequence variants. Exon 25, 26, 27, and 28 showed variable patterns of DNA bands in SSCP, which on sequencing gives various types of DNA sequence variations in intronic region of the FBN1 gene in 14%, 14%, 6%, and 44% respectively. CT radiology:SI and CCT correlated with both BI and AAD (p < 0.01). The mean SI value in controls: 83.35° ± 8.65°, and in patients with BI and AAD:129° ± 24.05°. Mean CCT in controls: 60.2° ± 9.2°, and in patients with BI and AAD: 86.0° ± 18.1°. Mean CI in controls:110.3° ± 4.23°, and in cases: 125.15° ± 16.4°.

CONCLUSION

The study showed mutations in FBN1 gene (reported in Marfan syndrome). There is also an alteration of joint morphology, correlating with AAD and BI severity. Hence, we propose a double-hit hypothesis: the presence of weak ligaments (due to FB1 gene alterations) and abnormal joint morphology may contribute to AAD and BI.

Trends in spinal deformity surgery in Marfan syndrome

STUDY DESIGN

Analysis of a national database.

OBJECTIVE

To analyze trends in fusion surgery for spinal deformity in Marfan syndrome (MFS) patients, compare patients with and without Marfan, and evaluate differences in surgical approaches.

SUMMARY OF BACKGROUND DATA

National trends of fusion surgery for spinal deformities in MFS patients are not known. Given the rarity of MFS and the nuanced differences in the spinal deformity it causes, it is important to explore differences in fusion surgery between spinal deformity patients with and without MFS.

METHODS

We identified 314 patients (1,410 weighted) with a diagnosis of MFS and spinal deformity who underwent spinal fusion between the years 2003 and 2014. Our primary outcome was national trends in the use of posterior (PSF), anterior-posterior (APSF), and anterior (ASF) spinal fusions. We also compared perioperative complications, mortality rate, length of stay, and hospital charges in a propensity score matched sample of spinal fusion patients with and without a diagnosis of MFS.

RESULTS

The proportion of PSF surgeries increased significantly (p<.01) from 66.7% in 2003 to 92.0% in 2014. MFS patients were more likely to have higher neurologic (2.4% vs. 0.79%, p=.01) complications. There was a significant association between age and approach (p<.01). PSF had a mean age of 20.2, whereas APSF and ASF had mean ages of 27.1 and 35.2, respectively. Approximately 62% of cervical fusions used ASF.

CONCLUSIONS

Our study provides findings from the largest sample analyzed to date and is the only thus far that investigates national trends. Our results are largely consistent with those of other works in that MFS patients undergoing spinal fusion surgery have higher neurologic complications. We also report that surgical treatment has shifted toward a posterior approach. Our findings can give surgeons a better understanding of the postoperative complications and changing national trends in spinal fusion surgery for patients with MFS.

Non-cardiac manifestations of Marfan syndrome

Because of the widespread distribution of fibrillin 1 in the body, Marfan syndrome (MFS) affects virtually every system. The expression of this single dominantly inherited gene is variable within a family, and between families. There is some genotype-phenotype correlation which is helpful in guiding long-term prognosis, and management. In general gene mutations have been reported in clusters, with those having mainly ocular manifestations occurring in exons 1 to 15 of this 65-exon gene; those causing cardiac problems often involving cysteine replacement in a calcium binding EGF-like sequence; the most severe mutations occurring in exons 25-32, causing neonatal MFS diagnosed at birth, and severe enough to cause death frequently before the age of 2. Other correlations will certainly be found in future. This condition is progressive, and the manifestations unfold according to age. For example, if the lens is going to dislocate this usually occurs by age 10; scoliosis usually presents itself between the ages of 8 and 15; height should be monitored carefully between the onset of puberty and cessation of growth approximately age 17 or 18. Holistic care should be offered by one doctor who oversees the patient's welfare. This should be a paediatrician, paediatric cardiologist, or general practitioner in the case of an affected child. Thereafter, the physician in charge of the most seriously affected system should be aware that other systems need to be managed through a referral network.

