Cervical spine issues in Down syndrome

The Change of Asymptomatic Atlantoaxial Instability With Down Syndrome From Infant to Adolescent in Japanese Population: Minimum 10 Years Follow-Up

BACKGROUND

Although 10% to 60% of patients with Down syndrome (DS) develop atlantoaxial instability (AAI), clarifying the course of asymptomatic AAI may prevent unnecessary clinical interactions and investigations. This study investigates the radiographic changes observed in asymptomatic AAI associated with DS in Japanese children as they grow from infancy to adolescence over a minimum of 10 years.

METHODS

A retrospective analysis of cervical radiographs acquired from asymptomatic patients with DS in both infancy and adolescence was carried out. Radiographic evaluation included measuring the atlantodental interval (ADI) and the space available for the cord (SAC). In neutral lateral cervical radiographs, AAI was defined as ADI >6 mm and SAC <14 mm.

RESULTS

Two hundred thirty-nine patients were included. The mean follow-up was 12.8 years. ADI was 2.3 mm at initial evaluation and 2.7 mm at final evaluation ( P <0.01) in a neutral position, 3.1 and 3.3 mm in flexion ( P =0.18), and 1.7 and 2.1 mm in extension ( P <0.01), respectively. SAC was 15.8 mm at initial evaluation and 20.9 mm at final evaluation ( P <0.01) in neutral position, 15.6 and 20.7 mm in flexion ( P <0.01), and 16.8 and 21.0 mm in extension ( P <0.01), respectively. Forty-five patients (18.8%) showed evidence of AAI at the initial evaluation with 4 patients meeting the threshold for AAI at the final evaluation, one of which had os odontoideum. In contrast, of the 194 patients who did not have AAI at the initial evaluation, 3 (1.3%) developed AAI at the final evaluation. One of these with a normal den developed AAI at 13 years.

CONCLUSIONS

As 1 patient with a normal dens developed AAI at 13 years, we recommend screening for AAI with X-ray in infancy and adolescence regardless of the presence or absence of an os odontoideum.

EVIDENCE LEVEL

Level IV.

Atlantoaxial Subluxation in a 10-Year-Old Girl With Down Syndrome: A Case Report

Down syndrome is the most common inherited chromosomal disorder caused by trisomy 21. Atlantoaxial instability (AAI) is more common in children with Down syndrome, resulting from ligament laxity and odontoid dysplasia. We report the case of a 10-year-old girl with Down syndrome submental. She came to the ER with a history of abnormal gait for one week and was admitted with a case of ataxia for investigations. Moreover, we discovered that she had atlantoaxial subluxation, which was treated surgically.

Outcomes of Posterior Spinal Fusion in Pediatric Patients with Down Syndrome

BACKGROUND

Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients.

METHODS

An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification.

RESULTS

A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission.

CONCLUSIONS

Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Otolaryngologic Disease in Down syndrome

As the most common human chromosomal abnormality, Trisomy 21 is a condition that many otolaryngologists and likely all pediatric otolaryngologists will encounter during their careers. There are several considerations regarding airway obstruction, otologic conditions, anesthetic implications, and endocrine disorders that will impact the treatment of these patients. Further, there is increasing literature supporting the use of early instrumental assessment of swallowing, drug-induced sleep endoscopy at the time of first surgical intervention for sleep apnea, consideration of concurrent upper and lower airway evaluation, and early otologic management including potential surgical hearing rehabilitation.

Complications of Posterior Fusion for Atlantoaxial Instability in Children With Down Syndrome

Objective

To clarify the complications of posterior fusion for atlantoaxial instability (AAI) in children with Down syndrome and to discuss the significance of surgical intervention.

Methods

Twenty pediatric patients with Down syndrome underwent posterior fusion for AAI between February 2000 and September 2018 (age, 6.1±1.9 years). C1–2 or C1–3 fusion and occipitocervical fusion were performed in 14 and 6 patients, respectively. The past medical history, operation time, estimated blood loss (EBL), duration of Halo vest immobilization, postoperative follow-up period, and intra- and perioperative complications were examined.

Results

The operation time was 257.9±55.6 minutes, and the EBL was 101.6±77.9 mL. Complications related to the operation occurred in 6 patients (30.0%). They included 1 major complication (5.0%): hydrocephalus at 3 months postoperatively, possibly related to an intraoperative dural tear. Other surgery-related complications included 3 cases of superficial infections, 1 case of bone graft donor site deep infection, 1 case of C2 pedicle fracture, 1 case of Halo ring dislocation, 1 case of pseudoarthrosis that required revision surgery, and 1 case of temporary neurological deficit after Halo removal at 2 months postoperatively. Complications unrelated to the operation included 2 cases of respiratory infections and 1 case of implant loosening due to a fall at 9 months postoperatively.

