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Moy N, Flynn D, Henriquez J, Connelly LB, Vale L, Paolucci F. Interventions for improving clinical outcomes and health-related quality-of-life for people living with skeletal dysplasias: an evidence gap map. Qual Life Res 2023; 32:2751-2762. [PMID: 37294397 PMCID: PMC10474209 DOI: 10.1007/s11136-023-03431-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE Skeletal dysplasias are rare genetic disorders that are characterized by abnormal development of bone and cartilage. There are multiple medical and non-medical treatments for specific symptoms of skeletal dysplasias e.g. pain, as well as corrective surgical procedures to improve physical functioning. The aim of this paper was to develop an evidence-gap map of treatment options for skeletal dysplasias, and their impact on patient outcomes. METHODS We conducted an evidence-gap map to identify the available evidence on the impact of treatment options on people with skeletal dysplasias on clinical outcomes (such as increase in height), and dimensions of health-related quality of life. A structured search strategy was applied to five databases. Two reviewers independently assessed articles for inclusion in two stages: titles and abstracts (stage 1), and full text of studies retained at stage 2. RESULTS 58 studies fulfilled our inclusion criteria. The included studies covered 12 types of skeletal dysplasia that are non-lethal with severe limb deformities that could result in significant pain and numerous orthopaedic interventions. Most studies reported on the effect of surgical interventions (n = 40, 69%), followed by the effect of treatments on dimensions of health quality-of-life (n = 4, 6.8%) and psychosocial functioning (n = 8, 13.8%). CONCLUSION Most studies reported on clinical outcomes from surgery for people living with Achondroplasia. Consequently, there are gaps in the literature on the full range of treatment options (including no active treatment), outcomes and the lived experience of people living with other skeletal dysplasias. More research is warranted to examine the impact of treatments on health-related quality-of-life of people living with skeletal dysplasias, including their relatives to enable them to make preference- and valued based decisions about treatment.
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Affiliation(s)
- Naomi Moy
- Department of Sociology and Business Law, University of Bologna, Bologna, Italy
| | - Darren Flynn
- Department of Midwifery, Nursing and Health, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Josefa Henriquez
- Department of Sociology and Business Law, University of Bologna, Bologna, Italy
| | - Luke B Connelly
- Department of Sociology and Business Law, University of Bologna, Bologna, Italy
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Australia
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Francesco Paolucci
- Department of Sociology and Business Law, University of Bologna, Bologna, Italy.
- Newcastle Business School, Faculty of Business and Law, University of Newcastle, Callaghan, Australia.
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Shafi K, Lovecchio F, Sava M, Steinhaus M, Samuel A, Carter E, Lebl D, Farmer J, Raggio C. Complications and Revisions After Spine Surgery in Patients With Skeletal Dysplasia: Have We Improved? Global Spine J 2023; 13:268-275. [PMID: 33596686 PMCID: PMC9972265 DOI: 10.1177/2192568221994786] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE To report contemporary rates of complications and subsequent surgery after spinal surgery in patients with skeletal dysplasia. METHODS A case series of 25 consecutive patients who underwent spinal surgery between 2007 and 2017 were identified from a single institution's skeletal dysplasia registry. Patient demographics, medical history, surgical indication, complications, and subsequent surgeries (revisions, extension to adjacent levels, or for pathology at a non-contiguous level) were collected. Charlson comorbidity indices were calculated as a composite measure of overall health. RESULTS Achondroplasia was the most common skeletal dysplasia (76%) followed by spondyloepiphyseal dysplasia (20%); 1 patient had diastrophic dysplasia (4%). Average patient age was 53.2 ± 14.7 years and most patients were in excellent cardiovascular health (88% Charlson Comorbidity Index 0-4). Mean follow up after the index procedure was 57.4 ± 39.2 months (range). Indications for surgery were mostly for neurologic symptoms. The most commonly performed surgery was a multilevel thoracolumbar decompression without fusion (57%). Complications included durotomy (36%), neurologic complication (12%), and infection requiring irrigation and debridement (8%). Nine patients (36%) underwent a subsequent surgery. Three patients (12%) underwent a procedure at a non-contiguous anatomic zone, 3 (12%) underwent a revision of the previous surgery, and another 3 (12%) required extension of their previous decompression or fusion. CONCLUSIONS Surgical complication rates remain high after spine surgery in patients with skeletal dysplasia, likely attributable to inherent characteristics of the disease. Patients should be counseled on their risk for complication and subsequent surgery.
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Affiliation(s)
- Karim Shafi
- Hospital for Special Surgery, New York,
NY, USA
| | | | - Maria Sava
- Hospital for Special Surgery, New York,
NY, USA
| | | | | | - Erin Carter
- Hospital for Special Surgery, New York,
NY, USA
| | - Darren Lebl
- Hospital for Special Surgery, New York,
NY, USA
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Liu HT, Song J, Zhou FC, Liang ZH, Zhang QQ, Zhang YH, Shao J. Cervical spine involvement in pediatric mucopolysaccharidosis patients: Clinical features, early diagnosis, and surgical management. Front Surg 2023; 9:1059567. [PMID: 36684186 PMCID: PMC9852728 DOI: 10.3389/fsurg.2022.1059567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/22/2022] [Indexed: 01/08/2023] Open
Abstract
Mucopolysaccharidosis (MPS) is a progressive genetic disease that causes a deficiency in lysosomal enzymes, which play an important role in the degradation pathway of glycosaminoglycans. As a result of enzyme defects, mucopolysaccharides cannot be metabolized and thus accumulate. The cervical spine is one of the most commonly involved sites; thus, prompt surgical management before the onset of severe neurological deterioration is critical. However, because of the rarity of the disease, there is no standard treatment. In this review, we characterize the cervical spinal involvement in pediatric patients with MPS, describe the useful imaging technologies for diagnosis, and provide screening procedure for children with MPS. Surgical managements, including indications, surgical methods, possible difficulties, and solutions, are reviewed in detail.
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Affiliation(s)
| | | | | | | | | | | | - Jiang Shao
- Correspondence: Yue-Hui Zhang Jiang Shao
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4
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Dysplasias in the Child’s Spine. Neurosurg Clin N Am 2022; 33:e1-e10. [DOI: 10.1016/j.nec.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Ohba T, Oda K, Tanaka N, Masanori W, Endo T, Haro H. Posterior occipitocervical instrumented fusion for atlantoaxial instability in a 27-month-old child with Down syndrome: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2175. [PMID: 36046513 PMCID: PMC9394695 DOI: 10.3171/case2175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Upper cervical spine instability is one of the most serious orthopedic problems in patients with Down syndrome. Despite the recent advancement of instrumentation techniques, occipitocervical fusion remains technically challenging in the very young pediatric population with small and fragile osseous elements. OBSERVATIONS A 27-month-old boy with Down syndrome was urgently transported to the authors’ hospital because of difficulty in standing and sitting, weakness in the upper limbs, and respiratory distress. Radiographs showed os odontoideum, irreducible atlantoaxial dislocation, and substantial spinal cord compression. Emergency posterior occipitoaxial fixation was performed using O-arm navigation. Improvement in the motor paralysis of the upper left limb was observed from the early postoperative period, but revision surgery was needed 14 days after surgery because of surgical site infection. The patient showed modest but substantial neurological improvement 1 year after the surgery. LESSONS There are several clinical implications of the present case. It warns that Down syndrome in the very young pediatric population may lead to rapid progression of spinal cord injury and life crisis. This 27-month-old patient represents the youngest case of atlantoaxial instability in a patient with Down syndrome. O-arm navigation is useful for inserting screws into very thin pedicles.
