Dural ectasia and the Marfan syndrome

Spinal extradural arachnoid cyst: A rare cause of thoracic myelopathy

A spinal extradural arachnoid cyst (SEAC) is a rare condition which can lead to back pain, radiculopathy, and compressive myelopathy. It accounts for approximately 1% of spinal tumours. The exact aetiology of SEACs is not well understood; however, this study is supportive of a traumatic aetiology of this disease in addition to supporting a uni-directional valve as a mechanism of CSF accumulation. The purpose of this study is to review the presentation, work-up, treatment and postoperative course of a patient with SEAC. We present the case of a 40-year-old male with a history of trauma who developed a SEAC and was treated surgically at our unit. Although a rare disease, we highlight the importance of early diagnosis and surgical treatment as it is a surgically curable disease with a good postoperative prognosis.

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SEAC is an important differential diagnosis for compressive myelopathy.

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Trauma may be an underlying cause of SEAC development.

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Uni-directional valve is the likely mechanism of CSF accumulation in a SEAC.

Exposure of Pedicle Screws due to Chronic Vertebral Erosion by Tracheostomy Tube Cuff Balloon: A Case Report

CASE

We report a patient with permanent tracheostomy in the context of muscular dystrophy presented for pneumonia. On bronchoscopy, a pedicle screw was seen penetrating the trachea. Computed tomography revealed significant anterior erosion of the T1-T3 vertebrae due to chronic pressure injury from the tracheostomy cuff, exposing pedicle screws implanted >10 years earlier. The patient was fitted for a custom low-pressure cuff. No further sequelae developed for 4 months.

CONCLUSION

To the best of our knowledge, this is the first case of exposed spinal fusion instrumentation due to chronic vertebral erosion. Early sagittal imaging and the use of low-pressure cuffs may help prevent this complication.

Dural ectasia in Marfan syndrome and other hereditary connective tissue disorders: a 10-year follow-up study

BACKGROUND CONTEXT

Dural ectasia is widening of the dural sac often seen in patients with Marfan syndrome and other hereditary connective tissue disorders. Dural ectasia can cause specific symptoms and is associated with surgical complications. The knowledge on how and at which age dural ectasia develops is incomplete. There is no established gold standard for diagnosing dural ectasia, making it difficult to compare results from different studies.

PURPOSE

Our primary aim was to explore whether the radiological findings of dural ectasia changed after 10 years in an adult cohort with suspected Marfan syndrome. Our secondary aim was to re-evaluate the radiological criteria of dural ectasia.

STUDY DESIGN

Prospective cohort study.

PATIENT SAMPLE

Sixty-two persons from a cross-sectional study of 105 persons with suspected Marfan syndrome were included in a 10-year follow-up of dural ectasia. Forty-six were diagnosed with Marfan syndrome, 7 with Loeys-Dietz syndrome, and 5 with other hereditary connective tissue disorders. For comparison 64 matched hospital controls were evaluated.

OUTCOME MEASURES

Previously used radiological criteria for dural ectasia based on quantitative measurements of the lumbosacral spine.

METHODS

MRI of the lumbosacral spine was performed if not contraindicated, and if so then CT was performed. Differences in the study group between baseline and follow-up were assessed with paired Student t test, Wilcoxon rank signed test, and McNemar test. Receiver operating characteristic curves were constructed to assess the ability of radiological measurement to differentiate between the study and control group.

RESULTS

Fifty-two of 58 patients with hereditary connective tissue disorders and 11 controls had dural ectasia at follow-up. Forty-five Marfan patients had dural ectasia at follow-up vs. 41 at baseline. Five Loeys-Dietz patients had dural ectasia at follow-up vs. four at baseline. Twenty-four Marfan and 2 Loeys-Dietz patients had anterior sacral meningocele at follow-up, compared with 21 and 1, respectively, at baseline. Three Marfan patients developed herniation of a nerve root sleeve during follow-up. This was not seen in other individuals. The dural sac ended significantly lower at follow-up, and the dural sac ratio at level L5 was significantly increased from baseline in the Marfan patients.

CONCLUSIONS

In Marfan and Loeys-Dietz syndrome, dural ectasia may present or worsen during adulthood. The cut-off value of dural sac ratio at level S1 is suggested elevated to 0.64. The results from the present study may help as guidance for appropriate follow-up of patients with dural ectasia.

Non-cardiac manifestations of Marfan syndrome

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

Marfan Syndrome: A Clinical Update

Marfan syndrome is a connective tissue disorder that can affect many organ systems. Affected patients present with orthopaedic manifestations of the syndrome during all phases of life. Pain caused by musculoskeletal abnormalities often requires definitive orthopaedic treatment. Orthopaedic surgeons must understand the phenotypes of Marfan syndrome so they can recognize when screening is warranted and can appropriately address the skeletal manifestations. Through medical advancements, patients with Marfan syndrome are living longer and more active lives. Knowledge of the latest diagnostic criteria for the disorder, as well as of advances in understanding the skeletal phenotype, clinical trials of medication therapy, and lifestyle considerations is important for orthopaedic surgeons who treat these patients because these clinicians often are the first to suspect Marfan syndrome and recommend screening.

Anterior sacral meningocele presenting as intracystic bleeding

PURPOSE

To report a case of anterior sacral meningocele with intralesional bleeding secondary to sacrococcygeal trauma. Likewise, there is a discussion about the physiopathology and the surgical approach to these types of lesions.

METHODS

A 43-year-old man diagnosed with Marfan syndrome suffered sacrococcygeal trauma. He was admitted to the emergency room due to symptoms of headache, nausea, and lower limb subjective weakness. CT and MRI showed a large retroperitoneal mass with hemorrhagic content close to the sacrum. Likewise, the MRI showed an image compatible with subarachnoid hemorrhage in the thoracic spinal area, cerebral convexity, and the basal cisterns. The patient went into surgery for an anterior abdominal approach in the midline to reduce the content of the lesion, and subsequently, in the same act, a posterior approach was done with an S1-S2 laminectomy and obliteration of the pedicle. Postoperative MRI 5 months later showed resolution of the ASM.

RESULTS

Anterior sacral meningocele is characterized by herniation of the dura mater and the arachnoid mater outside the spinal canal through a defect of the sacrum. We add the risk of bleeding after trauma-never seen in the literature-as one of the possible inherent complications of this lesion.

CONCLUSIONS

This report highlights a complication never seen in the literature of a relatively rare condition. In our case, the combined approach was effective for both clinical control and lesion regression.