Complications of Anterior and Posterior Cervical Spine Surgery

Cervical spine surgery performed for the correct indications yields good results. However, surgeons need to be mindful of the many possible pitfalls. Complications may occur starting from the anaesthestic procedure and patient positioning to dura exposure and instrumentation. This review examines specific complications related to anterior and posterior cervical spine surgery, discusses their causes and considers methods to prevent or treat them. In general, avoiding complications is best achieved with meticulous preoperative analysis of the pathology, good patient selection for a specific procedure and careful execution of the surgery. Cervical spine surgery is usually effective in treating most pathologies and only a reasonable complication rate exists.

High prevalence of cervical deformity and instability requires surveillance in Loeys-Dietz syndrome

BACKGROUND

Loeys-Dietz syndrome is a connective tissue disorder characterized by vascular, craniofacial, and musculoskeletal malformation. Our goal was to report the manifestations, surgical treatment, and complications in the cervical spine in patients with Loeys-Dietz syndrome.

METHODS

We reviewed the clinical and cervical spine imaging data of eighty patients with Loeys-Dietz syndrome who were seen at our institution from January 2005 through January 2014. Their mean age at presentation was 17.3 years (range, three months to seventy-five years). We tested associations with use of the Fisher exact test (type of TGF-βR [transforming growth factor-beta receptor] mutation and cervical abnormalities) and the Student t test (age at presentation and type of TGF-βR mutation) (significance, p = 0.05).

RESULTS

Vertebral anomalies and cervical instability were common; we found no significant association of TGF-βR-type with cervical abnormalities or age at presentation. Twenty-eight patients had atlas defects (anterior and/or posterior arch defects or hypoplasia), fifty-three had axis malformations (elongation, apex-anterior dens angulation, or spondylolysis), and twelve had focal kyphosis. Ten patients had hypoplastic subaxial vertebrae, leading to focal kyphosis (eight) and subaxial instability (nine). Eight patients had atlantoaxial instability. Of the thirteen patients with cervical instability, nine were treated surgically: fusion (eight patients) and halo application (one) (mean age, four years; range, three months to twelve years). Postoperative complications (seven patients) were pseudarthrosis, failure of fixation, junctional kyphosis or instability, and development of occipital-cervical instability.

CONCLUSIONS

Cervical midline defects (most often C1-C3) are common in Loeys-Dietz syndrome. Patients have a high prevalence of cervical instability, particularly a pattern of instability at C2-C3 associated with C3 vertebral body hypoplasia and C2-C3 focal kyphosis. Patients requiring surgery typically present in early childhood.

Association between joint hypermobility, scoliosis, and cranial base anomalies in paediatric Osteogenesis imperfecta patients: a retrospective cross-sectional study

BACKGROUND

Joint hypermobility is a common clinical characteristic of patients with Osteogenesis imperfecta (OI), a disorder with serious comorbidities of scoliosis and cranial base anomalies. This study aimed at evaluating how prevalent joint hypermobility is in paediatric OI patients, and to find out whether it serves as a potential predictive marker of the different spinal complications; scoliosis and craniovertebral anomalies (basilar impression and basilar invagination).

METHODS

In this cross-sectional one-center study we analysed retrospectively clinical patient records and radiographs of 47 OI patients, aged 1-19 years, some of whom were treated with bisphosphonates. Presence of joint hypermobility, scoliosis, and craniovertebral anomalies was recorded and possible connections between the phenomena were explored with correlation analysis.

RESULTS

Joint hypermobility was found in 70% of the patients. Scoliosis and cranial base anomalies had developed in 26%. The presence of spinal complications was independent of the bisphosphonate treatment status and joint hypermobility.

CONCLUSIONS

Scoliosis and craniovertebral anomalies are strongly associated in paediatric OI patients. Joint hypermobility that is much more common appears, however, to be a poor predictor.