Conclusion

The complication rate of upper cervical fusion in patients with Down syndrome remained high; however, major complications decreased substantially. Improved intra- and perioperative management facilitates successful surgical intervention for upper cervical instability in pediatric patients with Down syndrome.

Repeat Pediatric Trisomy 21 Radiographic Exam: Does Atlantoaxial Instability Develop Over Time?

BACKGROUND

Atlantoaxial instability (AAI) is common in pediatric patients with Trisomy 21 and can lead to spinal cord injury during sports, trauma, or anesthetized neck manipulation. Children with Trisomy 21 therefore commonly undergo radiographic cervical spine screening, but recommendations on age and timing vary. The purpose of this study was to determine if instability develops over time.

METHODS

We performed a retrospective review for all pediatric Trisomy 21 patients receiving at least 2 cervical spine radiographic series between 2008 and 2020 at our institution. Atlantodens interval (ADI) and space available for the cord at C1 (SAC) were measured; bony abnormalities such as os odontoidium, and age and time between radiographs were noted. AAI was determined by ADI ≥6 mm or SAC ≤14 mm based on our groups' prior study. Those who developed instability were compared with those who did not.

RESULTS

A total of 437 cervical spine radiographic series from 192 patients were evaluated, with 160 included. Mean age at first radiograph was 7.4±4.4 years, average ADI was 3.1 mm (±1.2), and SAC was 18.1 mm (±2.6). The average time between first and last radiographs was 4.3 years (±1.8), with average final ADI 3.2 mm (±1.4) and SAC 18.9 mm (±2.9). Seven patients (4%) had instability: 4 were unstable on their initial studies and 3 (1.6%) on subsequent imaging. Os odontoideum was found in 5 (71%) unstable spines and 3 (2%) stable spines (P<0.0001); only 1 patient that became unstable on subsequent radiograph did not have an os. There was no specific age cut-off or surveillance time period after which one could be determined no longer at risk.

CONCLUSIONS

Trisomy 21 patients have a 4.4% overall rate of AAI in our series with a 1.6% rate of progression to instability over ∼4 years. Given this nearly 1 in 23 risk of instability, we recommend initial surveillance radiograph for all children over 3 years with Trisomy 21; repeat asymptomatic surveillance should continue in those with os odontoideum given their high instability risk.

LEVEL OF EVIDENCE

Level II-diagnostic study.

Anterior atlantoaxial subluxation with Down syndrome and arthritis: case report

Down syndrome (DS) occurs when an individual has a full or partial extra copy of chromosome 21 and is the most common of all malformation syndromes. Associating with numerous pathologies like anterior atlantoaxial subluxation (AAAS) which is an increase in the space between the anterior arch of the first cervical vertebra (C1) and the odontoid process of the second vertebra (C2), most of the time its asymptomatic, only 1-2% to all the 30% who may have the AAAS and DS develop clinical symptoms. In this occasion, we present the case of a patient with SD and Juvenile chronic arthritis (JCA) who has atlantoaxial subluxation of approximately 11mm, basilar impression and platybasia with severe medullary compression in 2 points, requiring surgical management by the Neurological Surgery Service in Bucaramanga-Colombia.

Morphologic variations of the second cervical vertebra in Down syndrome compared with age-matched peers