Neurological and spinal manifestations of the Ehlers-Danlos syndromes

The Ehlers-Danlos syndromes (EDS) are a heterogeneous group of heritable connective tissue disorders characterized by joint hypermobility, skin extensibility, and tissue fragility. This communication briefly reports upon the neurological manifestations that arise including the weakness of the ligaments of the craniocervical junction and spine, early disc degeneration, and the weakness of the epineurium and perineurium surrounding peripheral nerves. Entrapment, deformation, and biophysical deformative stresses exerted upon the nervous system may alter gene expression, neuronal function and phenotypic expression. This report also discusses increased prevalence of migraine, idiopathic intracranial hypertension, Tarlov cysts, tethered cord syndrome, and dystonia, where associations with EDS have been anecdotally reported, but where epidemiological evidence is not yet available. Chiari Malformation Type I (CMI) has been reported to be a comorbid condition to EDS, and may be complicated by craniocervical instability or basilar invagination. Motor delay, headache, and quadriparesis have been attributed to ligamentous laxity and instability at the atlanto-occipital and atlantoaxial joints, which may complicate all forms of EDS. Discopathy and early degenerative spondylotic disease manifest by spinal segmental instability and kyphosis, rendering EDS patients prone to mechanical pain, and myelopathy. Musculoskeletal pain starts early, is chronic and debilitating, and the neuromuscular disease of EDS manifests symptomatically with weakness, myalgia, easy fatigability, limited walking, reduction of vibration sense, and mild impairment of mobility and daily activities. Consensus criteria and clinical practice guidelines, based upon stronger epidemiological and pathophysiological evidence, are needed to refine diagnosis and treatment of the various neurological and spinal manifestations of EDS. © 2017 Wiley Periodicals, Inc.

Economic and care considerations of Marfan syndrome

INTRODUCTION

Marfan syndrome is a rare multisystem disease of the connective tissue, which affects multiple organ systems. advances in healthcare have doubled the life-expectancy of patients over the past three decades. to date, there is no comprehensive review that consolidates economic considerations and care for marfan patients. Areas covered: Present research suggests that there may be a link between treatment pattern, disease progression and economic costs of Marfan syndrome. It indicates that an early detection of the disease and preventive interventions achieve a dual aim. From a patient perspective, it may reduce the amount of emergency surgery or intervention, and inpatient stays. In addition, it slows disease progression, lowers lifestyle restrictions, reduces psychological stress, and improves health-related quality of life. Expert commentary: Early detection and preventive measures are likely to achieve a dual aim by simultaneously containing costs and reducing the number and length of inpatient stays.

Dural ectasia in a child with Larsen syndrome

INTRODUCTION

We present a case of an incidental finding of dural ectasia in a child diagnosed with Larsen syndrome. Larsen syndrome is a rare inherited disorder of connective tissue characterized by facial dysmorphism, congenital joint dislocations of the hips, knees and elbows, and deformities of the hands and feet. Dural ectasia is as an abnormal expansion of the dural sac surrounding the spinal cord and may result in spinal morphologic changes, instability, and spontaneous dislocation. To the best of our knowledge, the presence of dural ectasia in Larsen syndrome has not previously been reported.

CASE STUDY

A 6-year-old boy diagnosed with Larsen syndrome presented with an upper thoracic curve measuring 74 degrees, a right thoracic curve measuring 65 degrees, and significant cervicothoracic kyphosis with 50% anterior subluxation of C6 on C7 and C7 on T1. Advanced imaging studies showed dural ectasia (evidenced by spinal canal and dural sac expansion), thinning of pedicles and lamina, and C4 and C6 pars defects with cervical foramen enlargement. The patient received growing rod instrumentation (attached to cervical spine fixation) by a combined anterior/posterior surgical approach using intraoperative halo. Complications included intraoperative medial breach (fully resolved), wound dehiscence, 2 instances of bilateral broken rods, and a broken cervical rod. Following 7 lengthening procedures, the patient underwent definitive fusion.

DISCUSSION

Surgeons should be aware of the potential for dural ectasia in patients with Larsen syndrome. Its presence will cause difficulties in the surgical intervention for spinal deformity. Multiple factors must be considered, and surgical approach and technique will require modification to avoid complications. Although dural ectasia confounds surgical intervention in these patients, surgery still appears to outweigh the risks associated with delayed intervention. The presence of dural ectasia should not preclude surgical decompression and stabilization. This report adds to the body of knowledge on the treatment of Larsen syndrome by demonstrating the potential existence of dural ectasia and highlights the importance of careful and thorough preoperative evaluation and diagnostic imaging.

Comparison of posterior correction results between Marfan syndrome scoliosis and adolescent idiopathic scoliosis-a retrospective case-series study

Background

The X-ray films of the patients with Marfan syndrome scoliosis (MSS) look like those with adolescent idiopathic scoliosis (AIS). In literature, there are many reports on the correction results of AIS, while there are a few studies focused on the difference of the correction results between MSS and AIS. This study aims to analyze whether there are differences of posterior correction surgery in MSS and AIS.

Methods

All the patients included underwent posterior correction surgery. The radiographic data, operation duration, estimated blood loss, transfusion, fusion levels, and correction rate were retrospectively reviewed and analyzed between the two groups.

Results

Group MSS included 42 patients, 11 male and 31 female, with an average age of 15.2 years old. Group AIS included 168 patients (ratio, 1:4), 34 male and 134 female, with an average age of 14.5 years old. Twenty-three patients in group MSS and 94 patients in group AIS were followed up regularly, with an average time of 18.4 and 18.5 months, respectively. The mean coronal Cobb angle of the major curve before operation and at final follow-up, the correction rate, fusion level, operation duration, estimated blood loss during operation, and transfusion between the two groups were 60.4 and 57.5°, 14.6 and 15.2°, 76.4 and 74.1 %, 11.5 and 11.0 vertebrae, 4.6 and 4.0 h, 845 and 698 ml, and 1151 and 894 ml, respectively. The age, gender ratio, curve type, and coronal Cobb angle of the major curve were all matched (all P > 0.05). Group MSS had a longer operation duration and more estimated blood loss compared with those of group AIS (both P < 0.05), while there was no significant difference in terms of fusion level, transfusion, coronal Cobb angle of the major curve at final follow-up, and the correction rate (all P > 0.05).

Conclusions

When performing posterior correction for scoliosis, the surgeons should be aware that the patients with Marfan syndrome scoliosis had more estimated blood loss and longer operation duration than AIS patients, while the correction rate was similar.

