Spine deformities in rare congenital syndromes: clinical issues

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

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

Instrumentation of hypoplastic pedicles with patient-specific guides

PURPOSE

Hypoplastic pedicles of the thoracolumbar spine (<5 mm diameter) are often found in syndromic deformities of the spine and pose a challenge in pedicle screw instrumentation. 3D-printed patient-specific guides might help overcome anatomical difficulties when instrumenting pedicles with screws, thereby reducing the necessity for less effective fixation methods such as hooks or sublaminar wires. In this study, the surgical feasibility and clinical outcome of patients with hypoplastic pedicles following pedicle screw instrumentation with 3D-printed patient-specific guides were assessed.

METHODS

Hypoplastic pedicles were identified on preoperative computed tomography (CT) scans in six patients undergoing posterior spinal fusion surgery between 2017 and 2020. Based on these preoperative CT scans, patient-specific guides were produced to help with screw instrumentation of these thin pedicles. Postoperatively, pedicle-screw-related complications or revisions were analyzed.

RESULTS

93/105 (88.6%) pedicle screws placed with patient-specific guides were instrumented. 62/93 (66.7%) of these instrumented pedicles were defined as hypoplastic with a mean width of 3.07 mm (SD  ±0.98 mm, 95% CI [2.82-3.32]). Overall, 6 complications in the 62 hypoplastic pedicles (9.7%) were observed and included intraoperatively managed 4 cerebrospinal fluid leaks, 1 pneumothorax and 1 delayed revision due to 2 lumbar screws (2/62, 3.3%) impinging the L3 nerve root causing a painful radiculopathy. The mean follow-up time was 26.7 (SD  ±11.7) months. Complications were only noted when the pedicle-width-to-screw-diameter ratio measured less than 0.62.

CONCLUSION

Patient-specific 3D-printed guides can aid in challenging instrumentation of hypoplastic pedicles in the thoracolumbar spine, especially if the pedicle-width-to-screw-diameter ratio is greater than 0.62.

Risk Factors for Progression of Cervical Congenital Scoliosis and Associated Compensatory Curve Behavior

Background: This study investigated risk factors for progression of deformity in pediatric congenital cervical scoliosis (CCS) and evaluated the correlation between congenital cervical curves and compensatory thoracic and lumbar curves. Methods: Medical records were retrospectively reviewed for 38 pediatric patients with CCS with a minimum 2-year follow-up. Curve progression was defined as >10° increase in cervical coronal curve angle between presentation and last follow-up. Results: A total of 38 patients (16 girls, 22 boys) with a mean age at presentation of 5.6 ± 4.1 years met the inclusion criteria. Sixteen patients (42%) had curve progression with a mean follow-up of 3.1 ± 3.0 years. At presentation, T1 slope was significantly larger among children with progressive deformities (p = 0.041). A total of 18 of the 38 patients with strictly cervical spine deformity were then selected for subanalysis to evaluate the progression of compensatory curves. Cervical major coronal curves were found to significantly correlate with lumbar major coronal curves (r = 0.409), C2 central sacral vertical line (CSVL) (r = 0.407), and C7-CSVL (r = 0.403) (p < 0.05). Thoracic major coronal curves did not significantly correlate with cervical major coronal curves (r = 0.218) (p > 0.05). Conclusion: In conclusion, 42% of osseous CCS curves progressed over time in the overall cohort, and high initial T1 slope was found to be most highly correlated with progression of cervical deformity. Cervical major coronal curves significantly correlated with lumbar curve magnitude but not with thoracic curve size in isolated CCS, possibly due to the increased flexibility of the lumbar spine which may allow greater compensatory balance and thus have a greater correlation with cervical curve magnitude and possibly progression.

Correction of a congenital kyphoscoliosis associated with diastematomyelia

Congenital scoliosis is one of the most common deformities of the spine in children. Intraspinal anomalies are always accompanied with congenital scoliosis. Diastematomyelia is one of the most common intraspinal pathologies in congenital scoliosis. To date, there is no standard method for correcting the congenital spinal deformity associated with diastematomyelia. We present a clinical case of simultaneous correction of congenital scoliosis by an internal corrector with excision of diastematomyelia. The patient tolerated the surgery well without any complications. She was discharged home with improved symptoms without need for additional therapy. The patient's guardians consented to the procedure and to the publication of her image.

Congenital Cervical Stenosis: a Review of the Current Literature

PURPOSE OF REVIEW

Congenital cervical stenosis (CCS) is a phenomenon in which an individual has a narrow canal due to abnormal anatomy which can present with earlier degenerative symptoms due to a reduced sagittal diameter. The diagnosis of CCS is important to individual treatment and preventative measures. Often, athletes are warned against sport participation that may cause damage to the cervical spine. There may be a predisposition in certain populations, but lack of data limits conclusions. The current review investigates recent literature on the definition, pathoanatomy, clinical presentation, and management of CCS. It specifically interrogates potential populations predisposed to this condition.

RECENT FINDINGS

The current literature reveals a potential predisposition for CCS in the black population when compared to the white population; however, many studies do not report race when discussing CCS patients. The lack of data limits a consensus on specific populations with a congenitally narrow canal. CCS may be more prevalent in specific populations. With knowledge of populations more at risk for this condition, physicians and teams can be alert when evaluating players and young adults. Furthermore, this may provide insight into risk for symptoms with degenerative disease. These findings introduce an avenue for further research into CCS.

Larsen Syndrome and Associated Spinal Deformities

Larsen syndrome is a rare genetic disorder that affects the connective tissue within the body. The present narrative review aims to examine the genetic basis of Larsen syndrome, clarify its symptoms, and define all the existing therapeutic approaches. A comprehensive search was performed in the PubMed database. Inclusion criteria considered molecular and clinical studies, management and surgical treatment of related deformities, case reports of patients with the syndrome, reviews of the associated anomalies, articles whose full text is available in PubMed, and articles published in the English language. Larsen syndrome is caused by mutations in the FLNB gene, which encodes the cytoskeletal protein filamin B, crucial in the development of the skeleton. Symptoms include joint dislocations, characteristic facial features and anomalies of the spine. Larsen syndrome may be conservatively treated initially, although surgical intervention is usually required. Various surgical techniques, including posterior spinal fusion, anterior decompression, circumferential arthrodesis, and single-stage 360° fixation, have been proposed along with growth-sparing procedures. Preoperative and postoperative care and education ensure optimal results. Further research is needed to identify novel therapeutic modalities for this condition.

