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Hoffmann K, Hainzl A, Stingl M, Kurz K, Biesenbach B, Bammer C, Behrends U, Broxtermann W, Buchmayer F, Cavini AM, Fretz GS, Gole M, Grande B, Grande T, Habermann-Horstmeier L, Hackl V, Hamacher J, Hermisson J, King M, Kohl S, Leiss S, Litzlbauer D, Renz-Polster H, Ries W, Sagelsdorff J, Scheibenbogen C, Schieffer B, Schön L, Schreiner C, Thonhofer K, Strasser M, Weber T, Untersmayr E. [Interdisciplinary, collaborative D-A-CH (Germany, Austria and Switzerland) consensus statement concerning the diagnostic and treatment of myalgic encephalomyelitis/chronic fatigue syndrome]. Wien Klin Wochenschr 2024; 136:103-123. [PMID: 38743348 PMCID: PMC11093804 DOI: 10.1007/s00508-024-02372-y] [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: 04/17/2024] [Indexed: 05/16/2024]
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a severe, chronic multisystemic disease which, depending on its severity, can lead to considerable physical and cognitive impairment, loss of ability to work and the need for nursing care including artificial nutrition and, in very severe cases, even death.The aim of this D-A-CH (Germany, Austria, Switzerland) consensus statement is 1) to summarize the current state of knowledge on ME/CFS, 2) to highlight the Canadian Consensus Criteria (CCC) as clinical criteria for diagnostics with a focus on the leading symptom post-exertional malaise (PEM) and 3) to provide an overview of current options and possible future developments, particularly with regard to diagnostics and therapy. The D-A-CH consensus statement is intended to support physicians, therapists and valuer in diagnosing patients with suspected ME/CFS by means of adequate anamnesis and clinical-physical examinations as well as the recommended clinical CCC, using the questionnaires and other examination methods presented. The overview of the two pillars of therapy for ME/CFS, pacing and symptom-relieving therapy options, is intended not only to provide orientation for physicians and therapists, but also to support decision-makers from healthcare policy and insurance companies in determining which therapy options should already be reimbursable by them at this point in time for the indication ME/CFS.
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Affiliation(s)
- Kathryn Hoffmann
- Allgemeinmedizin, Public Health und Versorgungsforschung, Abteilung für Primary Care Medicine, Zentrum für Public Health, Medizinische Universität Wien, Kinderspitalgasse 15, 1090, Wien, Österreich.
| | - Astrid Hainzl
- Österreichische Gesellschaft für ME/CFS, Wien, Österreich
| | | | - Katharina Kurz
- Innere Medizin, Universitätsklinik für Innere Medizin II, MedUni Innsbruck, Innsbruck, Österreich
| | - Beate Biesenbach
- Kinder- und Jugendheilkunde, kokon - Reha für junge Menschen, Kinder-Reha Rohrbach-Berg GmbH, Rohrbach-Berg, Österreich
| | - Christoph Bammer
- Innere Medizin, Nephrologie & Geriatrie, a. ö. BKH Kufstein, Kufstein, Österreich
| | - Uta Behrends
- MRI Chronische Fatigue Centrum für junge Menschen (MCFC), Zentrum für Kinder- und Jugendmedizin: eine Kooperation des Klinikums rechts der Isar, Technischen Universität München und der München Klinik gGmbH, München, Deutschland
| | | | - Florian Buchmayer
- Psychiatrie und Psychotherapie, Abteilung für Psychiatrie und Psychotherapie, Krankenhaus der Barmherzigen Brüder, Eisenstadt, Österreich
| | - Anna Maria Cavini
- Fachärztin für Kinder- und Jugendheilkunde, Psychotherapeutische Medizin, St.Veit/Glan, Österreich
| | - Gregory Sacha Fretz
- Department Innere Medizin, Medizinische Poliklinik, Kantonsspital Graubünden, Loestraße 170, 7000, Chur, Schweiz
| | - Markus Gole
- Psychologie und Philosophie, Praxis für Psychologie, Philosophie und Berufskunde, Linz, Österreich
| | - Bettina Grande
- Psychotherapie und Psychoanalyse, Heidelberg, Deutschland
| | - Tilman Grande
- Psychotherapie und Psychoanalyse, Heidelberg, Deutschland
| | | | - Verena Hackl
- Physiotherapie, AUVA Rehabilitationszentrum Meidling, Wien, Österreich
| | - Jürg Hamacher
- Innere Medizin und Pneumologie, Lindenhofspital, Bern, Schweiz
| | - Joachim Hermisson
- Biomathematik, Fakultät für Mathematik, Universität Wien, Wien, Österreich