OBJECTIVEAtlantoaxial instability is an important cause of pain and neurological dysfunction in patients with Down syndrome (DS), frequently requiring instrumented fusion of the upper cervical spine. This study provides a quantitative analysis of C2 morphology in DS patients compared with their peers without DS to identify differences that must be considered for the safe placement of instrumentation.METHODSA retrospective chart review identified age-matched patients with and without DS with a CT scan of the cervical spine. Three-dimensional reconstructions of these scans were made with images along the axis of, and perpendicular to, the pars, lamina, facet, and transverse foramen of C2 bilaterally. Two of the authors performed independent measurements of anatomical structures using these images, and the average of the 2 raters' measurements was recorded. Pedicle height and width; pars axis length (the distance from the facet to the anterior vertebral body through the pars); pars rostrocaudal angle (angle of the pars axis length to the endplate of C2); pars axial angle (angle of the pars axis length to the median coronal plane); lamina height, length, and width; lamina angle (angle of the lamina length to the median coronal plane); and transverse foramen posterior distance (the distance from the posterior wall of the transverse foramen to the tangent of the posterior vertebral body) were measured bilaterally. Patients with and without DS were compared using a mixed-effects model accounting for patient height.RESULTSA total of 18 patients with and 20 patients without DS were included in the analysis. The groups were matched based on age and sex. The median height was 147 cm (IQR 142-160 cm) in the DS group and 165 cm (IQR 161-172 cm) in the non-DS group (p < 0.001). After accounting for variations in height, the mean pars rostrocaudal angle was greater (50.86° vs 45.54°, p = 0.004), the mean transverse foramen posterior distance was less (-1.5 mm vs +1.3 mm, p = 0.001), and the mean lamina width was less (6.2 mm vs 7.7 mm, p = 0.038) in patients with DS.CONCLUSIONSPatients with DS had a steeper rostrocaudal trajectory of the pars, a more posteriorly positioned transverse foramen posterior wall, and a narrower lamina compared with age- and sex-matched peers. These variations should be considered during surgical planning, as they may have implications to safe placement of instrumentation.

Cervical instability in patients with Trisomy 21: The eternal gamble

Patients with Trisomy 21 are particularly at risk of cervical instability due to ligamentous laxity and osseous abnormalities. Up to 30% of Trisomy 21 patients are affected by atlanto-axial or atlanto-occipital instability, but only 1%-2% of cases are symptomatic. The radiologic assessment of cervical instability is not unanimously considered mandatory. The dynamic cervical spine radiograph is the most common screening tool for ruling out cervical spine instability in patients with Trisomy 21, and it is often requested before surgery. Several measurements have been investigated to assess the presence and degree of cervical instability; however, no conclusive recommendations have been forthcoming. In daily practice, many anesthesiologists may provide anesthesia via such means as laryngoscopy and tracheal intubation during surgery, without any radiological investigations before surgery. This review focuses on the diagnostic and prognostic measures available to evaluate the presence and degree of cervical instability in patients with Trisomy 21 and to propose practical recommendations to be applied in clinical practice.

The Outcomes of Posterior Arthrodesis for Atlantoaxial Subluxation in Down Syndrome Patients: A Meta-Analysis

STUDY DESIGN

This is a meta-analysis.

OBJECTIVE

To establish rates of (1) neurological complications, (2) bony-related complications, (3) complications delaying recovery, (4) reoperation, and (5) fatalities following posterior cervical arthrodesis in Down syndrome (DS) patients with atlantoaxial subluxation. To determine if presenting symptoms had any relationship to postoperative complications.

SUMMARY OF BACKGROUND DATA

Posterior arthrodesis is commonly utilized to correct cervical instability secondary to atlantoaxial instability in DS patients. However, there has never been a global evaluation of postoperative complications associated with posterior cervical spinal arthrodesis in DS patients.

METHODS

A comprehensive search of Medline/PubMed, EMBASE, and Ovid databases between January 1980 and July 2017 was utilized to identify DS patients with atlantoaxial subluxation who underwent posterior cervical arthrodesis. Data were sorted by neurological complications, complications delaying recovery, bony-related complications, reoperations, and fatalities. Patients were sorted into 2 groups based on presentation with or without neurological deficits.

RESULTS

Twelve studies met inclusion criteria, including 128 DS patients. Mean age was 13.8 years (range: 6.7-32.7 y; 47.8% male). Mean follow-up was 31.7 months (range: 14.9-77 mo). All patients underwent primary posterior cervical arthrodesis with an average of 2.5 vertebrae fused. A total of 39.6% of patients had bony-related complications [95% confidence interval (CI), 31.4%-48.5%], 23.3% had neurological deficits (95% CI, 16.6%-31.6%), and 26.4% experienced complications delaying recovery (95% CI, 19.4%-34.9%). The reoperation rate was 34.9% (95% CI, 25.5%-45.6%). The mortality rate was 3.9% (95% CI, 1.5%-9.7%). Neurological complications were 4-fold (P<0.05) and reoperation was 5.5-fold (P<0.05) more likely in patients presenting with neurological deficits compared with those without.

CONCLUSIONS

This study detailed global complication rates of posterior arthrodesis for DS patients, identifying bony-related complications and reoperations among the most common. Patients presenting with neurological symptoms and cervical instability have increased postoperative rates of neurological complications and reoperations than patients with instability alone. Further investigation into how postoperative complications effect patient independence is warranted.