Staged Bilateral Total Hip Arthroplasty in a Patient With Larsen Syndrome

Larsen syndrome is a rare genetic disorder characterized by weak connective tissues and various musculoskeletal abnormalities. This is a case report of a 39-year-old patient with Larsen syndrome who presented with over a decade of bilateral hip pain and difficulty ambulating. This patient has a prior history of bilateral congenital hip dislocations that were treated with open reduction and spica casting as a child with good result. Years later, she went on to develop bilateral hip osteoarthritis with significant remodeling of the proximal femur. The goal of this case presentation is to demonstrate the utility of total hip arthroplasty for this patient and discuss surgical challenges and considerations.

Growth-Friendly Spine Surgery in Arthrogryposis Multiplex Congenita

BACKGROUND

Arthrogryposis multiplex congenita (AMC) is a condition that describes neonates born with ≥2 distinct congenital contractures. Despite spinal deformity in 3% to 69% of patients, inadequate data exist on growth-friendly instrumentation (GFI) in AMC. Our study objectives were to describe current GFI trends in children with AMC and early-onset scoliosis (EOS) and to compare long-term outcomes with a matched idiopathic EOS (IEOS) cohort to determine whether spinal rigidity or extremity contractures influenced outcomes.

METHODS

Children with AMC and spinal deformity of ≥30° who were treated with GFI for ≥24 months were identified from a multicenter EOS database (1993 to 2017). Propensity scoring matched 35 patients with AMC to 112 patients with IEOS with regard to age, sex, construct, and curve. Multivariable linear mixed modeling compared changes in spinal deformity and the 24-item Early Onset Scoliosis Questionnaire (EOSQ-24) across cohorts. Cohort complications and reoperations were analyzed using multivariable Poisson regression.

RESULTS

Preoperatively, groups did not differ with regard to age (p = 0.87), sex (p = 0.96), construct (p = 0.62), rate of nonoperative treatment (p = 0.54), and major coronal curve magnitude (p = 0.96). After the index GFI, patients with AMC had reduced percentage of coronal correction (35% compared with 44%; p = 0.01), larger residual coronal curves (49° compared with 42°; p = 0.03), and comparable percentage of kyphosis correction (17% compared with 21%; p = 0.52). In GFI graduates (n = 81), final coronal curve magnitude (55° compared with 43°; p = 0.22) and final sagittal curve magnitude (47° compared with 47°; p = 0.45) were not significantly different at the latest follow-up after definitive surgery. The patients with AMC had reduced T1-S1 length (p < 0.001), comparable T1-S1 growth velocity (0.66 compared with 0.85 mm/month; p = 0.05), and poorer EOSQ-24 scores at the time of the latest follow-up (64 compared with 83 points; p < 0.001). After adjusting for ambulatory status and GFI duration, patients with AMC developed 51% more complications (incidence rate ratio, 1.51 [95% confidence interval (CI), 1.11 to 2.04]; p = 0.009) and 0.2 more complications/year (95% CI, 0.02 to 0.33 more; p = 0.03) compared with patients with IEOS.

CONCLUSIONS

Patients with AMC and EOS experienced less initial deformity correction after the index surgical procedure, but final GFI curve magnitudes and total T1-S1 growth during active treatment were statistically and clinically comparable with IEOS. Nonambulatory patients with AMC with longer GFI treatment durations developed the most complications. Multidisciplinary perioperative management is necessary to optimize GFI and to improve quality of life in this complex population.

LEVEL OF EVIDENCE

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

Altered Cogs of the Clock: Insights into the Embryonic Etiology of Spondylocostal Dysostosis

Spondylocostal dysostosis (SCDO) is a rare heritable congenital condition, characterized by multiple severe malformations of the vertebrae and ribs. Great advances were made in the last decades at the clinical level, by identifying the genetic mutations underlying the different forms of the disease. These were matched by extraordinary findings in the Developmental Biology field, which elucidated the cellular and molecular mechanisms involved in embryo body segmentation into the precursors of the axial skeleton. Of particular relevance was the discovery of the somitogenesis molecular clock that controls the progression of somite boundary formation over time. An overview of these concepts is presented, including the evidence obtained from animal models on the embryonic origins of the mutant-dependent disease. Evidence of an environmental contribution to the severity of the disease is discussed. Finally, a brief reference is made to emerging in vitro models of human somitogenesis which are being employed to model the molecular and cellular events occurring in SCDO. These represent great promise for understanding this and other human diseases and for the development of more efficient therapeutic approaches.

Prevalence and Key Radiographic Spinal Malalignment Parameters Associated with the Risk of Pulmonary Function Impairment in Patients Treated Surgically to Correct Adult Spinal Deformity

Introduction

There is a significant relationship between pulmonary function and degree of spinal deformity, location of apical vertebrae, and coronal imbalance in patients with childhood spinal deformity. By contrast, the pathophysiology, epidemiology, and influence of deformity on respiratory dysfunction in patients with adult spinal deformity (ASD) remain largely unknown. We sought to clarify and compare the prevalence of pulmonary function impairment in patients with ASD with that in patients with lumbar spinal stenosis (LSS), to determine radiographically which spinal malalignment parameters are associated with a risk of respiratory dysfunction, and to determine the association of respiratory dysfunction with corrective surgery.

Methods

We conducted a prospective study of consecutive patients with a diagnosis of ASD or LSS who underwent spinal surgery. We included data from 122 consecutive patients with ASD and 121 consecutive patients with LSS. Parameters were obtained from full-length lateral radiographs taken with the patients standing and in supine and prone positions. We compared respiratory dysfunction between a group of patients with ASD and LSS and determined correlations between respiratory dysfunction and spinopelvic parameters.

Results

Preoperative % forced vital capacity (FVC) of patients with ASD was significantly lower than that of patients with LSS, and the frequency of restrictive ventilatory impairment was significantly higher in those with ASD (15.7%) than those with LSS (7.4%). Thoracolumbar kyphotic curvature (TK) while the patients were in supine position was significantly greater in the group with restrictive ventilatory impairment, and a significant negative correlation was found between %FVC and TK with the patients in supine position. We found no significant improvement of respiratory dysfunction 1 year after surgery.

Conclusions

Spinal deformity is a potential risk factor for restrictive ventilatory impairment in the elderly. We propose that radiographs obtained when patients are in supine position are valuable for evaluating the flexibility of the TK. Rigid TK might be an etiology of restrictive ventilatory impairment in patients with ASD.