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Affiliation(s)
- Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi, Japan
| | - Kotaro Oda
- Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi, Japan
| | - Nobuki Tanaka
- Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi, Japan
| | - Wako Masanori
- Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi, Japan
| | - Tomoka Endo
- Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi, Japan
| | - Hirotaka Haro
- Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi, Japan
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6
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Singh S, Sardhara J, Raiyani V, Saxena D, Kumar A, Bhaisora KS, Das KK, Mehrotra A, Srivastava AK, Behari S. Craniovertebral junction instability in Larsen syndrome: An institutional series and review of literature. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:276-286. [PMID: 33824557 PMCID: PMC8019120 DOI: 10.4103/jcvjs.jcvjs_164_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 11/04/2022] Open
Abstract
Objective Larsen syndrome (LS) is characterized by osteo-chondrodysplasia, multiple joint dislocations, and craniofacial abnormalities. Symptomatic myelopathy is attributed to C1-C2 instability and sub-axial cervical kyphosis. In this article, we have analyzed the surgical outcome after posterior fixation in LS with craniovertebral junction instability. Methods Ten symptomatic pediatric patients, operated between 2011 and 2019, were included, and the clinical outcome was assessed by Nurick grade, neurological improvement, and complications. The requirement of anti-spasticity drugs, the degree of bony fusion, and restriction of neck movement were also noted. At last follow-up, patient satisfaction score (PSS) and back to school status were studied. We also reviewed the literature and categorized two types of presentation of reported LS patients and discussed the pattern of disease progression among both. Results Ten patients, age range 1.5-16 years, underwent 12 surgeries (6 C1-C2 fixation, 4 long-segment posterior cervical fixation, and 2 trans-oral decompressions as the second stage); the mean follow-up was 23 (range, 6-86 months). All the ten patients in our study had the characteristic "dish-" like face and nine patients had acral anomalies. The median Nurick grade improved from preoperative (median = 4) to follow-up (median = 3). The requirement of anti-spasticity drugs decreased in seven patients and the neck-pain improved in nine patients. The median satisfaction at follow-up was good (median PSS = 2); five patients were going back to school. Conclusion Craniovertebral junction instability in LS is rare and surgically challenging. Early posterior fixation showed a promising outcome with a halt in the disease progression.
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Affiliation(s)
- Suyash Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India
| | - Jayesh Sardhara
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vandan Raiyani
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Deepti Saxena
- Department of Medical Genetics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ashutosh Kumar
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh Singh Bhaisora
- Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arun Kumar Srivastava
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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7
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Singh S, Sardhara J, Raiyani V, Srivastava AK, Behari S. Lessons learned from surgical management of craniovertebral instability in Morquio syndrome: A series of four unusual cases. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:243-247. [PMID: 33100777 PMCID: PMC7546054 DOI: 10.4103/jcvjs.jcvjs_95_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/22/2020] [Indexed: 11/12/2022] Open
Abstract
Morquio syndrome (MS) is an autosomal recessive defect caused by the deficiency of N-acetylgalactosamine-6-sulfatase. Odontoid hypoplasia, periodontoid soft tissue deposition, and cervical stenosis lead to myelopathy and quadriparesis in these patients. Craniovertebral junction instability in MS possesses a surgical challenge as bones are yet to completely ossify. The atlantoaxial dislocation (AAD) is reducible, and the need of transoral decompression for the soft tissue deposition ventral to odontoid is debatable. We present a series of four cases (mean age 4.3 ± 0.4 years) operated through posterior-only approach (n = 2, C1-lateral mass to C2 pars-interarticularis [Goel's technique]; n = 1 sublaminar wiring followed by C1-lateral mass to C2 pars-interarticularis; and n = 1 suboccipital plate with pars-interarticularis of C2 screw and pedicle of C3 and rod fixation). All patients had acceptable outcome and doing well at the last follow-up (12–96-follow-up). None of our patient needed transoral decompression. Patients with MS frequently manifest with spastic quadriparesis at an early age due to reducible AAD. Early surgical fixation with posterior C1–C2 screw and rod technique is recommended for the favorable surgical outcome and long-term stability of the cervical spine.
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Affiliation(s)
- Suyash Singh
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh Sardhara
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vandan Raiyani
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arun Kumar Srivastava
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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8
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White KK, Bober MB, Cho TJ, Goldberg MJ, Hoover-Fong J, Irving M, Kamps SE, Mackenzie WG, Raggio C, Spencer SA, Bompadre V, Savarirayan R. Best practice guidelines for management of spinal disorders in skeletal dysplasia. Orphanet J Rare Dis 2020; 15:161. [PMID: 32580780 PMCID: PMC7313125 DOI: 10.1186/s13023-020-01415-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Disorders of the spine present a common and difficult management concern in patients with skeletal dysplasia. Due to the rarity of these conditions however, the literature, largely consisting of small, single institution case series, is sparse in regard to well-designed studies to support clinical decision making in these situations. METHODS Using the Delphi method, an international, multi-disciplinary group of individuals, with significant experience in the care of patients with skeletal dysplasia, convened to develop multi-disciplinary, "best practice" guidelines in the care of spinal disorders in patients with skeletal dysplasia. RESULTS Starting with 33 statements, the group a developed a list of 31 "best practice" guidelines. CONCLUSIONS The guidelines are presented and discussed to provide context for clinicians in their decision making in this often-challenging realm of care.
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Affiliation(s)
- Klane K White
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, 4800 Sand Point Way, OA.9.120, Seattle, Washington, 98105, USA. .,Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA.
| | - Michael B Bober
- Division of Orthogenetics, Nemours/ A.I. duPont Hospital for Children, Wilmington, DE, USA
| | - Tae-Joon Cho
- Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Michael J Goldberg
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, 4800 Sand Point Way, OA.9.120, Seattle, Washington, 98105, USA.,Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Julie Hoover-Fong
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Melita Irving
- Department of Clinical Genetics Guy's and St Thomas NHS, London, UK
| | - Shawn E Kamps
- Department of Radiology, Seattle Children's Hospital, Seattle, WA, USA.,Department of Radiology, University of Washington, Seattle, WA, USA
| | - William G Mackenzie
- Department of Orthopedic Surgery, Nemours/ A.I. duPont Hospital for Children, Wilmington, DE, USA
| | - Cathleen Raggio
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Samantha A Spencer
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Viviana Bompadre
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, 4800 Sand Point Way, OA.9.120, Seattle, Washington, 98105, USA
| | - Ravi Savarirayan
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, University of Melbourne, Parkville, Victoria, Australia
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An Evidence-based Approach to the Management of Children With Morquio A Syndrome Presenting With Craniocervical Pathology. Spine (Phila Pa 1976) 2018; 43:E1443-E1453. [PMID: 29901537 DOI: 10.1097/brs.0000000000002743] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series OBJECTIVE.: The aim of this study was to review clinical and radiological outcomes of craniovertebral surgery in children with Morquio A syndrome (Mucopolysaccharidosis type IVA) and develop an evidence-based management algorithm. SUMMARY OF BACKGROUND DATA Myelopathy secondary to craniovertebral pathology is a common cause of neurological disability in Morquio A syndrome. Previously unresolved surgical controversies include the value of surveillance, surgical indications, and operative technique. METHODS A retrospective case-based review of children with Morquio A syndrome and craniovertebral pathology seen in a tertiary referral pediatric center from 1992 to 2016 was performed. Patients treated nonoperatively and operatively were included. Medical records and imaging were reviewed to determine clinical and radiological findings at initial assessment, before cervical spine surgery, early postoperative period, and final follow-up. The clinical outcomes of interest were neurological status and mobility at follow-up, complications, and need for further surgery. RESULTS Twenty-seven patients were included. Surgical indications were radiological evidence of cervicomedullary compression alone (six cases) or with clinical evidence of myelopathy (12 cases). Eighteen patients (median age 6.2 years, range 3.5-15.9 years) underwent surgery, with median follow-up of 8.5 years. Occiput to upper cervical spine fusion with C1 decompression was performed in all cases with the addition of autologous calvarial graft in young patients (12 cases) and occipital-cervical plate fixation in older children (six cases). Neurological improvement occurred in 38% of cases but by one functional level only. Six of nine conservatively treated patients remained independent walkers. CONCLUSION Surgery for craniovertebral pathology is required in the majority of children with Morquio A syndrome. Close clinical and radiological surveillance is essential for timely intervention. Occiput to cervical fusion is safe and feasible even in young patients and improves clinical and radiological parameters. LEVEL OF EVIDENCE 4.