- Department of Structural and Computational Biology, Max Perutz Labs, Wien, Österreich
| | - Martina King
- Lehrstuhl für Medical Humanities, Mathematisch-Naturwissenschaftliche und Medizinische Fakultät, Universität Fribourg, Fribourg, Schweiz
| | - Sonja Kohl
- #MillionsMissing Deutschland, Bedburg-Hau, Deutschland
| | - Sandra Leiss
- Österreichische Gesellschaft für ME/CFS, Wien, Österreich
| | | | - Herbert Renz-Polster
- Kinder- und Jugendheilkunde, Zentrum für Präventivmedizin und Digitale Gesundheit, Abteilung Allgemeinmedizin, Universitätsmedizin Mannheim, Universität Heidelberg, Heidelberg, Deutschland
| | - Wolfgang Ries
- Nephrologie, Dialyse, DIAKO Krankenhaus gGmbH, Flensburg, Deutschland
| | | | - Carmen Scheibenbogen
- Institut für Med. Immunologie, Sektion Immundefekte und Postinfektiöse Erkrankungen, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Deutschland
| | - Bernhard Schieffer
- Klinik für Innere Medizin-Kardiologie- Angiologie und Internistische Intensivmedizin und Zentrums für Notfallmedizin, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Marburg, Deutschland
| | - Lena Schön
- Physiotherapie, Physio Austria: Fachgruppe für komplexe Multisystemerkrankungen, Wien, Österreich
| | - Claudia Schreiner
- Österreichische Gesellschaft für ME/CFS, Wien, Österreich
- #MillionsMissing Deutschland, Bedburg-Hau, Deutschland
| | | | - Maja Strasser
- Neurologie, Neurologische Praxis Solothurn, Solothurn, Schweiz
| | - Thomas Weber
- Schmerzmedizin, Facharzt für Anästhesie und Intensivmedizin, Graz, Österreich
| | - Eva Untersmayr
- Klinische Immunologie, Institut für Pathophysiologie und Allergieforschung, Zentrum für Pathophysiologie, Infektiologie und Immunologie, Medizinische Universität Wien, Wien, Österreich
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Meghwar S, Singh A. Letter to the editor: Craniocervical instability in patients with Ehlers Danlos syndromes: Outcomes analysis following occipitocervical fusion. Neurosurg Rev 2024; 47:364. [PMID: 39060869 DOI: 10.1007/s10143-024-02602-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2024] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 07/28/2024]
Affiliation(s)
- Shehdev Meghwar
- Liaquat University of Medical and Health Sciences, Jamshoro, 76090, Sindh, Pakistan.
| | - Ajeet Singh
- Dow University of Health Sciences, Karachi, 74200, Sindh, Pakistan
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3
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Gensemer C, Daylor V, Nix J, Norris RA, Patel S. Co-occurrence of tethered cord syndrome and cervical spine instability in hypermobile Ehlers-Danlos syndrome. Front Neurol 2024; 15:1441866. [PMID: 39087018 PMCID: PMC11288835 DOI: 10.3389/fneur.2024.1441866] [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: 05/31/2024] [Accepted: 07/05/2024] [Indexed: 08/02/2024] Open
Abstract
The Ehlers-Danlos Syndromes (EDS) represent a group of hereditary connective tissue disorders, with the hypermobile subtype (hEDS) being the most prevalent. hEDS manifests with a diverse array of clinical symptoms and associated comorbidities spanning the musculoskeletal, neurological, gastrointestinal, cardiovascular, and immunological systems. hEDS patients may experience spinal neurological complications, including cervico-medullary symptoms arising from cranio-cervical and/or cervical instability/hypermobility, as well as tethered cord syndrome (TCS). TCS is often radiographically occult in nature, not always detectable on standard imaging and presents with lower back pain, balance issues, weakness in the lower extremities, sensory loss, and bowel or bladder dysfunction. Cervical instability due to ligament laxity can lead to headaches, vertigo, tinnitus, vision changes, syncope, radiculopathy, pain, and dysphagia. TCS and cervical instability not only share clinical features but can also co-occur in hEDS patients, posing challenges in diagnostics and clinical management. We present a review of the literature and a case study of a 20-year-old female with hEDS, who underwent surgical interventions for these conditions, highlighting the challenges in diagnosing and managing these complexities and underscoring the importance of tailored treatment strategies to improve patient outcomes.