A symptomatic spinal extradural arachnoid cyst with lumbar disc herniation

Spinal epidural arachnoid cyst (EAC) is a rare, usually asymptomatic condition of unknown origin, which typically involves the lower thoracic spine. We report a case of posttraumatic symptomatic EAC with lumbar disc herniation. A 22-year-old man experienced back pain and sciatica after a traffic accident. Neurological examination revealed a right L5 radiculopathy. Magnetic resonance imaging demonstrated a cystic lesion at the L3 to L5 level and an L4-5 disc herniation; computed tomography myelography showed that the right L5 root was sandwiched between the cyst and the herniation. A dural defect was identified during surgery. The cyst was excised completely and the defect was repaired. A herniation was excised beside the dural sac. Histology showed that the cyst wall consisted of collagen and meningothelial cells. Postoperatively the symptoms resolved. Lumbar spinal EACs are rare; such cysts may arise from a congenital dural crack and grow gradually. The 6 cases of symptomatic lumbar EAC reported in the literature were not associated with disc herniation or trauma. In this case, the comorbid disc herniation was involved in symptom progression. Although many EACs are asymptomatic, comorbid spinal disorders such as disc herniation or trauma can result in symptom progression.

Pelvic pain from a giant presacral Tarlov cyst successfully obliterated using aneurysm clips in a patient with Marfan syndrome

Patients with Marfan syndrome used to succumb early in life from cardiovascular complications. With the current rapid advance in medical and surgical care, such patients may now have near-normal longevities. Consequently, rare late-life complications are emerging in these patients and represent challenges to clinicians for their diagnoses and treatments. The authors report a rare case of pelvic pain and genital prolapse from a giant presacral Tarlov cyst in a 67-year-old patient with Marfan syndrome.

This 67-year-old Caucasian female presented with progressively severe pelvic pain, intermittent explosive diarrhea, and dysuria. Physical and bimanual examination demonstrated genital prolapse and a nontender, cyst-like mass fixed in the midline. She underwent ultrasound, CT, and eventually MRI evaluations that led to the diagnosis of a giant (6.7 × 6.4 × 6.6 cm) Tarlov cyst originating from the right S-2 nerve root sleeve/sacral foramen with intrapelvic extension. She underwent S1–S2 and S2–S3 laminectomy with obliteration of the Tarlov cyst using aneurysm clips. Postoperatively, her pelvic pain and bowel symptoms resolved and the bladder symptoms improved. The 3-month follow-up CT of abdomen/pelvis demonstrated resolution of the cyst.

The present case illustrates that clinicians caring for elderly patients with Marfan syndrome need to increasingly recognize such unusual late-life complications. Also, these large Tarlov cysts can be simply and effectively obliterated with aneurysm clips.

Spinal imaging features in Japanese patients with Marfan syndrome: a case-control study

PURPOSE

The purpose of our study was to evaluate the morphology of the lumbosacral spine, i.e. the dura and vertebral body shape, of Japanese patients with Marfan syndrome (MFS) by comparing it with sex- and age-matched controls.

MATERIALS AND METHODS

Spinal MR or CT images of 32 MFS patients and 32 controls were retrospectively reviewed. The anteroposterior dural sac diameter (DSD), anteroposterior vertebral body diameter (VBD), and vertebral body height (VBH) were measured from L1 to S1 levels and the dural sac ratio [DSR = (DSD/VBD)] and vertebral body aspect ratio [VAR = (VBH/VBD)] were calculated.

RESULTS

At each level, mean DSD and DSR were significantly higher in MFS patients; VBD was not. The cutoff values for DSR to differentiate between MFS patients and the controls were 0.59, 0.46, 0.42, 0.45, 0.47, and 0.47 from the level of L1 to S1. At a sensitivity of 93.8 % and a specificity of 84.4 % the cutoff value at S1 was most diagnostic. In MFS patients VAR was significantly higher at L3 and L4.

CONCLUSION

Our cutoff value for DSR >0.47 at S1 may help to identify MFS in the Japanese population. A square-like appearance of the L3 and L4 vertebral bodies is a supplementary finding in MFS patients.

Ten-year clinical and imaging follow-up of dural ectasia in adults with Marfan syndrome

BACKGROUND CONTEXT

Dural ectasia in the lumbosacral spine is a common feature of Marfan syndrome and is associated with low back pain and surgical complications, but its natural history is unknown.

PURPOSE

To evaluate the natural history of dural ectasia in adults with Marfan syndrome by determining if, over time, symptoms associated with dural ectasia worsen, dural ectasia imaging findings worsen, or spondylolisthesis/spondylolysis develops or worsens.

STUDY DESIGN

Prospective cohort study.

PATIENT SAMPLE

For our prospective follow-up study, we enrolled 20 patients with Marfan syndrome and dural ectasia who, from 1998 through 1999, had undergone magnetic resonance imaging (MRI) and computed tomography (CT) of the lumbosacral spine and had completed the Oswestry Disability Index (ODI) questionnaire. Of the 20, five did not meet the inclusion criterion of a completed 2009 ODI questionnaire and were excluded. The remaining 15 patients (mean age, 49.6 years; mean follow-up, 10.5 years) formed our study group.

OUTCOME MEASURES

The ODI, MRI-based qualitative and quantitative measurements, CT-based quantitative measurements.

METHODS

We performed matched-pair analyses via Student t test and Wilcoxon signed-rank test of the ODI scores (15 pairs), dural volume of L5-S2 (eight pairs), dural sac ratio (DSR) of L4-S2 (nine pairs), development/progression of spondolysthesis/spondylolysis (11 pairs), and Fattori qualitative grading of dural ectasia size (10 pairs). Significance was set at p<.05.

RESULTS

We found no statistical differences in the 1998/1999 and 2009 ODI scores (25.8 vs. 22.2 points), dural volume (70.4 vs. 73.9 cm(3)), or DSR (0.68, 0.78, 2.04, and 58.1 vs. 0.69, 0.83, 2.30, and 70.20). There was also no development or progression of spondylolisthesis/spondylolysis and no increase in dural ectasia size.

CONCLUSIONS

During this 10-year period, the natural history of dural ectasia in adults with Marfan syndrome was not associated with a significant increase in ODI scores, dural ectasia size, or with the development/progression of spondylolisthesis or spondylolysis.