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10
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Abnormalities of the craniovertebral junction in the paediatric population: a novel biomechanical approach. Clin Radiol 2018; 73:839-854. [DOI: 10.1016/j.crad.2018.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 05/15/2018] [Indexed: 12/20/2022]
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Broomfield A, Zuberi K, Mercer J, Moss G, Finnegan N, Hensman P, Walker R, Bukhari S, Wright NB, Stewart F, Jones SA, Ramirez R. Outcomes from 18 years of cervical spine surgery in MPS IVA: a single centre's experience. Childs Nerv Syst 2018; 34:1705-1716. [PMID: 29946810 DOI: 10.1007/s00381-018-3823-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 05/04/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE This study examines the long-term outcomes of paediatric Morquio (MPS IVA) patients undergoing cervical spine surgery and evaluates the factors that impacting this. METHODS A retrospective review was performed on all MPS IVA patients undergoing cervical spine surgery, since the introduction of standardised neuroradiological screening. The impact of preoperative neurological status, growth, genotype and radiological status on outcome is assessed, whilst long-term surgical, radiological and neurological outcomes are documented. RESULTS Twenty-six of the eighty-two MPS IVA patients (31%) reviewed underwent cervical spine surgery at a median age of 6.1 years (range, 1.45 to 15.24). Preoperatively, cord signal change was seen in 11 patients with 5 being myelopathic; however, 6 clinically manifesting patients had no overt cord signal change. Postoperatively, none of the 14 preoperatively clinically asymptomatic patients followed long term progressed neurologically during a median follow-up of 77.5 months (range = 18-161). Of the ten preoperatively clinically symptomatic patients who were followed up for the same duration, seven continued to deteriorate, two initially improved and one remained stable. Radiological follow-up performed for a median duration of 7 years (range = 0.5-16) has shown a degree of stenosis at the level immediately caudal to the termination of the graft in 76% of patients, though only one has become clinically symptomatic and required revision. CONCLUSIONS Once clinically elicitable neurological signs become evident in patients with MPS IVA, they tend to progress despite surgical intervention. Referring clinicians should also not be falsely reassured by the lack of T2 spinal cord signal change but should consider surgical intervention in the face of new clinical symptomology or radiological signs of progressive canal stenosis or instability.
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Affiliation(s)
- A Broomfield
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK.
| | - K Zuberi
- Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Rd, Manchester, M13 9PL, UK
| | - J Mercer
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
| | - G Moss
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
| | - N Finnegan
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
| | - P Hensman
- Department of Physiotherapy, Royal Manchester Children's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
| | - R Walker
- Department of Paediatric Anaesthetics, Royal Manchester Children's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
| | - S Bukhari
- Department of Paediatric Neurosurgery, Royal Manchester Children's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
| | - N B Wright
- Department of Paediatric Radiology, Royal Manchester Children's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
| | - F Stewart
- N.I Regional Genetics Service, Level A, Belfast City Hospital, Lisburn Rd, Belfast, BT9 7AB, UK
| | - S A Jones
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
| | - R Ramirez
- Department of Paediatric Neurosurgery, Royal Manchester Children's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
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12
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Krenzlin H, Ta-Chih T, Lampe C, Lampe C, Knuf M, Horn P, Schwarz M. Stand-alone craniocervical decompression is feasible in children with mucopolysaccharidosis type I, IVA, and VI. Spine J 2018; 18:1455-1459. [PMID: 29649608 DOI: 10.1016/j.spinee.2018.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 03/03/2018] [Accepted: 04/02/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In patients with mucopolysaccharidosis (MPS), glycosaminoglycan deposits in the dura mater and supporting ligaments cause spinal cord compression and consecutive myelopathy, predominantly at the craniocervical junction. Disease characteristics of craniocervical stenosis (CCS) in patients with MPS differ profoundly from other hereditary and degenerative forms. Because of high periprocedural morbidity and mortality, patients with MPS pose a substantial challenge to the inexperienced medical care provider. As literature remains scarce, we present our experience with a large cohort of patients with MPS treated for CCS without atlanto-occipital instrumentation. PURPOSE The present study aimed to describe a safe and least traumatic approach for treating CCS in children with MPS, avoiding primary instrumentation. STUDY DESIGN This is a prospective follow-up (cohort) study. PATIENT SAMPLES We report 15 consecutive patients with CCS related to MPS, who were treated with stand-alone cervical decompression. OUTCOME MEASURES Myelopathy was assessed using magnetic resonance imaging (MRI), somatosensory evoked potentials, and clinical evaluation. Cervical instability was evaluated using plain x-ray and MRI. The disability status is quantified using either the Karnofsky or Lansky Performance Score. METHODS We describe 15 consecutive patients treated with craniocervical decompression. Data were collected prospectively. The mean follow-up is 6 years (5 standard deviation). The technique and treatment principles are described. RESULTS The overall clinical outcome in this patient cohort is good (mean Karnofsky Performance Score of 80). No patient developed signs of C0-C1-C2 instability or progressive myelopathy. Restenosis occurred in seven patients, requiring a total of eight reoperations. CONCLUSIONS Surgery in patients with MPS is associated with high morbidity and mortality of up to 4.2%. Because of the unique nature of the disease, recurring stenosis is inevitable. To shorten the procedure time and simplify the anticipated reoperation, we provide data that craniocervical decompression is feasible without the necessity of primary osteosynthesis. In the absence of craniocervical instability, decompression surgery without occipitocervical stabilization yields good postoperative results and challenges the long-standing paradigm of prophylactic craniocervical fixation.
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Affiliation(s)
- Harald Krenzlin
- Department of Neurosurgery and Paediatric Neurosurgery, HELIOS Dr. Horst-Schmidt Kliniken, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Tan Ta-Chih
- Department of Neurosurgery and Paediatric Neurosurgery, HELIOS Dr. Horst-Schmidt Kliniken, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany; Department of Pediatrics, HELIOS Dr. Horst-Schmidt Kliniken, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany
| | - Christina Lampe
- Center for Rare Diseases, HELIOS Dr. Horst-Schmidt Kliniken, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany
| | - Christian Lampe
- Department of Pediatrics, HELIOS Dr. Horst-Schmidt Kliniken, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany
| | - Markus Knuf
- Department of Pediatrics, HELIOS Dr. Horst-Schmidt Kliniken, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany
| | - Peter Horn
- Department of Neurosurgery and Paediatric Neurosurgery, HELIOS Dr. Horst-Schmidt Kliniken, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany
| | - Manfred Schwarz
- Department of Neurosurgery and Paediatric Neurosurgery, HELIOS Dr. Horst-Schmidt Kliniken, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany; Department of Pediatrics, HELIOS Dr. Horst-Schmidt Kliniken, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany
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13
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Abstract
BACKGROUND Paraplegia or death secondary to upper cervical spine instability and spinal cord compression are known consequences of spondyloepiphyseal dysplasia congenita (SEDC). Stabilization and occasionally decompression of the upper cervical spine are indicated to treat upper cervical instability and stenosis. The purpose of this study was to report the results of upper cervical spine fusion in children with SEDC who had upper cervical instability. METHODS Twenty children (17 females and 3 males) with SEDC who underwent upper cervical spine fusion at a mean age of 72 months were retrospectively analyzed. Three of these children were under the age of 2. Fifteen children had posterior instrumentation and fusion whereas 5 children had posterior in situ fusion without use of any implant. Thirteen of 20 children had iliac crest autograft. Radiographic and clinical results were reported. RESULTS The average follow-up period was 8 years and 8 months. All children with instrumentation achieved fusion. Three of 5 children who had no instrumentation had nonunion (1 child had a stable nonunion and did not need revision; 1 had a single noninstrumented revision and ended up with a stable nonunion without further intervention; and the third one had a noninstrumented revision and had to have a second, instrumented, revision to achieve fusion). Six children had thoracolumbar scoliosis or kyphoscoliosis which required surgical management.No postoperative neurological deficits were observed. Two of the 3 children with a preoperative neurological deficit showed full recovery and the third one remained unchanged. Pseudarthrosis is the main complication for the noninstrumented group. Distal junctional instability after successful fusion is seen at long-term follow-up (average=6 y) for 13% of patients in instrumented group. CONCLUSIONS Instrumentation and iliac bone grafting results in 100% upper cervical fusion for SEDC children who demonstrated instability before surgery. LEVEL OF EVIDENCE Level IV-therapeutic.