Marfan syndrome

Marfan syndrome is a variable autosomal dominant disorder; most cases result from mutations of fibrillin-1. Diagnosis is guided by the Ghent nosology. The condition may manifest in the cardiovascular and ocular systems. Musculoskeletal manifestations include scoliosis, dural ectasia, protrusio acetabuli, and ligamentous laxity. Compared with patients with idiopathic scoliosis, patients with Marfan syndrome tend to have scoliosis that progresses at a faster rate and is more resistant to bracing; undergo scoliosis surgery complicated by greater blood loss, pseudarthrosis, and additional curvature; and have more frequent occurrences of dural ectasia, which may cause headaches, leg pain, or perineal pain. Protrusio acetabuli may result in hip joint arthritis and may require valgus osteotomy or total hip arthroplasty.

Severe cervical kyphosis complicating halo traction in a patient with Marfan syndrome

STUDY DESIGN

A case report of complications from using halo traction in a patient with Marfan Syndrome (MFS).

OBJECTIVE

The aim of the article is to describe a complication of halo traction in a patient with MFS.

SUMMARY OF BACKGROUND DATA

Scoliosis is a common presentation in MFS and may require surgery. Halo traction is a well-recognized adjunct for correcting severe, complex, rigid scoliotic curves. No articles have been published describing complications from the use of halo traction in patients with MFS.

METHODS

Review of records and radiographs.

RESULTS

A patient with MFS and severe scoliosis of 145 degrees underwent an anterior and posterior release with halo-gravity traction for 2 weeks duration, followed by a posterior fusion. Her postoperative major scoliosis curve correction was stable at 26 degrees. The patient developed cervical kyphosis and neck stiffness after the traction. Ultimately, 23 months later with 66 degrees of angulation, the increasing kyphosis warranted anterior and posterior fusion. Seven months after cervical surgery, her cervical kyphosis stabilized at 22 degrees.

CONCLUSION

This complication may be explained by the laxity of the connective tissue in MFS. Also, halo traction creates more tension in the cervical spine than the thoracolumbar spine. For patients with MFS and perhaps other connective tissue disorders, halo-gravity traction should be used with caution, especially when some pre-existing cervical kyphosis is present.

Spinal deformities in Marfan syndrome

Marfan syndrome is a connective tissue disease that affects the skeletal system among other organ systems. Kyphoscoliosis, spondylolisthesis, and atlantoaxial subluxation are common spinal deformities in Marfan syndrome, and distinctive vertebral morphology within such patients presents significant treatment challenges. Although most scoliosis curves in patients who have Marfan syndrome are minor, those that require treatment progress rapidly; brace treatment has proven ineffective for most patients. Surgical correction is associated with complications, such as failure of fixation and additional deformity; however good results are possible when consideration is given to the unique challenges presented by patients who have Marfan syndrome.

Ageing in Marfan syndrome

AIMS

Marfan syndrome (MFS) is a dominantly inherited connective tissue disorder caused by mutations in the fibrillin-1 gene. Past research has focused on younger patients as lifespan was known to be significantly reduced. This study aims to describe the complications, including those affecting the eyes, heart and musculoskeletal system, faced by older survivors.

METHODS

All 2500 patient records from the National Marfan Syndrome Clinical Database were searched for suitable participants aged 50 or older. One hundred and fifty-six questionnaires were posted to patients with MFS. These patients were sent a detailed questionnaire regarding medical aspects of their disease. Those included in the study were sent questionnaires for spouses and friends (not blood relatives) to complete, to provide control data. Other age- and sex-matched controls were recruited locally.

RESULTS

Sixty questionnaires from patients with MFS (35%) were returned and eligible for inclusion in the study, comprising 28 female patients and 32 male patients with a median age of 57. We recruited 56 eligible controls. Our results revealed that patients over 50 years of age with MFS may be at a higher risk than previously assumed for retinal detachment (reported by 24% of our respondents) and cardiovascular abnormalities (42% have had past aortic surgery; 53% report palpitation). Lesser known complications were also reported, including cataract (reported by 27%).

CONCLUSIONS

Medical practitioners should be aware of the range of complications that can occur in patients with MFS in addition to the normal ageing process. Health problems in MFS patients over 50 may require investigation and specific therapy earlier than in the normal ageing population, because of the degenerative nature of this genetic condition.