A cervical flexion-extension MRI study in Down syndrome

OBJECTIVE

To assess what kind of information MR examination in flexed and extended positions provides in Down syndrome subjects with suspected cranio-cervical instability.

METHODS

Between 2005 and 2008, 35 subjects with DS were recruited in the study. Ethics committee approval was granted and a signed informed consent was obtained from the parents. All the subjects were affected by hypotonic status and ligament laxity established by clinical evaluation, but were asymptomatic about focal neurological symptoms due to medullar damage caused by cranio-cervical instability. Each patient underwent lateral supine radiographs and MR imaging in the neutral, active flexed and extended positions. For evaluating the atlanto-axial and atlanto-occipital joint stability, multiple measurements were calculated.

RESULTS

A significant reduction of anterior subarachnoid space in flexed position was evident in DS subjects compared to healthy controls in neutral and flexed positions. Both, space available for cord and ligamentous thickness showed significant differences between DS subjects and healthy controls. In DS subjects with occipito-cervical instability, the anterior subarachnoidal space reduction was significantly reduced in flexed position.

CONCLUSIONS

In DS subjects with asymptomatic cranio-cervical instability, anterior subarachnoidal evaluation and ligamentous status could add new information about the risk of spinal cord damage.

Aneuploidy and skeletal health

The normal human chromosome complement consists of 46 chromosomes comprising 22 morphologically different pairs of autosomes and one pair of sex chromosomes. Variations in either chromosome number and/or structure frequently result in significant mental impairment and/or a variety of other clinical problems, among them, altered bone mass and strength. Chromosomal syndromes associated with specific chromosomal abnormalities are classified as either numerical or structural and may involve more than one chromosome. Aneuploidy refers to the presence of an extra copy of a specific chromosome, or trisomy, as seen in Down's syndrome (trisomy 21), or the absence of a single chromosome, or monosomy, as seen in Turner syndrome (a single X chromosome in females: 45, X). Aneuploidies have diverse phenotypic consequences, ranging from severe mental retardation and developmental abnormalities to increased susceptibility to various neoplasms and premature death. In fact, trisomy 21 is the prototypical aneuploidy in humans, is the most common genetic abnormality associated with longevity, and is one of the most widespread genetic causes of intellectual disability. In this review, the impact of trisomy 21 on the bone mass, architecture, skeletal health, and quality of life of people with Down syndrome will be discussed.

Supporting a happy, healthy adolescence for young people with Down syndrome and other intellectual disabilities: recommendations for clinicians

PURPOSE OF REVIEW

To review clinical updates and current healthcare issues for adolescents with Down syndrome and intellectual disabilities, including behavioral, social, and emotional issues, health supervision recommendations, and recommendations for supporting the transition process.

RECENT FINDINGS

Several recent findings merit particular attention: low activity levels and implications for overweight and poor bone density; high prevalence of obstructive sleep apnea and its implications; prevalence of mental health and behavioral concerns; and need for appropriate transition services.

SUMMARY

In guiding adolescents with Down syndrome towards healthy productive adult lives, clinicians can make use of healthcare guidelines and should also take a broader, more interdisciplinary approach to ensure that social, educational, and vocational plans are in place to support physical and mental health and development during transition into adulthood. Many of these issues have broader applicability to any adolescent with an intellectual disability.

A review of the neurological and neurosurgical implications of Down syndrome in children

Down syndrome is the most commonly encountered chromosomal translation and has been associated with significant congenital abnormalities in various organ systems. Along with classic facial findings, it may involve the gastroenterologic, cardiac, ophthalmologic, endocrine, immunologic, orthopedic, or neurologic systems. With respect to the neurological system, a higher incidence of moyamoya, seizure disorders, strokes, and spinal ligamentous laxity has been described in these children. We have summarized the current available literature with respect to children who have Down syndrome and the varying neurological pathologic entities associated to help health care providers better understand these patients.

Successful cranio-cervical fusion in a patient with Down syndrome

We present a patient with Down syndrome with neck pain and severe cervical myelopathy. Imaging revealed occipito-atlantal and atlanto-axial instability with severe spinal cord compression. There are no standardized radiological or clinical guidelines to aid in managing this unique subset of patients. We demonstrate a successful occiput-C3 internal fixation and fusion without complication. Due to the largely unknown natural history and ongoing management difficulties in this population, we demonstrate a case that may aid future decision making for this specialized field. We also discuss an approach to reduce this deformity, which, to our knowledge, has not been published before.