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14
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Rigid Occipitocervical Instrumented Fusion for Atlantoaxial Instability in an 18-Month-Old Toddler With Brachytelephalangic Chondrodysplasia Punctata: A Case Report. Spine (Phila Pa 1976) 2017; 42:E1380-E1385. [PMID: 28338574 DOI: 10.1097/brs.0000000000002170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE We report here on an 18-month-old boy with brachytelephalangic chondrodysplasia punctata (BCDP), whose atlantoaxial instability was successfully managed with occipitocervical instrumented fusion (OCF) using screw and rod instrumentations. SUMMARY OF BACKGROUND DATA Recently, there have been a number of reports on BCDP with early onset of cervical myelopathy. Surgical OCF is a vital intervention to salvage affected individuals from the life-threatening morbidity. Despite recent advancement of instrumentation techniques, however, rigid OCF is technically demanding in very young children with small and fragile osseous elements. To our best knowledge, this is the first report on application of the instrumentation technique to a toddler patient with BCDP. METHODS A 16-month-old boy with BCDP presented with tetraplegia and swallow obstacle. Hypoplasia of the odontoid process and atlantoaxial instability were present in lateral radiographs. T2-weighted magnetic resonance (MR) images revealed a high signal region in the spinal cord at the C1-2 and C7-T1 levels. Cervical computed tomography (CT) showed that the pedicles and lateral masses in the cervical spine were small and immature, but the laminae were comparatively thick. RESULTS One week before surgery, the patient was fitted with a Halo-body jacket. We performed plate-rod placement with occipital cortical screws and C2/C3 interlaminar screws, and added an autogenous bone graft using the right 8 and 9 ribs. Rigid fixation of the occipito-cervical spine was completed successfully without major complications. Postoperative halo-body jacket immobilization was continued for 3 months, after which Aspen collar was fitted. CT confirmed occipitocervical bone fusion at 6 months after surgery. Mild clinical improvements in motor power of the affected muscles and swallowing were witnessed at 1 year postoperatively. CONCLUSION Rigid fixation using screw, rod, and occipital plate instrumentation was successful in an 18-month-old toddler with BCDP and atlantoaxial instability. Bone fusion was achieved at postoperative 6 months. LEVEL OF EVIDENCE 5.
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15
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Abstract
PURPOSE To report indications, outcomes and complications of instrumented cervical spinal fusion in a consecutive series of children at major university hospitals. METHODS A retrospective, single surgeon series identified 35 consecutive children with a mean follow-up (FU) of 2.5 years undergoing instrumented cervical spinal fusion between 2005 and 2015. RESULTS The main indications were skeletal dysplasia and trauma associated cervical instability. Surgical complications were observed in 12 (34%) patients with multiple complications in four (11%). Four (11%) children required at least one revision surgery, three for nonunion and one for graft dislodgement. All were fused at FU. Surgical complications were more common in children undergoing occipitocervical (OC) fusion than in those avoiding fusion of the OC junction (60% versus 24%) (p = 0.043). Complications were found significantly more in children operated on under the age of ten years than above (50% versus 18%) (p = 0.004). The risk of complications was not dependent on the indications for surgery (skeletal dysplasia versus trauma) (p = 0.177). CONCLUSION Skeletal dysplasia associated cervical instability and cervical spine injuries represented the most common indications for instrumented cervical spinal fusion in children. Complications were observed in one-third of these children and 11% required revision surgery for complications. OC spinal fusion and spinal fusion before the age of ten years are associated with higher risk of surgical complications and increased mortality than non-OC fusions and cervical spinal fusions at an older age. We urge surgeons to employ caution to the patient, timing and procedure selection when treating paediatric cervical spine.
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Affiliation(s)
- M. Lastikka
- Department of Paediatric Orthopaedic Surgery and Department of Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland,Correspondence should be sent to M. Lastikka MD, Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20520 Turku, Finland. E-mail:
| | - J. Aarnio
- Medical Faculty, University of Turku, Finland
| | - I. Helenius
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
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16
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Aydın E, ERASLAN CENK, Canda E, Yazıcı H, Kalkan Uçar S, Çoker M, Çallı MC, Kitiş Ö. Mukopolisakkaridoz tip IVa’da (Morquio sendromu) spinal tutulum: Tanı ve izlemde MRG’nin önemi. EGE TIP DERGISI 2017. [DOI: 10.19161/etd.390224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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Tanaka Y, Watanabe K, Katsumi K, Ohashi M, Nagasaki K, Hirano T. Occipitocervical Fusion for Severe Atlantoaxial Dislocation in an Underdeveloped Child with Chondrodysplasia Punctata: A Case Report. JBJS Case Connect 2017; 7:e16. [PMID: 29244697 DOI: 10.2106/jbjs.cc.16.00121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE We present a case of brachytelephalangic chondrodysplasia punctata with a severe atlantoaxial dislocation in an underdeveloped child. The patient underwent halo jacket application using 10 halo pins with <1 lb/in of torque, followed by posterior occipitocervical fusion with onlay rib and iliac autografts. After bone grafts and replacement of the halo ring multiple times, successful osseous fusion had been achieved by the 2-year follow-up. CONCLUSION Although simple bone-grafting with a halo jacket is useful in underdeveloped patients with skeletal dysplasia, the complications related to halo fixation, including cranial bone perforation, and the patient's neurological status must be carefully monitored.
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Affiliation(s)
- Yuki Tanaka
- Departments of Orthopedic Surgery (Y.T., K.W., K.K., M.O., and T.H.) and Pediatrics (K.N.), Niigata University Medical and Dental General Hospital, Niigata City, Niigata, Japan
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18
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Khan S, Alméciga-Díaz CJ, Sawamoto K, Mackenzie WG, Theroux MC, Pizarro C, Mason RW, Orii T, Tomatsu S. Mucopolysaccharidosis IVA and glycosaminoglycans. Mol Genet Metab 2017; 120:78-95. [PMID: 27979613 PMCID: PMC5293636 DOI: 10.1016/j.ymgme.2016.11.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 12/21/2022]
Abstract
Mucopolysaccharidosis IVA (MPS IVA; Morquio A: OMIM 253000) is a lysosomal storage disease with an autosomal recessive trait caused by the deficiency of N-acetylgalactosamine-6-sulfate sulfatase. Deficiency of this enzyme leads to accumulation of specific glycosaminoglycans (GAGs): chondroitin-6-sulfate (C6S) and keratan sulfate (KS). C6S and KS are mainly produced in the cartilage. Therefore, the undegraded substrates are stored primarily in cartilage and in its extracellular matrix (ECM), leading to a direct impact on cartilage and bone development, and successive systemic skeletal dysplasia. Chondrogenesis, the earliest phase of skeletal formation, is maintained by cellular interactions with the ECM, growth and differentiation factors, signaling pathways, and transcription factors in a temporal-spatial manner. In patients with MPS IVA, the cartilage is disrupted at birth as a consequence of abnormal chondrogenesis and/or endochondral ossification. The unique skeletal features are distinguished by a disproportional short stature, odontoid hypoplasia, spinal cord compression, tracheal obstruction, pectus carinatum, kyphoscoliosis, platyspondyly, coxa valga, genu valgum, waddling gait, and laxity of joints. In spite of many descriptions of these unique clinical features, delay of diagnosis still happens. The pathogenesis and treatment of systemic skeletal dysplasia in MPS IVA remains an unmet challenge. In this review article, we comprehensively describe historical aspect, property of GAGs, diagnosis, screening, pathogenesis, and current and future therapies of MPS IVA.