Burden of care in families of patients with early onset scoliosis

Early onset scoliosis is a complex manifestation of a heterogenous group of disorders, often necessitating multiple medical and surgical interventions to address the spinal deformity and its accompanying comorbidities. Current literature documents decreases in the health-related quality of life of these patients; however, there is a distinct lack of published data examining the burden on their caregivers. The purpose of this study is to compare burden on caregivers of children with early onset scoliosis and those on caregivers of age-matched healthy peers. A multicenter retrospective cohort study was conducted by querying a national registry for patients with early onset scoliosis diagnosed before 10 years old whose caregivers completed the caregiver burden (CB) and financial burden (FB) domains of the Early Onset Scoliosis Questionnaire (EOSQ-24) before their treatment. Scores were compared by etiology and planned treatment. The study identified 503 patients categorized by etiology and eventual treatment type. Overall, FB and CB scores for patients with early onset scoliosis were ≥10% worse than those of their age-matched peers, greater than the minimal clinically important difference for the EOSQ-24 (P < 0.001). Non-idiopathic patients' scores were ≥16% worse than age-matched peers regardless of future treatment (P < 0.001), while scores for idiopathic patients were varied. Idiopathic patients who went on to be observed had similar scores to national norms, but those who were managed either non-operatively (14% worse FB, 7% worse CB; P < 0.001) or operatively (25% worse FB, 27% worse CB; P > 0.05) had caregivers who reported greater burdens compared to those of healthy peers. This study suggests burdens on caregivers of patients with early onset scoliosis of nearly all etiologies are greater than those imposed on caregivers of healthy children, even before the additional stress of treatment is imposed. Level of evidence: II.

The Natural History of Early-onset Scoliosis

BACKGROUND

Early-onset scoliosis (EOS) is defined as the diagnosis of a spinal deformity before the age of 5 years. It can be divided into idiopathic, neuromuscular/syndromic, and congenital etiologies.

METHODS

The literature on the natural history of EOS was summarized.

RESULTS

The natural history varies with the etiology of EOS. Idiopathic curves may benefit from early serial casting. The natural history of neuromuscular and syndromic scoliosis is highly dependent on the natural history of the underlying disorder. Congenital scoliosis has a variable prognosis depending on the location and extent of the congenital malformations.

CONCLUSIONS

Treatment of children with EOS is customized to the particular disorder. While lack of treatment has been shown to lead to increased mortality, extensive early definitive fusion may lead to thoracic insufficiency. Delaying definitive surgery and the use of growing instrumentation may provide benefit in maintaining pulmonary health.

CLINICAL RELEVANCE

Potential disturbance of growth must be considered in the treatment of young children with scoliosis.

Phenotypic heterogeneity of kyphoscoliosis with vertebral and rib defects: a case series

Disorders associated with multiple vertebral segmentation defects may have additional rib anomalies in form of absence or hypoplastic ribs, fanning of ribs, etc. Spondylocostal dysostosis is genetic disorder with abnormal vertebral segmentation and rib anomalies. Diagnosis is often delayed because of non-familiarity with the characteristic features. There are six genes identified for spondylocostal dysostosis, of which SCDO5 is responsible for autosomal dominant form of the disorder. Retrospective study was conducted in Genetic and Metabolic unit of a tertiary hospital in north India over a period of 9 years. Twenty patients with a clinical diagnosis of congenital scoliosis were identified, and reviewed. Three patients were discussed in an earlier report and 11 subsequent patients, are described in this case series here. The median age at presentation was 34 months. The patients showed hemivertebrae, vertebral fusion, fusion of ribs, fanning of ribs. Hydrocephalus/ventriculomegaly was found in three cases and diastematomyelia was identified in one case. Other associated anomalies included corpus callosal agenesis, club foot and capillary malformation. One parent showed rib/spinal defects in two cases. Further studies are needed to characterise the phenotype and genetic basis of scoliosis in Indian patients.

Surgical growth guidance with non-fused anchoring segments in early-onset scoliosis

PURPOSE

Surgical treatment of early-onset scoliosis (EOS) requires a balance between maintained curve correction and the capacity for spinal and thoracic growth. Spinal fusion creates irreversible conditions that prevent the implementation of further treatment methods. Our hypothesis was that non-fused anchors in growth guidance show a comparable outcome as the technique described in the literature, which involves spondylodesis of the anchoring segments.

METHODS

This retrospective study analysed 148 surgeries in 22 EOS patients (11 female, 11 male) over a 15-year period. Patients underwent surgery with non-fused anchors and growth guidance techniques. Scoliosis, kyphosis, growth and anchoring segments were measured. For the latter, a new measuring technique was developed. Complications were recorded and classified.

RESULTS

The mean Cobb angle reduced from 73.5 ± 24.4° to 28.4 ± 16.2° (60.2 ± 22.9%, p < 0.001) at the last follow-up. Spinal growth T1-S1 and T1-T12 were 41.1 ± 23.3 mm and 24.9 ± 16.6 mm (p < 0.001), respectively. Growth at the cranial and caudal anchoring segment was 1.5 mm/segment/year and 1.9 mm/segment/year, respectively. A total of 63 complications were documented in 20 patients, with 40 requiring unplanned revision surgery. Definitive spondylodesis was performed in three patients.

CONCLUSION

Patients demonstrated a significant spinal growth including the anchoring segments. A comparable correction in Cobb angle and the type of complications was noted, although the rate of device-related complications was higher. No permanent impairment was reported. The rate of device-related complications is acceptable and outweighed by the significant degree of growth preservation and more flexible and individualised treatment strategy for patients with EOS. These slides can be retrieved under Electronic Supplementary Material.

Trends in Treatment of Scheuermann Kyphosis: A Study of 1,070 Cases From 2003 to 2012

STUDY DESIGN

Retrospective review of KID Inpatient Database (KID) from 2003, 2006, 2009, and 2012.

OBJECTIVES

The aim of this study was to evaluate the impact of advances in spinal surgery on patient outcomes in the treatment of Scheuermann kyphosis (SK).

SUMMARY OF BACKGROUND DATA

SK is one of the most common causes of back pain in adolescents. Trends in diagnoses and surgical treatment and approach to SK have not been well described.

METHODS

SK patients aged 0-20 years in KID were identified by ICD-9 code 732.0. KID-supplied year- and hospital-trend weights were used to establish prevalence. Patient demographics, surgical details, and outcomes were analyzed with analysis of variance.