Regional anesthesia in Marfan syndrome, not all dural ectasias are the same: a report of two cases

BACKGROUND

The anesthetic management of women with Marfan syndrome and dural ectasia undergoing Cesarean delivery remains controversial. We present two cases of patients with Marfan syndrome and dural ectasia where neuraxial anesthesia was used successfully. CASE 1: A 31-yr-old G1P0 female with Marfan syndrome presented for elective Cesarean delivery at 35(3/7) weeks' gestation. The magnetic resonance imaging of her spine revealed significant dural ectasia in the lumbosacral area with a mean lumbar dural sac area of 4.71 cm(2). Intrathecal administration of 0.75% hyperbaric bupivacaine 9 mg produced only limited perineal analgesia. The epidural catheter was titrated, and 0.5% bupivacaine 150 mg were required to achieve a T4 sensory level. CASE 2: A 34-yr-old G1P0 female with Marfan syndrome presented for elective Cesarean delivery at 37 weeks' gestation. The intrathecal administration of 0.75% hyperbaric bupivacaine 13.5 mg produced a T5 sensory level. Magnetic resonance imaging of her spine prior to discharge confirmed the diagnosis of moderate dural ectasia with a mean lumbar dural sac area of 3.61 cm(2).

DISCUSSION

The two patients described in this report responded differently to spinal anesthesia, most likely based on the severity of their dural ectasia. Although preoperative magnetic resonance imaging may help to identify patients at risk for a failed spinal, we suggest considering a combined spinal-epidural technique in cases of dural ectasia.

Spinal deformity correction in Marfan syndrome versus adolescent idiopathic scoliosis: learning from the differences

STUDY DESIGN

Retrospective case control study.

OBJECTIVE

To compare patients with Marfan syndrome and matched patients with adolescent idiopathic scoliosis (AIS) to illustrate the differences and identify areas for potential surgical improvement.

SUMMARY OF BACKGROUND DATA

Patients with Marfan syndrome commonly require spinal deformity surgery, but practice guidelines and results are not as established as those for patients with AIS.

METHODS

We matched 34 adolescents with Marfan syndrome with patients with AIS (ratio, 1:2) for age, sex, and degree of major deformity. Overall mean age was 14 ± 2 years and mean curves were 51° thoracic and 46° lumbar. Mean follow-up was 5.3 and 3.6 years, respectively.

RESULTS

The Marfan syndrome group had significantly more thoracolumbar kyphosis correction (9.5° vs. 0.1°, P = 0.05), significantly more levels fused (12 ± 2 vs. 9 ± 3, P ≤ 0.01), significantly more fusions to the pelvis (7 vs. 0, P = 0.01), and significantly more correction of sagittal imbalance (2.4 vs. -0.6 cm, P = 0.035). The Marfan syndrome group also had more intraoperative cerebrospinal fluid leaks (3 vs. 0, P = 0.01), significantly more instrumentation complications (3 vs. 1, P = 0.007), more reoperations for indications [such as fixation failure, distal degeneration, and spine fracture (9 vs. 0, P = 0.01)], and lower SRS-22 total (3.9 vs. 4.5, P = 0.01) and partial (P < 0.015) subscores. There were no significant differences between the groups in progression of unfused proximal thoracic curves, blood loss, neurological deficit, hospital stay, percent correction, or infection rate.

CONCLUSION

Patients with Marfan syndrome differ in several ways from those with AIS: they require more levels of surgical correction, more distal fusion, greater correction of sagittal balance, and more reoperations, and they have more intraoperative cerebrospinal fluid leaks and instrumentation-related complications. Knowledge of these differences is important for planning surgery.

What is a reasonable surgical procedure for spinal extradural arachnoid cysts: is cyst removal mandatory? Eight consecutive cases and a review of the literature

BACKGROUND

Spinal epidural arachnoid cysts (EAC) are rare and may present with myelopathy, which can be completely curable with surgery. The majority of investigators believe that the repairment of dural defect is important to treat EAC. However, the necessity of excising EACs remains controversial. The purpose of this study was to find a reasonable surgical technique for treatment of EACs after considering the clinical outcome, recurrence, and complications.

METHODS

The data from 44 operations in the literature and eight cases from our own experience were analyzed. This data included the surgical method, patient characteristics, level and size of the EAC, global assessment of the clinical outcomes, and the incidence of recurrence.

RESULTS

The recurrence rate was 2.0 % and 66.7 % in the patients who underwent repair of the dural defect and in those failed to repair of the dural defect, respectively (p = 0.007). The recurrence rate was 8.3 % and 3.6 % in patients who underwent complete EAC excision totally, and those who underwent EAC fenestration only, respectively (p = 0.590). The clinical outcome in patients with repaired dural defects was significantly better than that in patients with unrepaired dural defects (2.61 vs.1.67) (p = 0.027). The clinical outcome score was 2.42 and 2.68 in patients who underwent complete EAC excision and those who underwent EAC fenestration only, respectively (p = 0.158). The mean EAC length was 5.04 vertebral body levels (range, 2-13). Six of the 51 patients (11.7 %) had multiple EACs.

CONCLUSIONS

Total excision of EACs may have little benefit in terms of cyst recurrence and clinical outcome. The procedure for EAC resection carries a risk of complications such as kyphosis. If EAC resection is performed, we suggest that a tailored short-level laminotomy be used to allow for the repair of dural defects. Particularly in patients with small EAC, a partial hemilaminectomy with dural defect repair may be a possible method to reduce complications.

Thoracolumbar extradural arachnoid cysts: a study of 14 consecutive cases

BACKGROUND

To investigate characteristic clinical and radiological features of extradural arachnoid cysts (EDACs) in the thoracolumbar region, a retrospective review of medical records and imaging studies was performed. EDACs are well known but relatively rare lesions in the thoracolumbar spinal canal. The most common site is the lower thoracic spine, and it may cause neurological symptoms by compressing the spinal cord or nerve root. In this study, the pathogenesis, symptomatology, diagnostic approach, and surgical management of EDACs will be discussed.

METHODS

We studied 14 consecutive patients who were surgically treated for EDACs in the thoracolumbar region at our institute between March 2000 and January 2011. The history, clinical presentations, image findings, operative findings, and surgical outcomes of these patients were retrospectively analyzed. The mean follow-up period was 28 months (range: 6-72 months).