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Affiliation(s)
- Cortney Gensemer
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, United States
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Victoria Daylor
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, United States
| | - Jared Nix
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, United States
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Sunil Patel
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
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Henderson FC, Schubart JR, Narayanan MV, Tuchman K, Mills SE, Poppe DJ, Koby MB, Rowe PC, Francomano CA. Craniocervical instability in patients with Ehlers-Danlos syndromes: outcomes analysis following occipito-cervical fusion. Neurosurg Rev 2024; 47:27. [PMID: 38163828 PMCID: PMC10758368 DOI: 10.1007/s10143-023-02249-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/30/2023] [Accepted: 12/09/2023] [Indexed: 01/03/2024]
Abstract
Craniocervical instability (CCI) is increasingly recognized in hereditary disorders of connective tissue and in some patients following suboccipital decompression for Chiari malformation (CMI) or low-lying cerebellar tonsils (LLCT). CCI is characterized by severe headache and neck pain, cervical medullary syndrome, lower cranial nerve deficits, myelopathy, and radiological metrics, for which occipital cervical fusion (OCF) has been advocated. We conducted a retrospective analysis of patients with CCI and Ehlers-Danlos syndrome (EDS) to determine whether the surgical outcomes supported the criteria by which patients were selected for OCF. Fifty-three consecutive subjects diagnosed with EDS, who presented with severe head and neck pain, lower cranial nerve deficits, cervical medullary syndrome, myelopathy, and radiologic findings of CCI, underwent open reduction, stabilization, and OCF. Thirty-two of these patients underwent suboccipital decompression for obstruction of cerebral spinal fluid flow. Questionnaire data and clinical findings were abstracted by a research nurse. Follow-up questionnaires were administered at 5-28 months (mean 15.1). The study group demonstrated significant improvement in headache and neck pain (p < 0.001), decreased use of pain medication (p < 0.0001), and improved Karnofsky Performance Status score (p < 0.001). Statistically significant improvement was also demonstrated for nausea, syncope (p < 0.001), speech difficulties, concentration, vertigo, dizziness, numbness, arm weakness, and fatigue (p = 0.001). The mental fatigue score and orthostatic grading score were improved (p < 0.01). There was no difference in pain improvement between patients with CMI/LLCT and those without. This outcomes analysis of patients with disabling CCI in the setting of EDS demonstrated significant benefits of OCF. The results support the reasonableness of the selection criteria for OCF. We advocate for a multi-center, prospective clinical trial of OCF in this population.
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Affiliation(s)
- Fraser C Henderson
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.
- The Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA.
| | - Jane R Schubart
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Malini V Narayanan
- Division of Neurosurgery, University of Maryland Capital Region Medical Center, Largo, Maryland, USA
| | - Kelly Tuchman
- The Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
| | - Susan E Mills
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Dorothy J Poppe
- Bobby Jones Chiari & Syringomyelia Foundation, Staten Island, New York, USA
| | - Myles B Koby
- Luminis Health, Doctors Community Medical Center, Lanham, Maryland, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Lucas AT, Lin AE, Cohen A, Muñoz W, Kahle KT, Shin JH, Buch K, Sahai I, Carroll RW. Atlantoaxial instability associated with ALDH18A1 mutation. Am J Med Genet A 2023; 191:2898-2902. [PMID: 37655511 DOI: 10.1002/ajmg.a.63388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 09/02/2023]
Abstract
We report a 10-year-old boy with a de novo pathogenic variant in ALDH18A1, a rare form of metabolic cutis laxa, which was complicated by atlantoaxial instability and spinal cord compression following a fall from standing height. The patient required emergent cervical spine fusion and decompression followed by a 2-month hospitalization and rehabilitation. In addition to the core clinical features of joint and skin laxity, hypotonia, and developmental delays, we expand the connective tissue phenotype by adding a new potential feature of cervical spine instability. Patients with pathogenic variants in ALDH18A1 may warrant cervical spine screening to minimize possible morbidity. Neurosurgeons, geneticists, primary care providers, and families should be aware of the increased risk of severe cervical injury from minor trauma.