Atlanto-axial rotatory fixation in a girl with Spondylocarpotarsal synostosis syndrome

We report a 15-year-old girl who presented with spinal malsegmentation, associated with other skeletal anomalies. The spinal malsegmentation was subsequently discovered to be part of the spondylocarpotarsal synostosis syndrome. In addition, a distinctive craniocervical malformation was identified, which included atlanto-axial rotatory fixation. The clinical and the radiographic findings are described, and we emphasise the importance of computerised tomography to characterize the craniocervical malformation complex. To the best of our knowledge, this is the first clinical report of a child with spondylocarpotarsal synostosis associated with atlanto-axial rotatory fixation.

Marfan syndrome: what internists and pediatric or adult cardiologists need to know

Marfan syndrome (MFS) is one of the most frequent connective tissue disorders, showing striking pleiotropism and clinical variability. There is autosomal dominant inheritance with complete penetrance but variable expression. Approximately 25% of MFS patients have no family history of the syndrome and represent sporadic cases due to new mutations. This hazardous condition is often associated with premature cardiovascular death unless surveillance and management are optimized. The fibrillin gene (FBN1) encodes the structure of the connective tissue protein fibrillin. MFS is caused by mutations in the fibrillin gene, located on chromosome 15 at locus 15q21. Fibrillin abnormalities reduce the structural integrity of different body systems, primarily involving the heart valves, blood vessels, lungs, bones, tendons, ligaments, cartilages, eyes, skin, spinal dura and the CNS. Patients with MFS are likely to have too little fibrillin within these structures, resulting in clinically relevant problems. For example, in the aortic wall, deficient fibrillin may trigger progressive aortic ectasia and may result in aortic dissection.

Nontraumatic upper cervical spine instability in children

The upper cervical spine begins at the base of the occiput, continues caudally to the C2-C3 disk space, and includes the occipitoatlantal and atlantoaxial joints. Nontraumatic upper cervical spine instability can result from abnormal development of osseous or ligamentous structures or from gradually increasing ligamentous laxity associated with connective tissue disorders. Such instability can lead to compression of the spinal cord during movement of the cervical spine. Establishing a correct diagnosis includes performing a thorough physical examination as well as evaluating radiographic relationships and measurements. Appropriate management of syndromes associated with instability of the upper cervical spine includes preventive care and recommendations for sports participation. Surgical treatment for the upper cervical spine includes a posterior surgical approach, used for instability, and the use of rigid plate implants, wiring, and bone graft materials to achieve a solid spinal fusion.

Surgical treatment for scoliosis in Marfan syndrome

STUDY DESIGN

Review of results of patients with Marfan syndrome treated with instrumented posterior fusion alone for scoliosis.

OBJECTIVE

To analyze the results of surgical treatment for scoliosis in Marfan syndrome.

SUMMARY OF BACKGROUND DATA

Few studies have been reported in the literature on surgical treatment for scoliosis in Marfan syndrome, analyzing long-term results of posterior instrumented fusion.

METHODS

Twenty-three patients with Marfan syndrome with a mean age of 17 years (range, 11-31 years) were treated surgically from 1982 to 1995 for scoliosis, using a posterior instrumented fusion alone (Harrington rod with sublaminar wires in the first 16 cases, and a more recent hybrid instrumentation in the remaining 7 cases). All of the patients received a long posterior instrumented fusion, including 12.3 levels on average (range, 9-17), extending the fusion area to vertebrae that were neutral and stable in both coronal and sagittal planes before surgery. Patients were analyzed as two different groups (Group 1 and Group 2) according to the different posterior instrumentations employed: Group 1 included 16 patients treated by the Harrington distraction rod technique with sublaminar wires, while Group 2 included 7 patients treated using more recent hybrid instrumentations. Presentation features, complications, and results were analyzed.