RESULTS

Progressive motor weakness was the predominant symptom in all patients. Nine patients had radicular leg pain and back pain in the thoracolumbar area. On MRI, the cyst compressed the dural sac and spinal cord posteriorly typically with bilateral foraminal extensions. On radiological study, a communication point with the subarachnoid was hardly observed. The surgical treatment of EDACs included complete resection of the walls and closing the communicating point with the subarachnoid space. All patients showed excellent outcomes according to Odom's criteria without recurrence. One CSF leakage and one postoperative hematoma were noted.

CONCLUSIONS

Thoracolumbar EDAC patients presented paraparesis and leg pain. Complete excision and closing the communicating point with the subarachnoid space were the choices of treatment, and the outcomes were favorable.

Radicular dysfunction due to spinal deformities in Marfan syndrome at older age: three case reports

Marfan syndrome is a inherited connective tissue disorder due to mutations in fibrillin-1. It presents with cardiovascular, ocular, skeletal, pulmonary and dural signs and symptoms. Some of the symptoms of later onset are those associated with scoliosis and dural ectasia. This is the enlargement of the neural canal especially in the lower lumbar and sacral region and occurs in over 90% of Marfan patients. We here report three patients with lumbar and/or sacral radiculopathy due to (kypho)scoliosis and dural ectasia with spinal meningeal cysts. The pain, muscle weakness, muscle atrophy, and sensory disturbances illustrate the severe neurological complications which may occur in Marfan syndrome, especially at later age. Awareness of these complications and development of management protocols is essential since life expectancy of Marfan patients has increased. Marfan syndrome might gradually become recognized as an inherited connective tissue disorder with potentially severe neurological complications during ageing.

Dural ectasia in Marfan syndrome: a case control study

BACKGROUND AND PURPOSE

Dural ectasia (DE) is one of the major criteria of Marfan syndrome (MFS). Our aim was to establish the prevalence of DE in an adult population fulfilling the Ghent criteria for MFS and to assess definitions of DE.

MATERIALS AND METHODS

One hundred five adults with suspected MFS were included. MR imaging at 1.5T was performed unless contraindicated; then CT was obtained. Lumbosacral anteroposterior vertebral body diameters (VBD) and dural sac diameters (DSD) were measured. Dural sac ratios (DSR = DSD/VBD) at levels L3 through S1 were calculated. Anterior meningoceles, herniations of nerve root sleeves, and scalloping were characterized. One hundred one sex- and age-matched patients were included as controls.

RESULTS

We identified 3 patient groups: 1) fulfilling Ghent criteria independent of DE (n = 73), 2); fulfilling Ghent criteria dependent on DE (n = 14), and 3); and suspected MFS, not fulfilling Ghent criteria (n = 18). DE was found in 86% of group 1. At levels L4-S1, mean DSRs were significantly higher in group 1 than in group 3 and controls (P < .001). Herniations of the nerve root sleeves were present in 73% in group 1 versus 1% in controls. Anterior meningoceles were found in 37% and 14% in groups 1 and 2, respectively, but not in group 3 or controls.

CONCLUSIONS

The diagnosis of DE on MR imaging or CT should be based on the presence of at least 1 of the following criteria: anterior meningoceles or nerve root sleeve herniation, DSD at S1 or below larger than DSD at L4, and DSR at S1 >0.59.

Spinal deformities in Marfan syndrome

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

Multiple extradural arachnoid cysts: report of two operated cousin cases

STUDY DESIGN

Report of 2 operated cousin cases of the multiple spinal extradural arachnoid cysts.

OBJECTIVE

To report the operative findings of cousin cases of the multiple spinal extradural arachnoid cysts and analyze a genetic etiology with the pedigree of all family members.

SUMMARY OF BACKGROUND DATA

Spinal extradural arachnoid cyst is a relatively rare condition that occupies the intraspinal space and sometimes causes neurologic disturbances. The exact etiology is unknown since most reported cases are sporadic. Minimally invasive treatments have been recently applied to a single extradural arachnoid cyst. However, it is still unknown which minimally invasive treatments can be applied to the multiple extradural arachnoid cysts.

METHODS

We experienced 2 cousin cases of multiple spinal extradural arachnoid cysts. Operative findings were described. The pedigree of all family members was made, and a genetic etiology was discussed.

RESULTS

Minimally invasive treatment was tried in Case 1. However, it failed to remove all cysts completely. Each cyst had each stalk communicating with subarachnoid space in both cases. Pedigree showed that the mode of inheritance was likely autosomal dominant.

CONCLUSION

When the cysts are multiple, it is necessary to identify a dural defect in each cyst. The etiology of the multiple extradural arachnoid cysts may be hereditary.

Spinal extradural arachnoid cysts associated with distichiasis and lymphedema

Spinal extradural arachnoid cysts (SEDAC) are lesions communicating to the subarachnoid space of the spinal canal via a dural defect. SEDAC occupies intraspinal space and sometimes causes neurological disturbances. Although most reported cases are sporadic, several familial cases have been described, suggesting a genetic etiology. Here we report on a family with SEDAC inherited in an autosomal dominant mode. Detailed study showed that the family has the lymphedema-distichiasis syndrome. Among family members examined, a total of ten in two generations manifested all or some of the following features: SEDAC, distichiasis and lymphedema. Seven had spinal cysts, four had both SEDAC and distichiasis, and one had SEDAC distichiasis and lymphedema; three did not have SEDAC. These findings, together with rarity of both distichiasis and lymphedema in the general population, support that all of the ten members were affected with one clinical entity, the lymphedema-distichiasis syndrome. The distribution of features illustrates the variable expressivity of clinical manifestations. Although FOXC2 mutation analysis was not performed in our family, it is likely that SEDAC is a component manifestation of lymphedema-distichiasis syndrome and more consistent in our family than those reported.

Multiple spinal extradural meningeal cysts presenting as acute paraplegia

✓Multiple spinal extradural meningeal cysts are rare. To the authors' knowledge, there have been only four reported cases in the world literature. The authors report a case of multiple spinal extradural meningeal cysts in a 31-year-old woman presenting with acute paraplegia. Magnetic resonance imaging of the thoracolumbar spine revealed multiple extradural cystic lesions extending from T-7 to T-8 and from T-12 to L-3. Intraoperative findings demonstrated a white, fibrous, and tense cyst filled with cerebrospinal fluid–like colorless fluid. Excision of the posterior wall of the symptomatic cyst was followed by immediate neurological improvement. The examination of the pathological specimen showed a thick duralike layer of collagen and an inner membrane of arachnoid that is often not found in these lesions. The final diagnosis was based on combined imaging, intraoperative, and histopathological findings. The authors review the literature and discuss the etiological, diagnostic, and therapeutic aspects of this lesion.