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Affiliation(s)
- Alexandra T Lucas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mass General for Children, Boston, Massachusetts, USA
| | - Angela E Lin
- Medical Genetics, Department of Pediatrics, Mass General for Children, Boston, Massachusetts, USA
| | - Andrew Cohen
- Department of Pediatrics, MassGeneral for Children, Harvard Medical School, Boston, Massachusetts, USA
| | - William Muñoz
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen Buch
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Inderneel Sahai
- Medical Genetics, Department of Pediatrics, Mass General for Children, Boston, Massachusetts, USA
| | - Ryan W Carroll
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mass General for Children, Boston, Massachusetts, USA
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Brodbelt A, Timothy J, Haden N, George J. Hypermobility of the spine: Ehlers Danlos and neurosurgery, the route forward in the UK? Br J Neurosurg 2023; 37:587-588. [PMID: 37405932 DOI: 10.1080/02688697.2023.2216993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
- Andrew Brodbelt
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Liverpool University, Liverpool, UK
| | | | | | - Joshi George
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance, Manchester, UK
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Ramírez-Paesano C, Rodiera Clarens C, Sharp Segovia A, Coila Bustinza A, Rodiera Olive J, Juanola Galceran A. Perioperative opioid-minimization approach as a useful protocol in the management of patients with Ehlers-Danlos syndrome-hypermobility type, craniocervical instability and severe chronic pain who are to undergo occipito-cervical fixation. Orphanet J Rare Dis 2023; 18:214. [PMID: 37491286 PMCID: PMC10369693 DOI: 10.1186/s13023-023-02829-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
Patients suffering from connective tissue disorders like Ehlers-Danlos syndrome hypermobility type/joint hypermobility syndrome (EDS-HT/JHS) may be affected by craniocervical instability (CCI). These patients experience myalgic encephalomyelitis, chronic fatigue, depression, extreme occipital-cervical pain, and severe widespread pain that is difficult to relieve with opioids. This complex and painful condition can be explained by the development of chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization. Given the challenges in treating such severe physical pain, we evaluated all the analgesic methods previously used in the perioperative setting, and updated information was presented. It covers important physiopathological aspects for the perioperative care of patients with EDS-HT/JHS and CCI undergoing occipital-cervical/thoracic fixation/fusion. Moreover, a change of paradigm from the current opioid-based management of anesthesia/analgesia in these patients to the perioperative opioid minimization strategies used by the authors was analyzed and proposed as follow-up considerations from our previous case series. These strategies are based on total-intravenous opioid-free anesthesia, multimodal analgesia, and a postoperative combination of anti-hyperalgesic coadjuvants (lidocaine, ketamine, and dexmedetomidine) with an opioid-sparing effect.
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Affiliation(s)
- Carlos Ramírez-Paesano
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain.