RESULTS

At a minimum follow-up of 7 years (maximum, 18 years), all 23 patients were reviewed. The mean age was 26.8 years (range, 20-38 years). The average preoperative scoliosis value of 69.91 degrees was initially corrected to 38.17 degrees, averaged 40.89 degrees 1 year after surgery, and was finally equal to 44.09 degrees at the last follow-up. Differences in terms of scoliosis correction achieved with different instrumentations (Groups 1 and 2) did not reach statistical significance. In Group 2 patients, the percentage of postoperative correction was slightly lower (44.23%) than that of Group 1 (46.55%) but remained more stable at the last follow-up (40.97% vs. 36.38% of Group 1). There were 11 complications in 10 of the 23 patients (43.4%); two complications occurred in 1 patient. Intraoperatively, dural tears occurred in 2 cases (8.6%). Pseudarthrosis with instrumentation failure in 2 cases (8.6%) required revision surgery. Five (21.7%) distal hook dislodgements with moderate loss of scoliosis correction, 1 (4.3%) mild loss of correction without instrumentation failure, and 1 asymptomatic cervicothoracic junctional kyphosis. did not require surgery. All complications occurred among the 16 Group 1 patients, treated using the Harrington rod instrumentation with sublaminar wires.

CONCLUSIONS

These results seemed to demonstrate that a satisfactory stabilization of scoliosis can be achieved by posterior instrumentation alone in patients with Marfan syndrome. Instrumented posterior fusion should be extended to include vertebrae that are neutral and stable in both coronal and sagittal planes before surgery, in order to ensure stabilization of the deformity and reduce the risks of decompensation of the spine.

Acute atlanto-axial post-operative subluxation following posterior C1/2 fusion

Two cases referred with acute post-operative C1/2 subluxation following posterior fusion are reported. Both cases had initial treatment for atlanto-axial instability with posterior cable (Brooks and interspinous) and graft techniques, and placed immediately in a Philadelphia collar. One case was found to have subluxed immediately post-operatively when failing to breathe following reversal of anaesthetic agents, and despite immediate realignment and reoperation was left with a significant quadriparesis. The other patient was noted to have subluxed on routine X-ray on day 4, and had no neurological deficit before or after reoperation. Risk factors for this dangerous complication are discussed and the techniques of C1/2 posterior fusion and stabilization are reviewed in detail. Surgeons performing atlanto-axial stabilization procedures should be familiar with and have expertize in the complete range of techniques described and choose the one most appropriate for the patient's individual requirements.

Sudden Death Due to Atlantoaxial Subluxation in Marfan Syndrome

Marfan syndrome is 1 of the commonest inherited connective tissue disorders. Sudden death may occur and is usually attributed to cardiovascular manifestations of the syndrome. Atlantoaxial hypermobility, increased odontoid height, and rotatory subluxation are well described in this syndrome, but this paper details what seems to be the first reported case of sudden and unexpected death due to spontaneous atlantoaxial subluxation in Marfan syndrome.

Marfan syndrome: orthopedic and genetic review

Marfan syndrome is an autosomal dominant disorder of connective tissue that affects the cardiac, eye, and skeletal systems. More than 135 mutations have been identified in the fibrillin-1 gene, localized on chromosome 15q21.1 [corrected] and responsible for the clinical manifestations of Marfan syndrome. The major orthopedic manifestations of Marfan syndrome include scoliosis, chest wall deformity, dural ectasia, joint hypermobility, and acetabular protrusion. In addition, decreased bone mineral density has been reported in patients with Marfan syndrome. This review summarizes recent developments in the genetic and orthopedic aspects of Marfan syndrome. Increased practitioner awareness of the clinical features associated with Marfan syndrome may facilitate earlier diagnosis and optimize patient treatment.