Spinal extradural arachnoid cysts: clinical, radiological, and surgical features

Extradural arachnoid cysts in the spine are rare and are seldom a cause of spinal cord compression. They are thought to arise from congenital defects in the dura mater, and they almost always communicate with the intrathecal subarachnoid space through a small defect in the dura. The mainstay of treatment in patients with neurological symptoms is surgical removal of the cyst together with ligation of the communicating pedicle and closure of the dural defect. In the present paper the authors review the literature and discuss the clinical and pathological features, mechanisms of pathogenesis, neuroimaging characteristics, and surgical management of spinal extradural arachnoid cysts. The surgical technique for removal of these lesions is illustrated in a patient with a large thoracolumbar spinal extradural arachnoid cyst causing neurogenic claudication.

Chiari-like tonsillar herniation associated with intracranial hypotension in Marfan syndrome

The authors describe the case of a 12-year-old girl with Marfan syndrome, sacral dural ectasia, and tonsillar herniation, who presented with headache. Initially, it was hypothesized that the headaches were secondary to the tonsillar herniation, and the patient consequently underwent surgical decompression of the foramen magnum. Postoperatively, the patient's condition did not improve, and additional magnetic resonance (MR) imaging demonstrated evidence of a cerebrospinal fluid (CSF) leak at the level of the dural ectasia. It was surmised that the girl's symptoms were due to spontaneous intracranial hypotension (SIH) and that the tonsillar herniation was caused by the leakage. The patient responded well to application of a blood patch at the level of the demonstrated leak, and her headache resolved. This appears to be the first reported case of a patient with Marfan syndrome presenting with a symptomatic spontaneous CSF leak complicated by tonsillar herniation. In this rare association of SIH and connective tissue disorders, recognition of the clinical signs and typical MR imaging features of SIH may lead to more appropriate and less invasive treatment, potentially avoiding surgery.

Fibrillin-1 Gene Analysis of Korean Patients With Spontaneous CSF Hypovolemia

BACKGROUND

Mutations in different domains of the Fibrillin-1 (FBN1) gene may be responsible for the variable phenotypic expression of Marfan's syndrome that may present with CSF hypovolemia.

OBJECTIVES

To evaluate the association between mutations in the Fibrillin-1 (FBN1) gene and spontaneous CSF hypovolemia (SCH) in a Korean population.

METHODS

We studied 10 consecutive patients with SCH without clinical characteristics of Marfan's syndrome. The genetic analysis was performed.

RESULTS

Direct sequencing analysis of the FBN1 gene identified 15 genetic variations, of which 5 coding (3 synonymous, 2 nonsynonymous) and 8 intronic variations were listed in the single nucleotide polymorphism database (dbSNP). The other 2 variations, c.2728 - 12T > C in intron 21 and c.4582 - 19A > G in intron 35, were also observed in normal controls with estimated frequencies of 0.06 and 0.15, respectively.

CONCLUSIONS

We could not identify any FBN1 variations possibly associated with SCH in our study population.

Cauda equina syndrome resulting from treatment of dural ectasia with fibrin glue injection

The use of fibrin glue injection to treat symptomatic dural ectasia is controversial. A case of cauda equina syndrome following percutaneous fibrin glue injection is presented, followed by a review of dural ectasia and its possible treatments.

Alterations of the thoracic spine in Marfan's syndrome

OBJECTIVE

The purpose of this study was to determine if the thoracic vertebral elements are altered in patients with Marfan's syndrome.

MATERIALS AND METHODS

Thirty patients underwent helical CT of the thorax because of suspected thoracic aortic dilatation and acute dissection. Thirteen had Marfan's syndrome and 17 did not. Two reviewers, unaware of the final diagnosis, evaluated the images by consensus for laminar thickness, foraminal width, dural sac ratios, and vertebral scalloping for T2-T12.

RESULTS

At T9-T12, dural sac ratios at the midcorpus level (p = 0.031) and foraminal width (p = 0.0124) were significantly greater in the patients with Marfan's syndrome than in the patients without. Dural sac ratios at lower endplate levels (p = 0.0685), laminar thickness (p = 0.951), and vertebral scalloping (p = 0.24) were not significantly greater in the patients with Marfan's syndrome than in the patients without.

CONCLUSION

Because the phenotypic expression of Marfan's syndrome is variable, information on the spine from thoracic studies in combination with major criteria may be helpful clinically.

Extradural spinal arachnoid cysts associated with spina bifida occulta

INTRODUCTION

Spinal extradural arachnoid cysts are an uncommon cause of neural compression in children. Even more uncommon is the association of such cysts with spina bifida occulta.

MATERIAL

Two girls, 12 and 8-years-old, presented with left leg pain, deteriorating gait, clinical signs of left L5 and S1 root compression, without bladder or bowel symptoms. The first patient had left foot drop. The second patient had muscle wasting and smaller left foot with pes cavus. Radiographs showed spina bifida occulta of S1 in both. MRI revealed an extradural cyst at the S1 level, indenting the thecal sac and the L5 and S1 roots. At operation in both patients a large arachnoid cyst arising from a small dural defect in the axilla of the left S1 root was compressing and displacing it and the dural sac. It was removed and the defect was repaired. The first patient improved with complete recovery of the foot drop. An MRI at 12 months showed no cyst recurrence. The second patient made good recovery initially, but at 10 months developed recurrent symptoms. An MRI scan showed recurrence of the cyst with root compression. On repeat exploration a different dural defect was identified in a more anterior position and was repaired.

DISCUSSION

The coexistence of extradural arachnoid cyst and corresponding bifid spinal segment has not been described previously. It raises the suspicion that the dural defect giving rise to the arachnoid cyst may be due to segmental dural dysgenesis in the context of the dysrhaphic neuroectodermal malformation.

Surgical treatment for scoliosis in Marfan syndrome

STUDY DESIGN

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intracranial hypotension induced by cervical spine chiropractic manipulation

STUDY DESIGN

Case report.

OBJECTIVES

We report a case of intracranial hypotension ensuing after a spinal chiropractic manipulation leading to cerebrospinal fluid (CSF) isodense effusion in the upper cervical and thoracic spine.

SUMMARY OF BACKGROUND DATA

The etiology of intracranial hypotension is not fully understood, but CSF leakage from spinal meningeal diverticula or dural tears may be involved.