Posterior occipito-axial fixation applied C2 laminar screws for pediatric atlantoaxial instability caused by Down syndrome: Report of 2 cases

Background

Upper cervical spine instability is one of the most critical orthopedic problems in patients with Down syndrome. However, arthrodesis of the upper cervical spine in these patients can be very difficult to achieve and has a high complication rate because of mental retardation and accompanying various medical conditions of the vital organs. Even now, surgeries in such patients, especially pediatric cases, are challenging and the optimal operative procedure remains unsettled. The purpose of this study was to report 2 cases of pediatric atlantoaxial instability due to Down syndrome in which posterior occipito-axial fixation with C2 laminar screws was performed.

Methods

Case 1 was a girl aged 6 years 10 months who had atlantoaxial rotatory fixation with os odontoideum. Atlantoaxial rotatory fixation was incompletely reduced by halo traction, and it was not maintained without halo-ring and -vest fixation. Posterior occipito-axial fixation with bilateral C2 laminar screws was then performed. Case 2 was a boy aged 10 years 7 months who had atlantoaxial subluxation with os odontoideum. He also had incomplete quadriplegia, so he could neither walk nor have a meal by himself. Posterior occipito-axial fixation with right C2 pedicle and left C2 laminar screws was then carried out.

Results

In case 1 bone union was obtained at 3 months after surgery and the patient's symptoms were resolved. In case 2 bone union was obtained at 3 months after surgery and the paralysis was improved.

Conclusions/level of evidence

In cases of atlantoaxial instability due to Down syndrome, symptomatic patients often present between ages 5 and 15 years and mental retardation interferes with postoperative cervical immobilization. C2 laminar screws can be safely applied for the pediatric axis and biomechanically accomplished rigid fixation. The C2 laminar screw is one of the most useful options to achieve stability of the pediatric atlantoaxial complex without the risk of vertebral artery injuries (level IV case series).

Feasibility of intralaminar, lateral mass, or pedicle axis vertebra screws in children under 10 years of age: a tomographic study

BACKGROUND

There are several techniques for screw insertion in upper cervical spine surgery, and the use of the 3.5-mm screw is usually the standard. However, there is no consensus regarding the feasibility of using these screws in the pediatric population.

OBJECTIVE

To determine the measurement of the lamina angle, lamina and pedicle length and thickness, and lateral mass length of the topographic axial view of the axis vertebra of 2- to 10-year-old children to guide the use of surgical screws.

METHODS

Seventy-five computed tomography scans from 24- to 120-month-old patients were studied. Measurements were taken in an axial view of C2 and correlated with 2 age groups and both sexes. Statistical analysis was performed with the Student t test.

RESULTS

In the 24- to 48-month age group, only 5.5% of the lamina and 8.3% of the pedicles had thicknesses < 3.5 mm. In the 49- to 120-month age group, there were no lamina thickness values < 3.5 mm, and 1.2% of pedicle thicknesses were < 3.5 mm. Both age groups had no lamina and pedicle lengths < 12 mm and no lateral mass lengths > 12 mm.

CONCLUSION

In the majority of cases, the use of 3.5-mm lamina and pedicle screws in children is feasible. A base value of 45° for the spinolaminar angle can be adopted as a reference for insertion of screws in the C2 lamina. This information can be particularly useful for decision making during preoperative planning for C1-C2 or craniocervical arthrodesis in children.

Review of cervical spine anomalies in genetic syndromes

STUDY DESIGN

Focused review of the literature.

OBJECTIVE

Assist spine specialists in diagnosis and treatment of cervical spine anomalies found in selected genetic syndromes.

SUMMARY OF BACKGROUND DATA

Cervical spine instability and/or stenosis are potentially debilitating problems in many genetic syndromes. These problems can be overlooked among the other systemic issues more familiar to clinicians and radiologists evaluating these syndromes. It is imperative that spine specialists understand the relevant issues associated with these particular syndromes.

METHODS

The literature was reviewed for cervical spine issues in 10 specific syndromes. The information is presented in the following order: First, the identification and treatment of midcervical kyphosis in Larsen syndrome and diastrophic dysplasia (DD). Next, the upper cervical abnormalities seen in Down syndrome, 22q11.2 Deletion syndrome, pseudoachondroplasia, Morquio syndrome, Goldenhar syndrome, spondyloepiphyseal dysplasia congenita, and Kniest dysplasia. Finally, the chin-on-chest deformity of fibrodysplasia ossificans progressiva.