Evaluation for sleep apnea in patients with Ehlers-Danlos syndrome and Marfan: a questionnaire study

Sleep complaints are frequently reported by patients with Marfan and Ehlers-Danlos syndrome (EDS). We examined the exact nature of sleep complaints in these patients. A representative sample of Marfan and EDS patients responded to a general sleep questionnaire, including the Epworth Sleepiness Scale (ESS) and the Medical Outcomes Study Short-Form 36 (SF-36) health-related quality of life (QOL) questionnaire. Fifteen Marfan patients and 9 EDS patients were evaluated and compared to 24 healthy controls, matched for age, sex and body mass index. Maintaining sleep was frequently disturbed in Marfan (40%, p < 0.04) as well as in EDS patients (56%, p < 0.01). Sleep apnea was exclusively reported by Marfan patients (27%, p = 0.03). Periodic limb movements were much more reported in EDS (67%, p = 0.02) than in Marfan (27%, p = 0.25) compared to controls (8%). Pain and back complaints were highly presented in both groups, but most pronounced in EDS patients (47% in Marfan versus 77% in EDS). No differences for the scores in the ESS were found. For all SF-36 questionnaire items, scores were much lower in patient groups, except for emotional problems. We found that sleep complaints were not rare in Marfan and EDS patients and correlated well with different QOL items. Our study calls for greater attention to the presence of apnea, pain and periodic limb movements in these patients.

The lumbar interpediculate distance is widened in adults with the Marfan syndrome: data from 32 cases

32 patients with Marfan syndrome, diagnosed with DePaepe's criteria, volunteered for this study. All patients underwent standard anteroposterior radiographs of the lumbar spine. Interpediculate distances (IPD) at each level were compared to those of previously established norms. Criteria were developed to determine the presence of Marfan using "cut-off values" for the IPDs at each lumbar level. The IPDs were significantly larger in the Marfan patients at all lumbar levels. Cut-off values were calculated setting the specificity at 95% at each lumbar level. The cut-off value at L4 yielded the greatest sensitivity. We conclude that the IPDs are widened in patients with Marfan syndrome. The IPD at L4 is a good criterion for Marfan with specificity of 95% and sensitivity of 75%. One must consider using this as a skeletal criterion or a screening tool for Marfan.

Subluxation of a lumbar vertebra in a patient with Marfan syndrome. Case report

Marfan syndrome is a hereditary disorder of the connective tissue that, in its most classic form, includes cardiovascular, ocular, and skeletal features. The neurological problems associated with the disease are mainly caused by intracranial vascular abnormalities and spinal meningeal defects, but other neurological manifestations are rarely present. Scoliosis, a skeletal manifestation of the syndrome, occurs frequently, but its onset, natural history, and radiological characteristics differ from those of the idiopathic form. Scoliosis in a patient with Marfan syndrome seldom accompanies other spinal deformities. In this article the authors describe the case of a patient with Marfan syndrome and scoliosis in whom lumbar subluxation occurred. This rare deformity, diagnosed on three-dimensional computerized tomography scanning, has not been reported previously in association with Marfan syndrome. Its development can be explained in terms of the theory of progressive rotatory dislocation. The morphological characteristics, clinical features, and surgical treatment of the deformity are presented.

Clinical considerations in the chiropractic management of the patient with Marfan syndrome

OBJECTIVE

To describe the chiropractic management of a patient with whiplash-associated disorder and a covert, concomitant dissecting aneurysm of the thoracic aorta caused by Marfan syndrome or a related variant.

CLINICAL FEATURES

A 25-year-old man was referred by his family physician for chiropractic assessment and treatment of neck injuries received in a motor vehicle accident. After history, physical examination, and plain film radiographic investigation, a diagnosis of whiplash-associated disorder grade I was generated.

INTERVENTION AND OUTCOME

The whiplash-associated disorder grade I was treated conservatively. Therapeutic management involved soft-tissue therapy to the suspensory and paraspinal musculature of the upper back and neck. Rotary, manual-style manipulative therapy of the cervical and compressive manipulative therapy of the thoracic spinal column were implemented to maintain range of motion and decrease pain. The patient achieved full recovery within a 3-week treatment period and was discharged from care. One week after discharge, he underwent a routine evaluation by his family physician, where an aortic murmur was identified. Diagnostic ultrasound revealed a dissecting aneurysm measuring 78 mm at the aortic root. Immediate surgical correction was initiated with a polyethylene terephthalate fiber graft. The pathologic report indicated that aortic features were consistent with an old (healed) aortic dissection. There was no evidence of acute dissection. Six month follow-up revealed that surgical repair was successful in arresting further aortic dissection.