RESULTS

A total of 1,070 SK patients were identified (33.2% female), with increasing incidence of SK diagnosed from 2003 to 2012 (3.6-7.5 per 100,000, p < .001). The average age of operative patients was 16.1±2.0 years and did not change (16.27-16.06 years, p = .905). The surgical rate has not changed over time (72.8%-72.8%, p = .909). Overall, 96.3% of operative patients underwent fusion, with 82.2% of cases spanning ≥4 levels; in addition, 8.6% underwent an anterior-only surgery, 74.6% posterior-only, and 13.6% combined approach. From 2003 to 2012, rates of posterior-only surgeries increased (62.4%-84.4%, p < .001) whereas the rate of combined-approach surgeries decreased (37.6%-8.8%, p < .001). Overall complication rates for SK surgeries have decreased (2003: 20.9%; 2012: 11.9%, p = .029). Concurrently, the rate of ≥4-level fusions has increased (43.5%-89.6%, p < .001), as well as the use of Smith-Peterson (7.8%-23.6%, p < .001) and three-column osteotomies (0.0%-2.7%, p = .011). In subanalysis comparing posterior to combined approaches, complication rates were significantly different (posterior: 9.88%, combined: 19.46%, p = .005). Patients undergoing a combined approach have a longer length of stay (LOS) than patients undergoing a posterior-only approach (7.8 vs. 5.6 days, p < .001).

CONCLUSIONS

Despite unchanged demographics and operative rates in SK, there has been a shift from combined to isolated posterior approaches, with a concurrent increase in levels treated. A combined approach was associated with increased complication rates, LOS, and total charges compared to isolated approaches. Awareness of these inherent differences is important for surgical decision making and patient education.

LEVELS OF EVIDENCE

Level III.

Patients Without Intraoperative Neuromonitoring (IONM) Alerts During VEPTR Implantation Did Not Sustain Neurological Injury During Subsequent Routine Expansions: A Retrospective Multicenter Cohort Study

BACKGROUND

The purpose of this study was to determine the rate of intraoperative neurological monitoring (IONM) alerts and neurological injury during vertical expandable prosthetic titanium rib (VEPTR) treatment and evaluate the utility of IONM during VEPTR expansion procedures in patients who have not previously had neurological injury or IONM alerts.

METHODS

After institutional review board approval, VEPTR procedures and IONM records were reviewed at 17 institutions for patients treated with VEPTR from 2005 to 2011. All consecutive cases in patients with minimum 2-year follow-up were included. Patients with prior history of growing rods or other invasive spine-based surgical treatment were excluded. Surgeries were categorized into implant, revision, expansion, and removal procedures. Cases with IONM alerts or neurological injury had additional detailed review. Descriptive statistics were used for data analysis.

RESULTS

In total, 2355 consecutive VEPTR procedures (352 patients) consisting of 299 implant, 377 revision, 1587 expansion, and 92 removal procedures were included. In total, 620 VEPTR procedures had IONM, and 539 of those had IONM records available for review. IONM alerts occurred in 9/539 procedures (1.7%): 3/192 implants (1.6%), 3/58 revisions (5.2%), and 3/258 expansions (1.2%). New neurological injury occurred in 3/2355 procedures (0.1%), 3/352 patients (0.9%). All 3 injuries were in implant procedures, only 1 had an IONM alert. All 3 had upper extremity motor deficits (1 had sensory deficit also). All had full recovery at 17, 30, and 124 days postinjury. One patient without prior neurological injury or IONM alert had an IONM alert during expansion that resolved after an increase in blood pressure. The remaining IONM alerts during expansions were all in children with prior IONM alerts during implant, revision, or exchange procedures.

CONCLUSIONS

The highest rate of neurological injury in VEPTR surgery was found for implant procedures. There were no instances of neurological injury during VEPTR expansion, revision, or removal procedures. IONM did not identify new neurological injuries in patients undergoing VEPTR expansion who did not previously have a history of IONM signal change or neurologic injury.

LEVEL OF EVIDENCE

Level IV-diagnostic study.

[Infant respiratory distress revealing Jeune syndrome]

Jeune syndrome (asphyxiating thoracic dystrophy) is a rare autosomal recessive osteochondrodysplasia with a variable degree of severity, clinically characterized by respiratory distress with a narrow chest and limb shortness. The reported incidence is one to five in 500,000 live births. Most patients develop severe respiratory failure during the first 2 years of life, leading to death in 60-80 % of cases. Survivors may suffer from renal, hepatic, or pancreatic complications. Expanding thoracic surgery can be used for severe cases. We describe the case of an 18-month-old boy who developed mild respiratory distress. The patient showed typical radiological features of Jeune syndrome: narrow thorax with short ribs and trident appearance of the pelvis. This case underscores the value of the right interpretation of the chest radiograph of the infant with a respiratory distress syndrome.

Rare diseases: matching wheelchair users with rare metabolic, neuromuscular or neurological disorders to electric powered indoor/outdoor wheelchairs (EPIOCs)

PURPOSE

To describe the clinical features of electric powered indoor/outdoor wheelchair (EPIOC) users with rare diseases (RD) impacting on EPIOC provision and seating.

METHOD

Retrospective review by a consultant in rehabilitation medicine of electronic and case note records of EPIOC recipients with RDs attending a specialist wheelchair service between June 2007 and September 2008. Data were systematically extracted, entered into a database and analysed under three themes; demographic, diagnostic/clinical (including comorbidity and associated clinical features (ACFs) of the illness/disability) and wheelchair factors.

RESULTS

Fifty-four (27 male) EPIOC users, mean age 37.3 (SD 18.6, range 11-70) with RDs were identified and reviewed a mean of 64 (range 0-131) months after receiving their wheelchair. Diagnoses included 27 types of RDs including Friedreich's ataxia, motor neurone disease, osteogenesis imperfecta, arthrogryposis, cerebellar syndromes and others. Nineteen users had between them 36 comorbidities and 30 users had 44 ACFs likely to influence the prescription. Tilt-in-space was provided to 34 (63%) users and specialised seating to 17 (31%). Four users had between them complex control or interfacing issues.

CONCLUSIONS

The complex and diverse clinical problems of those with RDs present unique challenges to the multiprofessional wheelchair team to maintain successful independent mobility and community living. Implications for Rehabilitation Powered mobility is a major therapeutic tool for those with rare diseases enhancing independence, participation, reducing pain and other clinical features. The challenge for rehabilitation professionals is reconciling the physical disabilities with the individual's need for function and participation whilst allowing for disease progression and/or growth. Powered wheelchair users with rare diseases with a (kypho) scoliosis require a wheelchair system that balances spine stability and movement to maximise residual upper limb and trunk function. The role of specialised seating needs careful consideration in supporting joint derangements and preventing complications such as pressure sores.