METHODS

A 36-year-old woman presented with neck and both shoulder pain 4 days earlier. She undertook a spinal chiropractic manipulation. After this maneuver, she complained of a throbbing headache with nausea and vomiting. Her headache worsened, and lying down gave the only measure of limited relief. In CSF study, it showed dry tapping. Brain MRI showed pachymeningeal gadolinum enhancement. Thoracic spine MRI showed CSF leakage. After admission to the hospital, she was treated by hydration and pain control over several days. However, her headache did not improve.

RESULTS

She was treated by epidural blood patch. Afterwards, her headache was improved. This is the first case of spontaneous intracranial hypotension in which spinal chiropractic manipulation coincided with the development of symptoms and in which a CSF collection in the upper cervical and thoracic spine was demonstrated radiographically in Korea.

CONCLUSIONS

From this case, we can understand the etiology of intracranial hypotension and consider the complication of chiropractic manipulation.

Characterization of the symptoms associated with dural ectasia in the Marfan patient

Dural ectasia, an expansion of the dural sac surrounding the spinal cord, is one of the most common orthopedic manifestations of Marfan syndrome. The purpose of the present study was to characterize the clinical symptoms associated with dural ectasia in patients with Marfan syndrome and to understand the effects of symptomatic dural ectasia on the overall health of affected patients. Twenty-two volunteers aged 9-55 years with Marfan syndrome, and dural ectasia diagnosed by MRI or CT, filled out a "symptoms" questionnaire and completed an SF-36 health survey. Overall, It appears that the symptoms associated with dural ectasia have a marked impact on the overall health of patients with Marfan syndrome. Based on our findings, a "classic" picture of dural ectasia in the Marfan patient may consist of low back pain, headache, proximal leg pain, weakness and numbness above and below the knee, and genital/rectal pain. Symptoms, when present, are typically moderate to severe, occur several times per week (often daily), are commonly exacerbated by upright posture, and are not always relieved by recumbency.

MR Evaluation of Dural Ectasia in Marfan Syndrome: Reassessment of the Established Criteria in Children, Adolescents, and Young Adults

PURPOSE

To retrospectively evaluate known criteria for assessment of dural ectasia by using magnetic resonance (MR) imaging in children, adolescents, and young adults with and those without Marfan syndrome.

MATERIALS AND METHODS

Local ethics committee approval and informed consent were obtained. MR images of the lumbar spine in 28 patients with clinically proved Marfan syndrome (group A; 17 male, 11 female; age range, 4-21 years; mean, 12.1 years), seven patients with suspicion of Marfan syndrome (group B; six male, one female; age range, 6-18 years; mean, 10.4 years), and 55 patients without Marfan syndrome (group C; 26 male, 29 female; age range, 4-20 years; mean, 10.7 years) were evaluated retrospectively for dural ectasia criteria (scalloping, dural sac ratio, nerve root sleeve diameter, sagittal dural sac width at S1 greater than that at L4) and according to classifications by Ahn et al and Fattori et al. For statistical comparison of results, one-way analysis of variance with Scheffe post hoc comparisons was used, with an overall two-tailed significance at alpha = .05.

RESULTS

No significant differences in scalloping and nerve root sleeve diameter were shown between groups. A significant difference was measured for dural sac ratios at L5 and S1 (F test, P = .003 and P < .001 at L5 and S1, respectively; post hoc t test for groups A vs C, P = .004 and P < .001 at L5 and S1, respectively). Significant differences were also obtained between groups A and C for sagittal dural sac width at S1 greater than that at L4 according to the calculated mean difference (for both F test and post hoc t test, P < .001 and P = .003 at S1 and L4, respectively). The Ahn et al and Fattori et al classifications were of limited value.

CONCLUSION

The data suggest that only dural sac ratio at L5 and S1 and a sagittal dural sac width at S1 greater than that at L4 are statistically significant criteria for the assessment of dural ectasia in children, adolescents, and young adults.

Asymptomatic Massive Dural Ectasia Associated with Neurofibromatosis Type 1 Threatening Spinal Column Support

We report the case of a girl with a dystrophic neurofibromatosis lumbar scoliosis with asymptomatic progression and spread of dystrophic characteristics over 18 years. Resorption of almost the entire anterior column of L1-L4 had occurred despite a previous posterior instrumentation and fusion. A vascularized fibula bone graft wrapped in titanium mesh was used as an anterior structural graft. With close follow-up, the need for this type of salvage surgery might have been averted. Further follow-up showed no graft resorption and unchanged sagittal alignment after 3 years.

Plain radiography of the lumbosacral spine in Marfan syndrome

BACKGROUND CONTEXT

Marfan syndrome is a connective tissue disorder that results from a defect in the production of fibrillin. These patients tend to have several osseous anomalies of the lumbosacral spine.

PURPOSE

This study examines the effectiveness of plain radiographic findings in predicting Marfan syndrome.

STUDY DESIGN/SETTING

Case-control study.

PATIENT SAMPLE

Fourteen height-matched controls and 33 patients with Marfan syndrome were obtained from our genetics clinic or through the National Marfan Foundation.

OUTCOME MEASURES

Determined using measurements taken on plain radiographs.

METHODS

Five measurements were acquired of the lumbosacral spine from the radiographs of both groups: interpedicular distance, scalloping value, sagittal canal diameter, vertebral body width and transverse process width.

RESULTS

The following measurements were significantly larger in patients with Marfan syndrome: interpedicular distance at L1-L5 (p<.0001); sagittal diameters of the vertebral canal at L4-S2 (p<.01); transverse process to vertebral body width ratio at L2-L5 (p<.01). There was no significant difference in the scalloping values from L1-L5 between the patients with Marfan syndrome and the controls. A multivariate regression analysis generated the following criteria for plain film diagnosis of Marfan syndrome (two criteria need to be met for diagnosis): interpedicular distance at L5 greater than or equal to 36.0 mm, sagittal diameter at L5 greater than or equal to 13.5 mm or transverse process to vertebral width ratio at L3 greater than or equal to 2.25.

CONCLUSION

Based on this criteria, patients can be diagnosed with Marfan syndrome with a high sensitivity (81.8%) but a low specificity (58.3%). Thus, plain radiography can be a useful means of screening patients with Marfan syndrome.