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Affiliation(s)
- Shaukat Khan
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Carlos J Alméciga-Díaz
- Institute for the Study of Inborn Errors of Metabolism, Pontificia Universidad Javeriana, Bogotá D.C., Colombia
| | - Kazuki Sawamoto
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - William G Mackenzie
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Mary C Theroux
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Christian Pizarro
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Robert W Mason
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Tadao Orii
- Department of Pediatrics, Gifu University, Gifu, Japan
| | - Shunji Tomatsu
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States; Department of Pediatrics, Gifu University, Gifu, Japan; Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, United States.
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19
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Yasuda E, Suzuki Y, Shimada T, Sawamoto K, Mackenzie WG, Theroux MC, Pizarro C, Xie L, Miller F, Rahman T, Kecskemethy HH, Nagao K, Morlet T, Shaffer TH, Chinen Y, Yabe H, Tanaka A, Shintaku H, Orii KE, Orii KO, Mason RW, Montaño AM, Fukao T, Orii T, Tomatsu S. Activity of daily living for Morquio A syndrome. Mol Genet Metab 2016; 118:111-22. [PMID: 27161890 PMCID: PMC5016714 DOI: 10.1016/j.ymgme.2016.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 04/07/2016] [Indexed: 01/26/2023]
Abstract
The aim of this study was to evaluate the activity of daily living (ADL) and surgical interventions in patients with mucopolysaccharidosis IVA (MPS IVA). The factor(s) that affect ADL are age, clinical phenotypes, surgical interventions, therapeutic effect, and body mass index. The ADL questionnaire comprises three domains: "Movement," "Movement with cognition," and "Cognition." Each domain has four subcategories rated on a 5-point scale based on the level of assistance. The questionnaire was collected from 145 healthy controls and 82 patients with MPS IVA. The patient cohort consisted of 63 severe and 17 attenuated phenotypes (2 were undefined); 4 patients treated with hematopoietic stem cell transplantation (HSCT), 33 patients treated with enzyme replacement therapy (ERT) for more than a year, and 45 untreated patients. MPS IVA patients show a decline in ADL scores after 10years of age. Patients with a severe phenotype have a lower ADL score than healthy control subjects, and lower scores than patients with an attenuated phenotype in domains of "Movement" and "Movement with cognition." Patients, who underwent HSCT and were followed up for over 10years, had higher ADL scores and fewer surgical interventions than untreated patients. ADL scores for ERT patients (2.5years follow-up on average) were similar with the-age-matched controls below 10years of age, but declined in older patients. Surgical frequency was higher for severe phenotypic patients than attenuated ones. Surgical frequency for patients treated with ERT was not decreased compared to untreated patients. In conclusion, we have shown the utility of the proposed ADL questionnaire and frequency of surgical interventions in patients with MPS IVA to evaluate the clinical severity and therapeutic efficacy compared with age-matched controls.
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Affiliation(s)
- Eriko Yasuda
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Department of Medical Informatics, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Yasuyuki Suzuki
- Department of Hospital Pharmacy, University Hospital, Kanazawa University, Kanazawa, Japan
| | - Tsutomu Shimada
- Medical Education Development Center, Gifu University, Gifu, Japan
| | - Kazuki Sawamoto
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | - Mary C Theroux
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | - Li Xie
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Freeman Miller
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Tariq Rahman
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | - Kyoko Nagao
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Thierry Morlet
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Thomas H Shaffer
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Yasutsugu Chinen
- Department of Pediatrics, Faculty of Medicine, University of the Ryukyus, Ryukyu, Japan
| | - Hiromasa Yabe
- Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Akemi Tanaka
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Haruo Shintaku
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kenji E Orii
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Koji O Orii
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Robert W Mason
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Adriana M Montaño
- Department of Pediatrics, Saint Louis University, St. Louis, MO, USA; Department of Biochemistry and Molecular Biology, Saint Louis University, St. Louis, MO, USA
| | - Toshiyuki Fukao
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Tadao Orii
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan.
| | - Shunji Tomatsu
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan.
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20
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Reintjes SL, Amankwah EK, Rodriguez LF, Carey CC, Tuite GF. Allograft versus autograft for pediatric posterior cervical and occipito-cervical fusion: a systematic review of factors affecting fusion rates. J Neurosurg Pediatr 2016; 17:187-202. [PMID: 26496632 DOI: 10.3171/2015.6.peds1562] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fusion rates are high for children undergoing posterior cervical fusion (PCF) and occipito-cervical fusion (OCF). Autologous bone has been widely used as the graft material of choice, despite the risk of donor-site morbidity associated with harvesting the bone, possibly because very low fusion rates were reported with posterior allograft cervical fusions in children several decades ago. Higher overall fusion rates using allograft in adults, associated with improvements in internal fixation techniques and the availability of osteoinductive substances such as bone morphogenetic protein (BMP), have led to heightened enthusiasm for the use of bank bone during pediatric PCF. A systematic review was performed to study factors associated with successful bone fusion, including the type of bone graft used. METHODS The authors performed a comprehensive PubMed search of English-language articles pertaining to PCF and OCF in patients less than 18 years old. Of the 561 abstracts selected, 148 articles were reviewed, resulting in 60 articles that had sufficient detail to be included in the analysis. A meta-regression analysis was performed to determine if and how age, fusion technique, levels fused, fusion substrate, BMP use, postoperative bracing, and radiographic fusion criteria were related to the pooled prevalence estimates. A systematic review of the literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. RESULTS A total of 604 patients met the specific inclusion and exclusion criteria. The overall fusion rate was 93%, with a mean age of 9.3 years and mean follow-up of 38.7 months. A total of 539 patients had fusion with autograft (94% fusion rate) and 65 patients with allograft (80% fusion rate). Multivariate meta-regression analysis showed that higher fusion rates were associated with OCF compared with fusions that excluded the occiput (p < 0.001), with the use of autograft instead of allograft (p < 0.001), and with the use of CT to define fusion instead of plain radiography alone. The type of internal fixation, the use of BMP, patient age, and the duration of follow-up were not found to be associated with fusion rates in the multivariate analysis. CONCLUSIONS Fusion rates for PCF are high, with higher rates of fusion seen when autograft is used as the bone substrate and when the occiput is included in the fusion construct. Further study of the use of allograft as a viable alternative to autograft bone fusion is warranted because limited data are available regarding the use of allograft in combination with more rigid internal fixation techniques and osteoinductive substances, both of which may enhance fusion rates with allograft.