Spinal correction of scoliosis in Jeune syndrome: a report of two cases

Background

Jeune syndrome (asphyxiating thoracic dystrophy) is an autosomal recessive disorder with constriction and narrowing of the thorax. To our knowledge, there are no reports regarding spinal deformity and correction in Jeune syndrome. Herein, we report two cases of spinal correction in patients with Jeune syndrome, and review the literature.

Case Presentation

We experienced cases of spinal scoliosis in an adolescent boy and a young adult woman, both with Jeune syndrome. Their spinal deformities had progressed by the time they came to our hospital for surgical correction. After preoperative evaluation of their general condition, including respiratory function in detail to confirm that they could undergo surgery, we treated both cases with posterior spinal correction and fusion. Spinal correction was performed safely and there were no severe complications, including respiratory depression, associated with surgery, and relatively satisfactory correction was obtained in both cases. In case 1, coronal deformity was corrected from 70° to 36° and from 82° to 42°, respectively. In case 2, Cobb angle was corrected from 52° to 20° and from 55° to 21°.

Conclusions

Posterior spinal correction can be performed safely in young patients with Jeune syndrome who have survived their infant stage and matured without a severe general condition.

Thoracic Insufficiency Syndrome

Thoracic insufficiency syndrome (TIS) is a broad grouping of disorders that have a substantial impact on the chest wall, spine, and in many situations, both. While the conditions are varied, they share a potentially substantial impact on respiratory capacity and development over time and a presentation and need for intervention that is often in early childhood. Addressing these conditions has required a new paradigm that involves both deformity correction and a preservation of growth capacity. While there are now a number of options to treat severe spinal deformity early in life, when the deformity causes or is caused by a chest wall deformity, the Vertical Expandable Prosthetic Titanium Rib(VEPTR) is able to support surgical correction of both. The skeletal correction is often quite dramatic, but the functional measurements of quality of life and pulmonary function often do not show as dramatic and improvement, but consistently show a stabilization indicating control of the progressive thoracospinal disorder that produced TIS.

Management of Thoracic Insufficiency Syndrome in Patients With Jeune Syndrome Using the 70 mm Radius Vertical Expandable Prosthetic Titanium Rib

BACKGROUND

Jeune syndrome (JS) often results in lethal thoracic insufficiency syndrome. Since 1991, vertical expandable prosthetic titanium rib Dynamic PosteroLateral Expansion Thoracoplasty was used at our institution for treatment of JS. This study assesses the safety and efficacy of this procedure.

METHODS

Twenty-four JS patients were treated, 2 lost to follow-up, 17 with a minimum of 2-year follow-up retrospectively reviewed for clinical course: Assisted Ventilation Rate, respiratory rate, capillary blood gases, pulmonary function testings, and complications. Upright anteroposterior/lateral radiographs were measured for Cobb angle, kyphosis, lordosis, thoracic width, and thoracic/lumbar spinal height. Computed tomography scan lung volumes were obtained in 12 patients.

RESULTS

Mean age at initial implant was 23 months (7 to 62 mo) with an average 8.4 years (2.3 to 15.6 y) of follow-up. Average chest width increased from 121 to 168 mm at follow-up (P<0.001). Preoperatively, 7/17 (41%) patients had scoliosis. The remainder developed scoliosis during treatment, 8 requiring additional implants. Thoracic and lumbar spinal height was normal preoperatively and stayed normal during treatment. Thoracic kyphosis/lumbar lordosis was stable. Average computed tomography scan total lung volumes increased 484 to 740 mm3 (P<0.001), and Assisted Ventilation Rate status tended to improve (P=0.07). Average forced vital capacity was 34% predicted at first test and 27% predicted at last follow-up. Early demise after surgery was common with multisystem disease. Mean respiratory rate decreased from 35 to 24 bpm at last follow-up (P<0.05). Survival rate of the 22 patients was 68%. Migration of the rib cradles/titanium slings occurred in 12 patients, superficial infections in 5 patients, deep infections in 4 patients, and wound dehiscence in 5 patients. Infection rate was 4.6% per procedure.

CONCLUSIONS

The survival rate in JS with surgery was nearly 70% (compared with 70% to 80% mortality without treatment) with less ventilator dependence. Both C1 stenosis and scoliosis are common in JS. Spinal height in JS is normal. Complications are frequent, but tolerable in view of the clinical gains and increase in survival.

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

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

Chest wall hypoplasia--principles and treatment

The chest is a dynamic structure. For normal movement it relies on a coordinated movement of the multiple bones, joints and muscles of the respiratory system. While muscle weakness can have clear impact on respiration by decreasing respiratory motion, so can conditions that cause chest wall hypoplasia and produce an immobile chest wall. These conditions, such as Jarcho-Levin and Jeune syndrome, present significantly different challenges than those faced with early onset scoliosis in which chest wall mechanics and thoracic volume may be much closer to normal. Because of this difference more aggressive approaches to clinical and surgical management are necessary.

Clinicoradiological correlation of scoliosis in children with Jarcho-Levin and Escobar syndromes: associated "flat bone or wing-like" imaging findings

Congenital or early onset scoliosis may be the lead clinical feature in several rare syndromes. In this paper, we present the imaging findings in two children with early onset scoliosis related to the Jarcho-Levin and Escobar syndromes and an osseous plate or wing-like bar extending along the posterior elements of the spine on computed tomography. The clinical phenotypes in these syndromes are variable. A thorough clinical evaluation with imaging correlation is essential. The recognition of underlying spinal anomalies is essential in planning treatment and estimating prognosis. In young children with progressive scoliosis, cross-sectional imaging plays a major role in the diagnostic work-up.

CONCLUSION

Congenital scoliosis requires a comprehensive clinical evaluation and imaging work-up. The presence of an osseous plate or wing-like fusion of posterior elements of the spine may suggest the diagnosis of Jarcho-Levin and Escobar syndromes.

Congenital thoracic lordosis and scoliosis in a cat

A 10-week-old domestic shorthair kitten was referred for intermittent episodes of dyspnea, cyanosis and a suspected congenital thoracic anomaly. Physical examination showed an obvious palpable concavity in the caudal thoracic spine. Thoracic radiographs showed severe caudal thoracic lordosis from T5 to T13 with a Cobb angle of -77°, a centroid lordosis angle of -68°, a vertebral index of 6.3 and a flattened sternum. Severe loss of vital capacity was suspected and surgical correction of the thoracic deformity was to be performed in two separate stages, the first being surgical ventral distraction on the sternum to increase thoracic volume and rigid fixation with an external splint. The second stage, if required, would be surgical correction of the spinal deformity to also increase thoracic volume. The initial stage of surgery was performed and postoperative radiographs showed a vertebral index of 10.3. The kitten suffered a left sided pneumothorax in recovery and died from cardiorespiratory arrest despite immediate pleural drainage and cardiopulmonary resuscitation. Treatment recommendations that may benefit future case management are discussed.