CONCLUSION

The patient had an old aortic dissection that pre-dated the chiropractic treatment (which included manipulative therapy) for the whiplash-associated disorder. Manipulative therapy, long considered an absolute contraindication for abdominal and aortic aneurysms, did not provoke the progression of the aortic dissection or other negative sequelae. The cause, histology, clinical features, and management considerations in the treatment of this patient's condition(s) are discussed.

The Marfan syndrome

The Marfan syndrome (MFS), initially described just over 100 years ago, was among the first conditions classified as a heritable disorder of connective tissue. MFS lies at one end of a phenotypic continuum, with people in the general population who have one or another of the features of MFS at the other end, and those with a variety of other conditions in between. Diagnosis of MFS and these other conditions remains based on clinical features. Mutations in FBN1, the gene that encodes fibrillin-1, are responsible for MFS and (in a few patients) other disorders in the continuum. In addition to skeletal, ocular, and cardiovascular features, patients with MFS have involvement of the skin, integument, lungs, and muscle tissue. Over the past 30 years, evolution of aggressive medical and surgical management of the cardiovascular problems, especially mitral valve prolapse, aortic dilatation, and aortic dissection, has resulted in considerable improvement in life expectancy.

Atlantoaxial rotatory subluxation in patients with Marfan syndrome. A report of three cases

STUDY DESIGN

This is a retrospective case series of three patients, ages 9 1/2, 13, and 20 years old, with Marfan syndrome treated for atlantoaxial rotatory subluxation. In the first two cases, acute torticollis was noted postoperatively, following pectus excavatum repair. The diagnosis was made in the third patient after she presented to the emergency room with a week-long history of unresolved neck pain following minor trauma.

OBJECTIVE

To report and discuss the courses and clinical sequelae of atlantoaxial subluxation in patients with Marfan syndrome.

SUMMARY OF BACKGROUND DATA

Radiographic analysis of patients with Marfan syndrome has shown that increased atlantoaxial translation, larger odontoid height, and basilar impression are more prevalent in this population compared to age-matched controls. Despite these findings, there are sparse data on injuries secondary to cervical spine instability or abnormalities in this population. To the authors' best knowledge, no report of atlantoaxial rotatory subluxation in patients with Marfan syndrome exists in the literature.

METHODS

Case records of rotatory instability of the atlanto-axial level were reviewed and are presented in the following report.

RESULTS

The first two patients described in this report were noted to have "cock robin" posturing of their necks following pectus excavatum repairs. The first patient's subluxation was partially reduced with halo traction, and he subsequently underwent posterior spinal fusion of C1-C2 with internal fixation. The patient was well aligned postoperatively, and had no neurologic deficits. The second patient's subluxation reduced after 20 days of halter and traction; he was immobilized in a collar following discharge and reduction was maintained. The third patient's subluxation failed to reduce with halo traction; further imaging studies revealed odontoid prominence in the foramen magnum. She underwent posterior spinal fusion, occiput to C3, with satisfactory result.

CONCLUSIONS

The cervical bony and ligamentous abnormalities seen in patients with Marfan syndrome may slightly increase their risk for atlantoaxial rotatory instability. Special attention to intubation and positioning, both intraoperatively and postoperatively, may be necessary in patients with Marfan syndrome. Additionally, rotatory subluxation should be included in the differential diagnosis for Marfan patients with neck pain after injury.

Spinal manifestations of skeletal dysplasias

Skeletal dysplasias, disorders of abnormal bone and cartilage development, are a heterogeneous group, each disorder with its own genetics, prevalence, prognosis, and treatment. More than 150 distinct conditions have been identified. Despite their obvious differences, the osteochondrodysplasias share many clinical and radiographic features. These patients present to the orthopedic surgeon for evaluation of disproportionate short stature, which may be apparent at birth or manifest itself only with further growth. This article discusses bone dysplasias commonly associated with spinal abnormalities. Spinal pathology can lead to deformity, neurologic sequelae, pain, and cardiopulmonary compromise and further contribute to short stature.