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Affiliation(s)
- Stephen L Reintjes
- Neuroscience Institute, and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida; and
| | - Ernest K Amankwah
- Department of Clinical and Translational Research, All Children's Hospital/Johns Hopkins Medicine, St. Petersburg
| | - Luis F Rodriguez
- Neuroscience Institute, and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida; and
| | - Carolyn C Carey
- Neuroscience Institute, and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida; and
| | - Gerald F Tuite
- Neuroscience Institute, and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida; and.,Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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21
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Pakkasjärvi N, Mattila M, Remes V, Helenius I. Upper cervical spine fusion in children with skeletal dysplasia. Scand J Surg 2015; 102:189-96. [PMID: 23963034 DOI: 10.1177/1457496913486742] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Skeletal dysplasias have been associated with upper cervical instability. Many patients are initially asymptomatic, but the instability may progress to subluxation and dislocation and complications thereof, including death. Surgery is hampered by petite osseous structures and low bone formation rate. AIM To review the outcomes of surgical fusion of upper cervical instability in children with rare skeletal dysplasias. MATERIAL AND METHODS A retrospective study of eight children with five different rare skeletal dysplasias needing upper cervical instrumented stabilization. Cases were evaluated for clinical, radiologic, and quality-of-life outcomes, with median follow-up time of 5 years. RESULTS Six patients underwent posterior, segmental cervical spine instrumentation and fusion (three C1/C2 fusions, three occipitocervical fusions), one anterior cervical instrumented spinal fusion, and one anteroposterior fusion. Autogenous bone grafting was used in all patients, and seven were immobilized using a halo body jacket. Nonunion in occipitocervical fusions was common in these patients (3/8 patients). Rib autograft from occiput to cervical spine with recombinant human BMP-2 was used to salvage nonunions. CONCLUSIONS Surgical fixation in the pediatric cervical spine is hampered by fragile posterior structures. A postoperative immobilization by halo vest for 4 months is customary. Selective anterior corpectomy and plate fixation is not recommended in pediatric patients with skeletal dysplasias. LEVEL OF EVIDENCE Level 4, Case Series.
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Affiliation(s)
- N Pakkasjärvi
- Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
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22
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Terhal PA, Nievelstein RJAJ, Verver EJJ, Topsakal V, van Dommelen P, Hoornaert K, Le Merrer M, Zankl A, Simon MEH, Smithson SF, Marcelis C, Kerr B, Clayton-Smith J, Kinning E, Mansour S, Elmslie F, Goodwin L, van der Hout AH, Veenstra-Knol HE, Herkert JC, Lund AM, Hennekam RCM, Mégarbané A, Lees MM, Wilson LC, Male A, Hurst J, Alanay Y, Annerén G, Betz RC, Bongers EMHF, Cormier-Daire V, Dieux A, David A, Elting MW, van den Ende J, Green A, van Hagen JM, Hertel NT, Holder-Espinasse M, den Hollander N, Homfray T, Hove HD, Price S, Raas-Rothschild A, Rohrbach M, Schroeter B, Suri M, Thompson EM, Tobias ES, Toutain A, Vreeburg M, Wakeling E, Knoers NV, Coucke P, Mortier GR. A study of the clinical and radiological features in a cohort of 93 patients with aCOL2A1mutation causing spondyloepiphyseal dysplasia congenita or a related phenotype. Am J Med Genet A 2015; 167A:461-75. [DOI: 10.1002/ajmg.a.36922] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 10/22/2014] [Indexed: 11/05/2022]
Affiliation(s)
- Paulien A. Terhal
- Department of Medical Genetics; University Medical Centre Utrecht; Utrecht The Netherlands
| | | | - Eva J. J. Verver
- Department of Otorhinolaryngology and Head and Neck Surgery; Rudolf Magnus Institute of Neuroscience; University Medical Centre Utrecht; Utrecht The Netherlands
| | - Vedat Topsakal
- Department of Otorhinolaryngology and Head and Neck Surgery; Rudolf Magnus Institute of Neuroscience; University Medical Centre Utrecht; Utrecht The Netherlands
| | | | | | - Martine Le Merrer
- Department of Genetics, INSERM UMR_1163, Paris Descartes-Sorbonne Paris Cité University, Imagine Institute; Hôpital Necker-Enfants Malades; Paris France
| | - Andreas Zankl
- Academic Department of Medical Genetics; Discipline of Genetic Medicine, The University of Sydney; Sydney Children's Hospital Network (Westmead); Sydney Australia
| | - Marleen E. H. Simon
- Department of Clinical Genetics; Erasmus Medical Centre; University Medical Centre; Rotterdam The Netherlands
| | - Sarah F. Smithson
- Department of Clinical Genetics; St. Michael's Hospital; Bristol United Kingdom
| | - Carlo Marcelis
- Department of Human Genetics; Nijmegen Centre for Molecular Life Sciences; Institute for Genetic and Metabolic Disease; Radboud University Medical Centre; Nijmegen The Netherlands
| | - Bronwyn Kerr
- Manchester Centre For Genomic Medicine, University of Manchester; St Mary's Hospital; Manchester United Kingdom
| | - Jill Clayton-Smith
- Manchester Centre For Genomic Medicine, University of Manchester; St Mary's Hospital; Manchester United Kingdom
| | - Esther Kinning
- Department of Clinical Genetics; Southern General Hospital; Glasgow United Kingdom
| | - Sahar Mansour
- SW Thames Regional Genetics Service; St George's NHS Trust; London United Kingdom
| | - Frances Elmslie
- SW Thames Regional Genetics Service; St George's NHS Trust; London United Kingdom
| | - Linda Goodwin
- Department of Genetics; Nepean Hospital; Penrith Australia
| | | | | | - Johanna C. Herkert
- Department of Genetics; University Medical Centre Groningen; Groningen The Netherlands
| | - Allan M. Lund
- Centre for Inherited Metabolic Diseases; Department of Clinical Genetics; Copenhagen University Hospital; Copenhagen Denmark
| | - Raoul C. M. Hennekam
- Department of Pediatrics; Academic Medical Centre; University of Amsterdam; Amsterdam The Netherlands
| | - André Mégarbané
- Unité de Génétique Médicale et Laboratoire Associé Institut National de la Santé et de la Recherche Médicale UMR-S910; Université Saint-Joseph; Beirut Lebanon
| | - Melissa M. Lees
- Department of Clinical Genetics; Great Ormond Street Hospital; London United Kingdom
| | - Louise C. Wilson
- Department of Clinical Genetics; Great Ormond Street Hospital; London United Kingdom
| | - Alison Male
- Department of Clinical Genetics; Great Ormond Street Hospital; London United Kingdom
| | - Jane Hurst
- Department of Clinical Genetics; Great Ormond Street Hospital; London United Kingdom
- Department of Clinical Genetics; Churchill Hospital; Oxford United Kingdom
| | - Yasemin Alanay
- Pediatric Genetics Unit; Department of Pediatrics; Acibadem University School of Medicine; Istanbul Turkey
| | - Göran Annerén
- Department of Immunology; Genetics and Pathology; Science for Life Laboratory; Uppsala University; Uppsala Sweden
| | - Regina C. Betz
- Institute of Human Genetics; University of Bonn; Bonn Germany
| | - Ernie M. H. F. Bongers
- Department of Human Genetics; Nijmegen Centre for Molecular Life Sciences; Institute for Genetic and Metabolic Disease; Radboud University Medical Centre; Nijmegen The Netherlands
| | - Valerie Cormier-Daire
- Department of Genetics, INSERM UMR_1163, Paris Descartes-Sorbonne Paris Cité University, Imagine Institute; Hôpital Necker-Enfants Malades; Paris France
| | - Anne Dieux
- Service de Génétique Clinique; Hôpital Jeanne de Flandre; Lille France
| | - Albert David
- Service de Génétique Médicale; CHU de Nantes; Nantes France
| | - Mariet W. Elting
- Department of Clinical Genetics; VU University Medical Centre; Amsterdam The Netherlands
| | - Jenneke van den Ende
- Department of Medical Genetics; Antwerp University Hospital; University of Antwerp; Edegem Belgium
| | - Andrew Green
- National Centre for Medical Genetics and School of Medicine and Medical Science; University College Dublin, Our Lady's Hospital Crumlin; Dublin Ireland
| | - Johanna M. van Hagen
- Department of Clinical Genetics; VU University Medical Centre; Amsterdam The Netherlands
| | - Niels Thomas Hertel
- H.C. Andersen Children's Hospital; Odense University Hospital; Odense Denmark
| | - Muriel Holder-Espinasse
- Service de Génétique Clinique; Hôpital Jeanne de Flandre; Lille France
- Department of Clinical Genetics; Guy's Hospital; London United Kingdom
| | | | | | - Hanne D. Hove
- Department of Clinical Genetics; Rigshospitalet; Copenhagen Denmark