RESULTS

Midcervical kyphosis in patients with Larsen syndrome and DD needs to be evaluated and imaged often to track deformity progression. Upper cervical spine instability in Down syndrome is most commonly caused by ligamentous laxity at C1 to C2 and occiput-C1 levels. Nearly 100% of patients with 22q11.2 deletion syndrome have cervical spine abnormalities, but few are symptomatic. Patients with pseudoachondroplasia and Morquio syndrome have C1 to C2 instability related to odontoid dysplasia (hypoplasia and os odontoideum). Morquio patients also have soft tissue glycosaminoglycan deposits, which cause stenosis and lead to myelopathy. Severely affected patients with spondyloepiphyseal dysplasia congenita are at high risk of myelopathy because of atlantoaxial instability in addition to underlying stenosis. Kniest syndrome is associated with atlantoaxial instability. Cervical spine anomalies in Goldenhar syndrome are varied and can be severe. Fibrodysplasia ossificans progressiva features severe, deforming heterotopic ossification that can become life-threatening.

CONCLUSION

It is important to be vigilant in the diagnosis and treatment of cervical spine anomalies in patients with genetic syndromes.

Health supervision for children with Down syndrome

These guidelines are designed to assist the pediatrician in caring for the child in whom a diagnosis of Down syndrome has been confirmed by chromosome analysis. Although a pediatrician's initial contact with the child is usually during infancy, occasionally the pregnant woman who has been given a prenatal diagnosis of Down syndrome will be referred for review of the condition and the genetic counseling provided. Therefore, this report offers guidance for this situation as well.

Down syndrome: orthopedic issues

PURPOSE OF REVIEW

The purpose of this review is to update the role of the orthopedic surgeon in the management of Down syndrome as these patients are living longer and participating in sporting activities.

RECENT FINDINGS

Approximately 20% of all patients with Down syndrome experience orthopedic problems. Upper cervical spine instability has the most potential for morbidity and, consequently, requires close monitoring. Other conditions such as scoliosis, hip instability, patellar instability and foot problems can cause disability if left untreated. In some of these conditions, early diagnosis can prevent severe disability.

SUMMARY

Surgical intervention in children with Down syndrome has a high risk of complications, particularly infection and wound healing problems. Careful anesthetic airway management is needed because of the associated risk of cervical spine instability.

Unilateral hyperplasia of a cervical spinous process as a rare congenital variant of the spine

Congenital variants of the cervical spine may mimic traumatic lesions and may cause recurrent episodes of pain. We report a 24-year-old female patient with chronic neck pain who had marked unilateral hyperplasia of the spinous process of the seventh cervical vertebra. CT and MRI clearly depicted the abnormality and, furthermore, ruled out posttraumatic spinal changes. To our knowledge, our case is the first patient reported with this rare congenital variant diagnosed by cross-sectional imaging.

Spinal disorders associated with skeletal dysplasias and syndromes

Skeletal dysplasias are a heterogeneous group of disorders in which there is abnormal cartilage and bone formation, growth, and remodeling. There are more than 200 described skeletal dysplasias. Skeletal dysplasias can affect the spine in various ways, with attendant neurosurgical implications for diagnosis and treatment. Craniocervical junction abnormalities, atlantoaxial subluxation, and kyphoscoliotic deformity are among the common spinal problems that are found in certain skeletal dysplasias.

Down syndrome in children: the role of the orthopaedic surgeon

Down syndrome, the result of trisomy of chromosome 21, is one of the most common chromosomal abnormalities. Patients have a characteristic facial appearance, variable levels of intelligence and self-care skills, and a variety of associated medical conditions. Orthopaedic manifestations occur frequently; most are related to hypotonia, joint hypermobility, and ligamentous laxity. Atlanto-occipital and atlantoaxial hypermobility, as well as bony anomalies of the cervical spine, can produce atlanto-occipital and cervical instability. Methods of screening for this instability, particularly with regard to participation in sports, are a subject of controversy. Scoliosis, hip instability, slipped capital femoral epiphysis, patellar instability, and foot deformities are other musculoskeletal conditions found in patients with Down syndrome that can be challenging for the orthopaedic surgeon to treat.

Current dilemmas in Down syndrome clinical care: Celiac disease, thyroid disorders, and atlanto-axial instability

This study will discuss our current understanding of celiac disease (CD), thyroid disorders, and atlanto-axial instability, three important areas of medical management in individuals with Down syndrome (DS). In this study, we highlight our current knowledge, as well as what we need to study in order to gather the necessary data to refine the empirically based screening protocols which are now in place.