Cervical stenosis in a patient with arthrogryposis: case report

Study Design Case report. Objective Amyoplasia-type arthrogryposis is a rare congenital disease that presents as multiple contractures involving various areas of the body. To the authors' knowledge, there have been no reports of adults with amyoplasia in the current literature. We report a case of an adult patient with cervical stenosis in the setting of amyoplasia. Patients and Methods A 48-year-old patient with amyoplasia and over 30 previous orthopedic reconstructive surgeries presented with neck pain radiating down his left shoulder and into the fingers, dysesthesia in his fingertips, and left-sided periauricular headache. A diagnosis of central spinal canal stenosis and bilateral foraminal stenosis at C3-C7 with radiculopathy was made based on computed tomography scans. Because of a prior right-side sternocleidomastoid muscle transfer, a left-side C3-C4, C5-C7 anterior cervical discectomy and fusion procedure was performed. Results The patient experienced significant improvement in symptoms that was transient. Symptoms returned to preoperative values after 1 year, despite significant and persistent improvement in stenosis. Conclusions Both amyoplasia and cervical stenosis can manifest in neurologic symptoms. Distinguishing the causing pathology can be challenging. The radiographic improvement of cervical stenosis in a patient with amyoplasia is not always associated with long-standing pain relief.

Scoliosis-Associated Cervical Spine Pathologies

STUDY DESIGN

A total of 126 scoliosis patients admitted to the hospital were screened for concomitant cervical pathologies.

OBJECTIVES

To investigate the prevalence of cervical spine pathologies and the clinical relevance of magnetic resonance imaging (MRI) in the evaluation of patients with neuromuscular, congenital, syndromic, and idiopathic scoliosis.

BACKGROUND SUMMARY

With the development of MRI, upper neural axis abnormalities such as syringomyelia and Chiari malformation are increasingly being found in patients with scoliosis, but no report in the literature describes other pathologies in the cervical area seen concomitant with different scoliosis types.

METHODS

A total of 126 consecutive patients who were classified as having neuromuscular, congenital, syndromic, and idiopathic scoliosis were retrospectively evaluated. Data regarding cervical neural axis abnormalities obtained from the MRI studies were analyzed and classified into each type of scoliosis group.

RESULTS

A total of 126 patients with scoliosis were evaluated for hindbrain and cervical spine anomalies. Patients were divided into 4 groups regarding the type of scoliosis. The cervical spine of all patients was evaluated with MRI and other radiologic methods when needed. The most frequently seen pathology was syringomyelia. Other pathologies found included congenital vertebral anomalies, Chiari malformation, arachnoid cyst, atlanto-axial dissociation, split cord, posterior vertebral fusion, vertebral hypoplasia, neurenteric cyst, myelomalacia, dermoid cyst, and decrease in craniovertebral angle. Cervical pathologies were most frequently seen in neuromuscular scoliosis, followed by congenital and syndromic groups.

CONCLUSIONS

Cervical spinal pathologies vary according to the type of scoliosis. The number of cervical spinal pathologies diagnosed in idiopathic scoliosis patients was least compared with neuromuscular and syndromic groups. The most common pathology was syringomyelia, followed by congenital vertebral anomalies and cerebral tonsillar hernia. Preoperative MRI scan provides vital information regarding cervical spinal pathologies encountered in scoliosis patients.

The efficacy of rib-based distraction with VEPTR in the treatment of early-onset scoliosis in patients with arthrogryposis

BACKGROUND

Although arthrogryposis multiplex congenital (AMC) is a rare condition, rapidly progressive scoliosis is common in children with AMC. Only a limited number of studies characterize the nature of these curves, and even fewer describe surgical outcomes. To determine efficacy or rib-based distraction in these patients, we reviewed the outcomes of the use of the Vertical Expandable Prosthetic Titanium Rib (VEPTR) device in what we believe is the first study to report this.

METHODS

Search of the Chest Wall Spinal Deformity Study Group database identified 10 children with AMC and early-onset scoliosis who were treated with the VEPTR device at 6 different pediatric health centers. The 7 female and 3 male patients had their initial surgery at an average age of 5 years. Mean follow-up was 4.2 years.

RESULTS

The most common curve was from T5 to L2. After initial VEPTR insertion, the scoliosis decreased from a mean of 67 to 43 degrees (37% correction) and kyphosis from 65 to 48 degrees (29% correction). The mean proximal junctional kyphosis after initial insertion was 33 degrees. At final follow-up, scoliosis and kyphosis were 55 degrees (17% correction) and 62 degrees (8% correction), respectively. Spinal growth during the treatment period showed a mean T1-S1 increase of 4.2 cm or approximately 1 cm/y. In the 62 procedures performed over the course of the study period, 6 complications occurred in 4 patients: 3 infections, 2 rib failures, and 1 implant failure. Six patients had proximal junctional kyphosis of ≥45 degrees at the last follow-up.

CONCLUSIONS

In children with AMC, rib-based distraction using the VEPTR is an effective treatment method for controlling scoliosis and kyphosis and maintaining thoracic growth, but proximal junctional kyphosis remains a problem.

Carbon Coated Implants as a New Solution for Metal Allergy in Early-Onset Scoliosis: A Case Report and Review of the Literature

STUDY DESIGN

Retrospective case report.

OBJECTIVE

To report the first known case of immunological camouflage of a metal spinal implant with carbon coating.

SUMMARY OF BACKGROUND DATA

Metal sensitivity is common and is a consideration when choosing orthopedic implants in susceptible individuals. The sensitivity often is to nickel, cobalt, or chromium, and titanium is used as a safe alternative. However, when the allergy is also to titanium, solutions may be much more difficult. This case describes an innovative solution to a complex metal allergy that includes titanium in a child requiring spinal instrumentation for early-onset scoliosis.

METHODS

At age 6 years 7 months, the patient underwent an uncomplicated placement of bilateral posterior Vertical Expandable Prosthetic Titanium Ribs (VEPTRs; Synthes, Inc., West Chester, PA). At that time, there were no known metal allergies. At 3 weeks, the right side had become erythematous and had serosanguineous drainage. It briefly improved after each of 2 surgical debridements and a course of intravenous antibiotics, but within 6 weeks of the index procedure, the pain was still worsening. A titanium allergy was suspected and blood was sent for allergy testing. A test confirmed hypersensitivity to titanium, niobium, molybdenum, iron, and aluminum, among others. The remaining rod was removed. An in vivo trial for tolerance to high-grade stainless-steel implants was done. The implant was removed after 2 weeks because of systemic symptoms that occurred.