| | - Susan Price
- Department of Clinical Genetics; Churchill Hospital; Oxford United Kingdom
| | - Annick Raas-Rothschild
- Institute of Medical Genetics; Meir Medical Centre, Kfar Saba, and Sackler School of Medicine Tel Aviv University; Tel Aviv Israel
| | - Marianne Rohrbach
- Division of Metabolism, Children's Research Centre, Connective Tissue Unit; University Children's Hospital Zurich; Zurich Switzerland
| | | | - Mohnish Suri
- Nottingham Clinical Genetics Service, City Hospital Campus; Nottingham University Hospitals NHS Trust; Nottingham United Kingdom
| | - Elizabeth M. Thompson
- SA Clinical Genetics, SA Pathology at the Women's and Children's Hospital, North Adelaide, South Australia, Australia and Department of Paediatrics; University of Adelaide; Adelaide North Terrace, South Australia
| | - Edward S. Tobias
- Medical Genetics, School of Medicine, Coll Med Vet and Life Sci; University of Glasgow; Glasgow Scotland
| | | | - Maaike Vreeburg
- Department of Clinical Genetics; Maastricht University Medical Centre; Maastricht The Netherlands
| | - Emma Wakeling
- North West Thames Regional Genetic Service; North West London Hospitals NHS Trust; London United Kingdom
| | - Nine V. Knoers
- Department of Medical Genetics; University Medical Centre Utrecht; Utrecht The Netherlands
| | - Paul Coucke
- Department of Medical Genetics; Ghent University Hospital; Ghent Belgium
- Ghent University; Ghent Belgium
| | - Geert R. Mortier
- Department of Medical Genetics; Antwerp University Hospital; University of Antwerp; Edegem Belgium
- Ghent University; Ghent Belgium
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23
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Francomano CA. Skeletal dysplasias. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00211-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE This study describes clinical and radiological results of a new cable technique for occipitocervical fusion (OCF) in children with skeletal dysplasia (SD). SUMMARY OF BACKGROUND DATA Anatomical variability and poor bone quality make upper cervical surgery technically challenging in patients with SD. We present a new cable technique for OCF in children with SD when the posterior elements are not of a size or quality for other types of instrumentation. METHODS Retrospective review of 24 patients with SD (8 boys, 16 girls) who underwent OCF between 2001 and 2011. In this technique, cables provide compression across a bone graft that is prevented from entering the canal and the graft resists excessive lordosis. Demographic and radiographical data are presented. All patients were followed for initial outcomes of surgery, and 20 patients (83%) were followed for 2 years or more for mid- and long-term outcomes. RESULTS Mean age at surgery was 6.5 years and mean follow-up was 4.1 ± 2.4 years. This technique was used as a primary procedure in 20 and a revision procedure in 4 patients. Diagnoses included Morquio syndrome (6), spondyloepiphyseal dysplasia (9), spondyloepimetaphyseal dysplasia (5), metatropic dysplasia (3), and Kniest syndrome (1). Ten patients had upper cervical instability and features of cervical myelopathy, and the remaining 14 patients had instability and signal changes on magnetic resonance image. Fusion extended from occiput to C2 in 71% patients, and upper cervical decompression was needed in 92% patients. Postoperatively, all patients were immobilized in a halo vest for mean duration of 12 weeks. Fusion was achieved in all patients. Complications included halo pin-tract infections (7), junctional instability (2), and extension of fusion (4). CONCLUSION This new cable technique is a good alternative for OCF in patients with SD who have altered anatomy at the craniocervical junction not amenable to rigid internal fixation. LEVEL OF EVIDENCE 4.
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Neurosurgical Interventions for Spondyloepiphyseal Dysplasia Congenita: Clinical Presentation and Assessment of the Literature. World Neurosurg 2013; 80:437.e1-8. [DOI: 10.1016/j.wneu.2012.01.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Revised: 12/05/2011] [Accepted: 01/19/2012] [Indexed: 12/26/2022]
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Dede O, Thacker MM, Rogers KJ, Oto M, Belthur MV, Baratela W, Mackenzie WG. Upper cervical fusion in children with Morquio syndrome: intermediate to long-term results. J Bone Joint Surg Am 2013; 95:1228-34. [PMID: 23824392 DOI: 10.2106/jbjs.j.01135] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Paraplegia or death secondary to upper cervical spine instability and spinal cord compression are known consequences of Morquio syndrome. Decompression and fusion of the upper cervical spine are indicated to treat spinal cord compression. The purpose of this study was to report the intermediate to long-term results of upper cervical spine fusion in children with Morquio syndrome. METHODS Twenty patients (nine female and eleven male) with Morquio syndrome who underwent upper cervical spine fusion at a mean age of sixty-three months were retrospectively analyzed with use of hospital records. Radiographic and clinical results were reported. RESULTS The average follow-up period was eight years and ten months. Fusion was achieved in all patients except one; this patient underwent a revision with transarticular C1-C2 screw fixation. Seven patients developed symptomatic instability below the fusion mass that required extension of fusion to lower levels at a mean of ninety-one months after the initial operation. Two patients required decompression and fusion of a site other than the upper cervical spine. Asymptomatic cervicothoracic and thoracolumbar kyphosis was prevalent among our patients. All patients were neurologically stable at the time of the latest follow-up visit. CONCLUSIONS Upper cervical spine fusion provides reliable fusion and a stable neural outcome in patients with Morquio syndrome. However, distal junctional instability is a major problem at long-term follow-up. Kyphotic deformity of the cervicothoracic and thoracolumbar junction may be present in a large number of patients with Morquio syndrome and evaluation for spinal stenosis at these levels should also be considered.
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Affiliation(s)
- Ozgur Dede
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA
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Möllmann C, Lampe CG, Müller-Forell W, Scarpa M, Harmatz P, Schwarz M, Beck M, Lampe C. Development of a Scoring System to Evaluate the Severity of Craniocervical Spinal Cord Compression in Patients with Mucopolysaccharidosis IVA (Morquio A Syndrome). JIMD Rep 2013; 11:65-72. [PMID: 23580366 DOI: 10.1007/8904_2013_223] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 03/07/2013] [Accepted: 03/08/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND As spinal cord compression at the craniocervical junction (CCJ) is a life-threatening manifestation in patients with mucopolysaccharidosis (MPS) IVA, surgical decompression should be performed before damage becomes irreversible. We evaluated the diagnostic value of several examinations for determining the need for decompression surgery. METHODS We retrospectively analysed results of clinical neurological examination, somatosensory evoked potential (SEP) and magnetic resonance imaging (MRI) in 28 MPS IVA patients. A scoring system - based on the severity of findings - was used to compare results of patients with and without indication for decompression surgery. Individual test scores and two composite scores were evaluated for their potential to assess severity of CCJ impairment. RESULTS Sixteen patients had an indication for surgery; 12 of them had undergone surgery. Twelve patients had no indication for surgery; none had received surgery. Neurological (P = 0.004), MRI (P < 0.001) and atlantoaxial subluxation (P = 0.006) scores, but not SEP and odontoid hypoplasia scores, differed significantly between patients with and without surgical indication. Both the abbreviated CCJ score, i.e. sum of neurological and MRI scores, and the extended CCJ score, i.e. sum of abbreviated CCJ and atlantoaxial subluxation score, discriminated between patients with and without surgical indication (abbreviated: 0-2 points vs 2-5 points, P < 0.001; extended: 0-3 points vs 3-7 points; P < 0.001). Although CCJ instability plays a major role in cervical cord pathology, decompression surgery without occipito-cervical stabilisation may yield good postoperative results. CONCLUSIONS The abbreviated and extended CCJ scores are objective, transparent and reproducible tools for assessing the CCJ pathology and the need for surgery.