| | - Claudia Rodiera Clarens
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Allan Sharp Segovia
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Alan Coila Bustinza
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Josep Rodiera Olive
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Albert Juanola Galceran
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
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Russek LN, Block NP, Byrne E, Chalela S, Chan C, Comerford M, Frost N, Hennessey S, McCarthy A, Nicholson LL, Parry J, Simmonds J, Stott PJ, Thomas L, Treleaven J, Wagner W, Hakim A. Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: International expert consensus recommendations. Front Med (Lausanne) 2023; 9:1072764. [PMID: 36743665 PMCID: PMC9893781 DOI: 10.3389/fmed.2022.1072764] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/29/2022] [Indexed: 01/19/2023] Open
Abstract
Experts in symptomatic generalized joint hypermobility (S-GJH) agree that upper cervical instability (UCI) needs to be better recognized in S-GJH, which commonly presents in the clinic as generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome. While mild UCI may be common, it can still be impactful; though considerably less common, severe UCI can potentially be debilitating. UCI includes both atlanto-occipital and atlantoaxial instability. In the absence of research or published literature describing validated tests or prediction rules, it is not clear what signs and symptoms are most important for diagnosis of UCI. Similarly, healthcare providers lack agreed-upon ways to screen and classify different types or severity of UCI and how to manage UCI in this population. Consequently, recognition and management of UCI in this population has likely been inconsistent and not based on the knowledge and skills of the most experienced clinicians. The current work represents efforts of an international team of physical/physiotherapy clinicians and a S-GJH expert rheumatologist to develop expert consensus recommendations for screening, assessing, and managing patients with UCI associated with S-GJH. Hopefully these recommendations can improve overall recognition and care for this population by combining expertise from physical/physiotherapy clinicians and researchers spanning three continents. These recommendations may also stimulate more research into recognition and conservative care for this complex condition.
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Affiliation(s)
- Leslie N. Russek
- Department of Physical Therapy, Clarkson University, Potsdam, NY, United States,St. Lawrence Health System, Potsdam, NY, United States,*Correspondence: Leslie N. Russek,
| | - Nancy P. Block
- Advanced Therapy Programs PT, San Jose, CA, United States
| | - Elaine Byrne
- Central Health Physiotherapy, London, United Kingdom
| | - Susan Chalela
- The Chalela Physical Therapy Institute for EDS/CCI, Charleston, SC, United States
| | - Cliffton Chan
- Department of Health Sciences, Faculty of Medicine, Health, and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Mark Comerford
- Performance Rehab, Brisbane, QLD, Australia,Comera Movement Science, Bristol, United Kingdom
| | | | | | - Ann McCarthy
- Central Health Physiotherapy, London, United Kingdom
| | - Leslie L. Nicholson
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jason Parry
- Central Health Physiotherapy, London, United Kingdom,University College London Hospital Trust, London, United Kingdom
| | - Jane Simmonds
- Central Health Physiotherapy, London, United Kingdom,Faculty of Population Health Sciences, University College London, London, United Kingdom
| | | | - Lucy Thomas
- Neck and Head Research Unit, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Julia Treleaven
- Performance Rehab, Brisbane, QLD, Australia,Neck and Head Research Unit, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, QLD, Australia
| | | | - Alan Hakim
- University College London Hospital Trust, London, United Kingdom,The Ehlers-Danlos Society, London, United Kingdom
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Rock MB, Zhao DY, Felbaum DR, Sandhu FA. Neurosurgical management of patients with Ehlers-Danlos syndrome: A descriptive case series. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:24-34. [PMID: 37213579 PMCID: PMC10198216 DOI: 10.4103/jcvjs.jcvjs_127_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/25/2022] [Indexed: 03/14/2023] Open
Abstract
Introduction Ehlers-Danlos syndrome (EDS) is a connective tissue disorder that has been linked to several neurological problems including Chiari malformations, atlantoaxial instability (AAI), craniocervical instability (CCI), and tethered cord syndrome. However, neurosurgical management strategies for this unique population have not been well-explored to date. The purpose of this study is to explore cases of EDS patients who required neurosurgical intervention to better characterize the neurological conditions they face and to better understand how neurosurgeons should approach the management of these patients. Methods A retrospective review was done on all patients with a diagnosis of EDS who underwent a neurosurgical operation with the senior author (FAS) between January 2014 and December 2020. Demographic, clinical, operative, and outcome data were collected, with additional radiographic data collected on patients chosen as case illustrations. Results Sixty-seven patients were identified who met the criteria for this study. The patients experienced a wide array of preoperative diagnoses, with Chiari malformation, AAI, CCI, and tethered cord syndrome representing the majority. The patients underwent a heterogeneous group of operations with the majority including a combination of the following procedures- suboccipital craniectomy, occipitocervical fusion, cervical fusion, odontoidectomy, and tethered cord release. The vast majority of patients experienced subjective symptomatic relief from their series of procedures. Conclusions EDS patients are prone to instability, especially in the occipital-cervical region, which may predispose these patients to require a higher rate of revision procedures and may require modifications in neurosurgical management that should be further explored.