RESULTS

A plasma-spray, carbon-coated VEPTR rod was designed. A rod sample was inserted into the patient's forearm for trial. After 3 months, there was no appreciable reaction. Carbon-coated VEPTRs were placed without complications. The patient has undergone multiple lengthening using the carbon-coated VEPTRs.

CONCLUSIONS

In the rare patient with multiple allergies, choosing orthopedic implants can be challenging. An innovative carbon coating was applied by plasma spray to the VEPTR system, with good results.

Jeune syndrome: considerations for management of asphyxiating thoracic dystrophy

Jeune syndrome (JS), or asphyxiating thoracic dystrophy, is a rare genetic disorder characterized by a small, narrow thorax, with associated shortening of limbs. Children with JS present with variable degrees of respiratory distress, frequently lethal in the neonatal period. Other associated complications include renal, hepatic, gastrointestinal, and retinal dysfunction. Management focuses on stabilization and support of respiratory function. Treatment may be palliative in nature or corrective. In recent years, the advance in surgical treatment of the thoracic hypoplasia in JS offers hope to those families with a child suffering from the syndrome. Even with increased research into treatment of this disorder, prognosis is usually poor. Comorbidities associated with JS lead to serious organ dysfunction in later years. Families who have a child with JS need genetic counseling and education focusing on the seriousness of the disorder, the risks and benefits of treatment, and the lifelong needs of those with JS.

Posterior vertebral column resection in early onset spinal deformities

PURPOSE

Early onset spinal deformities (EOSD) can be life-threatening in very young children. In the growing spine, surgical intervention is often unavoidable and should be carried out as soon as possible. A deformed section of the spine not only affects the development of the remaining healthy spine, but also that of the chest wall (which influences pulmonary function), the extremities and body balance. Posterior vertebral column resection (PVCR) represents an effective surgical solution to address such problems. However, reports in the literature concerning PVCR are mostly limited to its use in adolescents or adults. The purpose of this study was to illustrate our experience with PVCR in EOSD and to describe the surgical technique with respect to the unique anatomy of young children.

MATERIALS AND METHODS

Four children [mean age 3.7 (range 2.5-5.2) years] with severe spinal deformity underwent PVCR through a single approach. Multimodal intraoperative monitoring was used in all cases. Surgery included one stage posterior circumferential resection of one vertebral body along with the adjoining intervertebral discs and removal of all posterior elements. A transpedicular screw-rod system was used for correction and stabilisation. Fusion was strictly limited to the resection site, allowing for later conversion into a growing rod construct at the remaining spine, if necessary. Relevant data were extracted retrospectively from patient charts and long spine radiographs.

RESULTS

The mean operation time was 500 (range 463-541) min, with an estimated blood loss of 762 (range 600-1,050) ml. Mean follow-up time was 6.3 (range 3.5-12.4) years. After PVCR, the mean Cobb angle for scoliosis was reduced from 69° (range 50-99°) to 29° (5-44°) and the sagittal curvature (kyphosis) from 126° (87-151°) to 61° (47-75°). The mean correction of scoliosis was 57 % (18-92°) and of kyphosis, 51 % (44-62°). There were no spinal cord-related complications. In three patients, spinal instrumentation for growth guidance (fusion less growing rod technique) was applied. Two patients had complications: one patient had a complication of anesthesia, halo pin failure, and revision surgery with extension of the instrumentation cranially due to loss of correction; the second patient had a postoperative infection, which required plastic reconstructive measures.

CONCLUSION

PVCR appears to be an effective technique to treat severe EOSD. There are important differences in its use in young children when compared with older patients. In patients with EOSD, additional surgical procedures are often necessary during growth, and hence non-fusion instrumentation beyond the vertebral resection site is advantageous, as it permits spinal growth and the later addition of fusion.

VEPTR: past experience and the future of VEPTR principles

PURPOSE

This review summarizes the experience with the vertical expandable prosthetic titanium rib (VEPTR) device, which enables five new procedures to treat complex spine and chest wall abnormalities in pediatric patients, which cause thoracic insufficiency syndrome, the inability of the thorax to support normal respiration or lung growth.

METHODS

The literature on VEPTR was reviewed and discussed by the author, the inventor of the VEPTR.

RESULTS

The central VEPTR treatment principle is to correct volume depletion deformity of the thorax, and maintain the correction until skeletal maturity, at which time procedures such as spinal fusion can be considered. For individual cases of complex deformity, VEPTR strategies can differ remarkably. The goal of VEPTR surgery is to pursue the surgical strategy that provides the largest, most symmetrical, most functional thorax that can grow as normally as possible. Assessment of these results is difficult, since natural history of VEPTR-treated diseases are not clearly known and no current imaging test can measure thoracic insufficiency syndrome, but dynamic lung MRI have promise for the future in better defining this potentially lethal condition.

CONCLUSION

VEPTR and its principles of use have become an important first step toward improving the quality of life and longevity of children with thoracic insufficiency syndrome, but much work remains to advance both its design and its use.

Sporadic Occurrence of Jarcho-Levin Syndrome in an Ivorian Newborn

We report on an isolated chest-wall asymmetry with imaging findings of multiple vertebral and related rib defects in an Ivorian male newborn. He was born of a healthy and young couple without parental lineage, neither family malformative history nor teratogen exposure. This clinical presentation advocates Jarcho-Levin syndrome, a rare sporadic or familial disorder inherited as autosomal dominant or recessive mode and manifested by extensive vertebral segmentation defects with distinctive rib structural and morphological anomalies. According to our belief, this disorder has not been previously traced in the sub-Saharan African area.

Early onset scoliosis: current concepts and controversies

Early Onset Scoliosis (EOS) may be associated with long-term pulmonary morbidity, which is not commonly seen in Adolescent Idiopathic Scoliosis. Initial evaluation is based on determining any underlying etiology related to congenital or syndromic conditions. Assessing the impact of scoliosis on thoracic development may help guide treatment, which is often required at a young age in these children to prevent irreversible pulmonary insufficiency. Treatment is based on multiple factors but may include non-surgical strategies, such as casting or bracing, along with growth-sparing surgical procedures using growing rods or chest wall expansion. Definitive fusion is rarely indicated in young patients. This chapter will cover the diagnosis, evaluation, and treatment of children with EOS.