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Affiliation(s)
- Christian Möllmann
- Department of Paediatric and Adolescent Medicine, Villa Metabolica, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstr. 2, 55131, Mainz, Germany
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28
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Solanki GA, Martin KW, Theroux MC, Lampe C, White KK, Shediac R, Lampe CG, Beck M, Mackenzie WG, Hendriksz CJ, Harmatz PR. Spinal involvement in mucopolysaccharidosis IVA (Morquio-Brailsford or Morquio A syndrome): presentation, diagnosis and management. J Inherit Metab Dis 2013; 36:339-55. [PMID: 23385297 PMCID: PMC3590412 DOI: 10.1007/s10545-013-9586-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 12/29/2012] [Accepted: 01/07/2013] [Indexed: 11/30/2022]
Abstract
Mucopolysaccharidosis IVA (MPS IVA), also known as Morquio-Brailsford or Morquio A syndrome, is a lysosomal storage disorder caused by a deficiency of the enzyme N-acetyl-galactosamine-6-sulphate sulphatase (GALNS). MPS IVA is multisystemic but manifests primarily as a progressive skeletal dysplasia. Spinal involvement is a major cause of morbidity and mortality in MPS IVA. Early diagnosis and timely treatment of problems involving the spine are critical in preventing or arresting neurological deterioration and loss of function. This review details the spinal manifestations of MPS IVA and describes the tools used to diagnose and monitor spinal involvement. The relative utility of radiography, computed tomography (CT) and magnetic resonance imaging (MRI) for the evaluation of cervical spine instability, stenosis, and cord compression is discussed. Surgical interventions, anaesthetic considerations, and the use of neurophysiological monitoring during procedures performed under general anaesthesia are reviewed. Recommendations for regular radiological imaging and neurologic assessments are presented, and the need for a more standardized approach for evaluating and managing spinal involvement in MPS IVA is addressed.
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Affiliation(s)
- Guirish A Solanki
- Department of Paediatric Neurosurgery, Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, UK.
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Abstract
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.
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Mladenov KV, Kunkel P, Stuecker R. The use of recombinant human BMP-2 as a salvage procedure in the pediatric spine: a report on 3 cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 19 Suppl 2:S135-9. [PMID: 19876660 DOI: 10.1007/s00586-009-1179-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Revised: 07/21/2009] [Accepted: 09/15/2009] [Indexed: 12/22/2022]
Abstract
The study is a retrospective case series. The objective is to review the results after off-label recombinant human BMP-2 (rhBMP-2) use in the pediatric spine after previously failed spinal fusion. Non-union in the pediatric spine is a challenging condition associated with increased morbidity due to instability, neurological impairment or multiple revision surgeries. BMP has been used with good results in the adult spine; however, information on its use in the pediatric population is still lacking. rhBMP-2 was used at our institution at revision posterior spinal surgery in three patients. Solid spinal fusion was achieved in all three cases despite underlying bone dysplasia (Hurler's disease), instability or bony substance loss. No adverse reactions due to rhBMP-2 use were observed. rhBMP-2 should be considered as potential option to achieve spinal fusion in children with compromised bone healing due to congenital, local or systemic conditions.
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Affiliation(s)
- Kiril V Mladenov
- Department of Pediatric Orthopedic Surgery, Altonaer Children's Hospital, Bleickenallee 38, 22763 Hamburg, Germany.
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White KK, Steinman S, Mubarak SJ. Cervical stenosis and spastic quadriparesis in Morquio disease (MPS IV). A case report with twenty-six-year follow-up. J Bone Joint Surg Am 2009; 91:438-42. [PMID: 19181990 DOI: 10.2106/jbjs.h.00148] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Klane K White
- Department of Orthopaedic Surgery, Rady Children's Hospital of San Diego, San Diego, California, USA.
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Menezes AH, Vogel TW. Specific entities affecting the craniocervical region: syndromes affecting the craniocervical junction. Childs Nerv Syst 2008; 24:1155-63. [PMID: 18369644 DOI: 10.1007/s00381-008-0608-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The craniocervical junction is a vital component in understanding the function of the human central nervous system. It is the threshold for major pathways affecting both brain and spinal cord function, and these structures are intricately housed in a network of bone, ligaments, and soft tissues. Abnormal development of any of these components may lead to altered structure, and therefore, altered function in the central nervous system. MATERIALS AND METHODS We herein describe a set of genetic syndromes that commonly affect the craniovertebral junction and offer clinical examples from more than 6,000 patients who have been treated for these disorders. DISCUSSION The syndromes described include Chiari type I malformation, Conradi syndrome, Goldenhar syndrome, Klippel-Feil syndrome, Larsen syndrome, Morquio syndrome, Pierre-Robin syndrome, spondyloepiphyseal dysplasia congenital and Weaver syndrome. The genetic mechanisms responsible for these disorders may offer unique insight into the developmental pathways and patterning in the musculoskeletal and cranial systems and may, ultimately, guide future diagnosis and treatment.
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Affiliation(s)
- Arnold H Menezes
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 1824 JPP, Iowa, IA 52242, USA.
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Shetty GM, Song HR, Unnikrishnan R, Suh SW, Lee SH, Hur CY. Upper cervical spine instability in pseudoachondroplasia. J Pediatr Orthop 2008; 27:782-7. [PMID: 17878785 DOI: 10.1097/bpo.0b013e3181558c1d] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pseudoachondroplasia (PSACH) is a rare autosomal dominant skeletal dysplasia associated with os odontoideum and atlantoaxial instability. This study aims to define the characteristics of upper cervical spine instability in patients with PSACH and analyze the relation between the incidence of upper cervical instability and os odontoideum. METHODS Fifteen patients (10 women and 5 men) with PSACH of Korean ethnicity with mean age of 23.7 years (range, 3-44 years) at presentation to our hospital with varied complaints, including short stature, limb deformity, neck pain, and neurological symptoms, were evaluated clinicoradiologically for upper cervical spine instability. The patients were separated into group 1 (n = 9) with os odontoideum and group 2 (n = 6) without os odontoideum. Comparisons were made using parameters such as instability index, rotational instability, atlantodens interval and space available for cord, and analysis done to correlate cervical instability with age and Japanese Orthopedic Association (JOA) score. RESULTS Significant differences were found statistically when the 2 groups were compared on the basis of the space available for the cord (SAC), JOA scoring, and rotational instability. Linear relationship was found between instability and age and JOA score. Incidence of os odontoideum was 60% in our study group. CONCLUSIONS Os odontoideum led to an increase in the incidence of upper cervical spine instability. Instability increased with the age. The presence of os odontoideum and atlantoaxial instability did not warrant for surgery because no signs of cervical myelopathy developed or progressed in our patients during the follow-up period, but these patients should undergo regular clinical and radiological evaluation. LEVEL OF EVIDENCE Level IV prognostic study.
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Affiliation(s)
- Gautam M Shetty
- Department of Orthopedic Surgery, Korea University Guro Hospital, Rare Disease Institute, Seoul, Korea
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Stücker R. [Spinal problems in persons with skeletal dysplasias]. DER ORTHOPADE 2007; 37:63-8. [PMID: 18080108 DOI: 10.1007/s00132-007-1185-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Most skeletal dysplasias are characterized by small stature. Less well known is the fact that most skeletal dysplasias are also associated with specific spinal problems or deformities. This article summarizes the various aspects of spinal problems in this patient population as well as the diagnostic strategies and current and new treatment options.
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Affiliation(s)
- R Stücker
- Altonaer Kinderkrankenhaus, Bleickenallee 38, 22763 Hamburg, Deutschland.
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