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Affiliation(s)
- Mitchell B. Rock
- Department of Neurosurgery, Georgetown University School of Medicine, Washington, DC, USA
| | - David Y. Zhao
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Daniel R. Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Faheem A. Sandhu
- Department of Neurosurgery, Georgetown University School of Medicine, Washington, DC, USA
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10
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Mao G, Kopparapu S, Jin Y, Davidar AD, Hersh AM, Weber-Levine C, Theodore N. Craniocervical instability in patients with Ehlers-Danlos syndrome: controversies in diagnosis and management. Spine J 2022; 22:1944-1952. [PMID: 36028216 DOI: 10.1016/j.spinee.2022.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). Surgical decision-making in patients with EDS can be complicated by difficulty distinguishing from hypermobility inherent in the disease and true pathological instability necessitating intervention. Here we comprehensively review the available medical literature to critically appraise the evidence behind various proposed definitions of instability in the EDS population, and summarize the available outcomes data after OCF. Several radiographic parameters have been used, including the clivo-axial angle, basion-axial interval, and pB-C2 measurement. Despite increasing recognition of EDS by spine surgeons, there remains a paucity of data supporting proposed radiographic parameters for spinal instability among EDS patients. Furthermore, there is a lack of high-quality evidence concerning the efficacy of surgical treatments for chronic debilitating pain prevalent in this population. More standardized clinical measures and rigorous study methodologies are needed to elucidate the role of surgical intervention in this complex patient population.
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Affiliation(s)
- Gordon Mao
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Srujan Kopparapu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Yike Jin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA.
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Li C, Tian Y, Ren Q, Ji X, Mao Z, Wu M. Treatment of Atlantoaxial Dislocation in Children with Down Syndrome Using Posterior Atlantoaxial Screw Fixation. Front Surg 2022; 9:877929. [PMID: 35693316 PMCID: PMC9178121 DOI: 10.3389/fsurg.2022.877929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/05/2022] [Indexed: 11/21/2022] Open
Abstract
Background To investigate the effect of posterior atlantoaxial screw fixation for the treatment of atlantoaxial dislocation in children with Down syndrome (DS). Methods Children diagnosed with DS who underwent posterior atlantoaxial screw fixation or occipitocervical fusion from January 2017 to January 2020 in Hebei Children’s Hospital were retrospectively included. Preoperative CT and MRI were performed to check the os odontoideum (OsO) and spinal cord compression, signal changes and spinal cord injury grade (ASIA grade). Results All 5 children have atlantoaxial dislocation and OsO. Among which 60% (3/5) of children had changes in spinal cord signals and 40% (2/5) had dural sac compression. Every child underwent posterior atlantoaxial screw fixation (3.5-mm diameter), and the average fusion level was 1.8 (1–2). All 5 cases wore the head-neck-chest brace for 3–6 months after the operation. 1 case had dural tear and recovered well after timely suturing. 1 case had internal fixation breakage of the prosthetic joint and underwent revision surgery. At the last follow-up, all cases were fused and the neurological function were all ASIA grade E. Conclusion After posterior atlantoaxial screw fixation, fusion and nerve recovery were achieved in all children with atlantoaxial dislocation and OsO. Postoperative head-neck-chest braces are necessary for children, especially those with occipitocervical fusion.
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Affiliation(s)
- Chengxin Li
- Department of Orthopedic, Beijing Children’s Hospital, Capital Medical University, Beijing, China
| | - Yiren Tian
- Department of Orthopedic, Children’s Hospital of Hebei Province,Shijiazhuang, China
- Correspondence: Yiren Tian
| | - Qiang Ren
- Department of Orthopedic, Children’s Hospital of Hebei Province,Shijiazhuang, China
| | - Xiangqian Ji
- Department of Orthopedic, Children’s Hospital of Hebei Province,Shijiazhuang, China
| | - Ziwei Mao
- Department of Orthopedic, Children’s Hospital of Hebei Province,Shijiazhuang, China
| | - Ming Wu
- Department of Orthopedic, Children’s Hospital of Hebei Province,Shijiazhuang, China
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