Prevalence and patterns of scoliosis in children with multiple pterygium syndrome

BACKGROUND

Although scoliosis is a predominant feature of multiple pterygium syndrome (MPS), the pattern of deformity and the progression of the curvature have not been well described. The purpose of this study was to assess the prevalence of scoliosis among patients with MPS, and to characterize the abnormalities of the vertebrae and to assess the progression of the scoliosis.

METHODS

From 1969 to 2008, we identified 19 patients with MPS but only 16 patients (8 boys and 8 girls) had complete data. Medical records and radiographs of these 16 patients were reviewed. Magnetic resonance imaging was performed in 8 patients to evaluate intraspinal anomalies. Functional mobility score was used to assess the ambulatory ability.

RESULTS

Of 16 patients, 13 patients (81.3%) had scoliosis. The mean age when the scoliosis was first noticed was 3.3±2.6 years (range, 1 mo to 8.2 y). The mean Cobb angle at first visit was 37.4±18.1 degrees (range, 14.0 to 75.0 degrees). With a mean follow-up of 4.0±4.9 years, the Cobb angle at the last visit was 43.3±19.1 degrees (range, 20.0 to 72.0 degrees). Congenital scoliosis was observed in 7 patients (3 unilateral unsegmented bar, 3 fusion of the cervical spine, 1 block vertebrae), whereas neuromuscular scoliosis was observed in 1 patient. A common radiographic finding was narrowing of the intervertebral disc space with decreased height of vertebrae in the thoracic area. Intraspinal anomalies were seen in 4 patients (3 tethered spinal cords, 1 syrinx). At the last follow-up, 5 of 13 patients who had scoliosis were able to walk at school without assistance (Functional mobility scale-500 ≥5).

CONCLUSIONS

Scoliosis is common among children with MPS. It is frequently accompanied by fusion of the cervical area. Intraspinal anomalies such as tethered cord syndrome and syringomyelia are common associated anomalies. Therefore, it is important to look for intraspinal anomalies. Closed monitoring of the patient's ambulatory ability and bowel and bladder continence is also needed.

LEVEL OF EVIDENCE

Level IV, Diagnostic Study.

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.

Early definitive spinal fusion in young children: what we have learned

BACKGROUND

Early-onset scoliosis, when left untreated, leads to severe deformity. Until the last decade, treatment of progressive curves in young children often consisted of definitive spinal fusion. The recognition of thoracic insufficiency syndrome associated with definitive early fusion has led to the development of new surgical techniques developed to preserve spinal and thoracic growth in young patients with progressive scoliosis.

QUESTIONS/PURPOSES

We asked: (1) Does early definitive fusion arrest progression of spinal deformity? To what extent does early definitive spinal fusion influence (2) pulmonary function and (3) thoracic growth?

METHODS

A Medline search of the published literature on early-onset scoliosis, congenital scoliosis, and infantile scoliosis between 2008 and 2010 was performed on spinal fusion for early-onset scoliosis, focusing on studies reporting pulmonary function at followup.

RESULTS

Spinal deformity is apparently not well controlled by early fusion since revision surgery has been required in 24% to 39% of patients who underwent presumed definitive fusion in early childhood. Restrictive pulmonary disease, defined as forced vital capacity less than 50% of normal, occurs in 43% to 64% of patients who undergo early fusion surgery with those children who have extensive thoracic fusions and whose fusions involve the proximal thoracic spine at highest risk. Thoracic growth after early surgery is an average of 50% of that seen in children with scoliosis who do not have early surgery. Diminished thoracic spinal height correlates with decreased forced vital capacity.

CONCLUSIONS

The literature does not support routine definitive fusion of thoracic spinal deformity at an early age in children with scoliosis.

Clinical and radiological distinction between spondylothoracic dysostosis (Lavy-Moseley syndrome) and spondylocostal dysostosis (Jarcho-Levin syndrome)

In 1938, Saul Jarcho and Paul Levin from Johns Hopkins Hospital reported cases of thoracic insufficiency due to vertebral and rib anomalies. Nearly 30 years later, in 1966, Norman Lavy and associates from Indiana University reported a similar syndrome in a family from Puerto Rico. Lavy's description was followed by a report by John E. Moseley from New York City, where the name spondylothoracic dysplasia (dysostosis) was first used. For more than half a century, there has been confusion regarding the distinction between these two phenotypically similar syndromes that cause thoracic insufficiency. Spondylocostal dysostosis (SCD), or Jarcho-Levin syndrome, causes mild to moderate respiratory insufficiency, is panethnic and has been linked to genes such as DLL3, which is known to be associated with the Notch pathway. In contrast, spondylothoracic dysostosis (STD), or Lavy-Moseley syndrome, results in more severe respiratory compromise, is largely linked to Puerto Rican cohorts and is thought to be associated to the MESP2 gene, also a Notch pathway gene. Long-term studies of Puerto Rican cohorts with STD contradicts the previously held belief that individuals affected with STD have markedly diminished life expectancy with as many as 25% surviving into later childhood and adult life.

Preoperative medical and surgical planning for early onset scoliosis

STUDY DESIGN

A review of current medical and surgical preoperative planning knowledge and protocols for children with early-onset scoliosis (EOS; onset less than 5 years of age).

OBJECTIVE

To describe the preoperative planning process to undertake safe and effective treatment for the EOS patient.

SUMMARY OF BACKGROUND DATA

Children with EOS present with a myriad of medical and orthopedic conditions associated with their specific diagnosis, and frequently require intensive preoperative evaluation and nutritional, pulmonary, and other support to prepare them for safe and effective treatment of the spinal/chest wall deformity. Such patients are among the most difficult and complex to treat effectively.

METHODS

A literature review of known conditions associated with EOS, and a summary of current surgical techniques to maintain deformity control while promoting spine and thoracic growth, was undertaken. Current recommendations for preoperative support and postoperative management of these complex patients are summarized, drawn from the experiences of the author and members of study groups focusing on EOS.

RESULTS

Preoperative assessment of respiratory function, potential for respiratory failure, and determination of objective criteria to indicate surgical management (deformity progression, lack of growth of spine and/or thoracic volume, lack of weight gain) are weighed against the potential for development of thoracic insufficiency syndrome. Magnetic resonance imaging evaluation for neuraxis abnormalities is considered on the basis of diagnosis. Nutritional status, osteopenia, and airway management are evaluated to minimize postoperative complications. Current general recommendations for implants and constructs for specific deformities are reviewed.

CONCLUSION

Thorough preoperative evaluation of EOS patients provides the surgeon with the knowledge to produce a sound surgical plan for this difficult and complex to treat patient population.