Dural ectasia and back pain: review of the literature and case report

Dural ectasia is defined as a ballooning of the dural sac which is more common in patients with connective tissue disorders such as the Marfan syndrome. Several studies have shown that dural ectasia may be associated with such conditions as back pain, headaches, radiculopathies, or incontinence. We present a case of a 52 year old woman with Marfan syndrome who presented with a significantly large anterior sacral meningocele without having associated symptoms. In light of this case, we recommend that asymptomatic Marfan patients with dural ectasia should be closely observed without need for immediate surgical intervention.

Growth and maturation in Marfan syndrome

Understanding the growth pattern in Marfan syndrome is important for prediction of expected growth, prevention of excessive growth by hormone therapy, timing of surgical epiphysiodesis for cessation of growth, and instituting brace treatment for scoliosis. In this study, we analyze growth patterns and generate growth charts for persons with Marfan syndrome. From the charts of 180 clinically diagnosed Marfan patients, longitudinal height and weight measurements were obtained. From this data, growth charts and growth velocity charts were generated for males and females. Skeletal maturation was studied by determining the Risser signs from the x-rays of 71 males and 56 females. From 22 female patients, age of menarche was available and retrieved either by reviewing the charts or contacting the patients. Mean length at birth was 53 +/- 4.4 cm for males and 52.5 +/- 3.5 cm for females. Mean final height was 191.3 +/- 9 cm for males and 175.4 +/- 8.2 cm for females. Mean birth weight was 3.51 +/- 0.74 kg for males and 3.48 +/- 0.68 kg for females. The puberty-associated peak in growth velocity was 2.4 years earlier than the gender-matched general population for males with Marfan syndrome and 2.2 years earlier for females. Age of menarche was 11.7 +/- 2 years of age, which is also early compared to the general population. This study suggests that the growth spurt and pubertal skeletal maturation occur early in Marfan syndrome. The growth curves generated should help more accurately predict adult stature, as well as monitor progression toward it.

Marfan syndrome: orthopedic and genetic review

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

Quantitative assessment of dural ectasia as a marker for Marfan syndrome

PURPOSE

To establish normal values for lumbosacral dural sac dimensions with magnetic resonance (MR) imaging and to use these values to assess the sensitivity and specificity of dural ectasia as a marker for Marfan syndrome.

MATERIALS AND METHODS

MR imaging was performed to measure dural sac diameter (DSD) from L1 through S1 in 44 adult patients with Marfan syndrome and in 44 matched control subjects. DSD values were corrected for vertebral body size, yielding dural sac ratios (DSRs). The control subjects served to establish the upper limit of normal DSR values at the L1 through S1 levels.

RESULTS

Cutoff values for normal DSRs for L1 through S1 were 0.64, 0.55, 0.47, 0.48, 0.48, and 0.57. Significant DSR differences were shown at all levels between patients with Marfan syndrome and control subjects (P <.001 at all levels). At L1 through S1, the sensitivity of dural ectasia as a marker for Marfan syndrome was 45%-77%, and the specificity was 95% or greater. By combining levels L3 and S1, dural ectasia as a marker for Marfan syndrome yielded a sensitivity of 95% (42 of 44 patients) and a specificity of 98% (43 of 44). The presence of dural ectasia excelled, compared with the presence of other Marfan syndrome manifestations in the patient population.

CONCLUSION

Abnormal DSR values at L3 or S1 can be used to identify Marfan syndrome with 95% sensitivity and 98% specificity.

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

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

Multi-level Disruption of the Spinal Nerve Root Sleeves in Spontaneous Spinal Cerebrospinal Fluid Leakage. Two Case Reports

A 37-year-old male and an 18-year-old male presented with spontaneous spinal cerebrospinal fluid (CSF) leakage from multiple nerve root sleeves. Both patients suffered abrupt onset of intense headache followed by nausea, dizziness, and one patient with and one without positional headache. Radioisotope spinal cisternography of both patients revealed that the CSF leaks were not localized in a special zone but distributed to multiple spinal nerve root sleeves. Magnetic resonance (MR) myelography suggested that the spinal CSF column was fully expanded to the root sleeves. The extraspinal nerve bundles demonstrated numerous high intensity spots. Both patients were treated conservatively, and their symptoms resolved within one month. Repeat radioisotope cisternography and MR myelography confirmed the spine was normal after recovery. We suggest that spreading disruption of the arachnoid membrane occurs at the nerve root sleeves due to CSF overflow into the spinal canal.

Osseous anatomy of the lumbosacral spine in Marfan syndrome

STUDY DESIGN

This study examines pedicle widths, laminar thicknesses, and scalloping values for lumbosacral spine elements in Marfan volunteers. Comparisons were made between these measurements and norms as well as measurements between Marfan patients with and without dural ectasia.

OBJECTIVES

To determine if the lumbosacral vertebral elements are altered in the patient with Marfan syndrome.

SUMMARY OF BACKGROUND DATA

Several abnormalities have been noted in Marfan lumbar spine, including pedicular attenuation and widened interpediculate distances. This may be due to abnormalities of growth or presence of dural ectasia. Given the large numbers of Marfan patients requiring spinal surgery and the high postoperative failure rate, better understanding of the bony anatomy of Marfan lumbar spine is necessary, especially if use of instrumentation is anticipated.

METHODS

Thirty-two volunteers with Marfan syndrome based on the Ghent criteria underwent spiral computed tomography of the lumbosacral spine. Images were evaluated for dural ectasia, and measurements of pedicle width, laminar thickness, and vertebral scalloping were made.

RESULTS

Pedicle widths and laminar thicknesses were significantly smaller in Marfan patients at all levels (P<0.001). Mean pedicle widths at L1-L3 were smaller than the smallest available pedicle screw (5 mm). In Marfan patients with dural ectasia, laminar thickness from L5-S2 and pedicle widths at all lumbar levels were significantly reduced (P<0.01). Vertebral scalloping at S1 was significantly greater in Marfan patients with dural ectasia (P = 0.02).

CONCLUSION

Lumbar pedicle width and laminar thickness are significantly reduced in Marfan individuals. Those with dural ectasia demonstrate increased bony erosion of anterior and posterior elements of lumbosacral spine. Preoperative planning and routine computed tomography scans are recommended when operating on Marfan lumbosacral spine.

A comparison of the Berlin and Ghent nosologies and the influence of dural ectasia in the diagnosis of Marfan syndrome

PURPOSE

To compare the Berlin and Ghent diagnostic criteria for Marfan syndrome and evaluate the utility of screening for dural ectasia in the diagnosis of Marfan syndrome.

METHODS

Review of clinical and radiographic data on 73 patients evaluated for Marfan syndrome at the National Institutes of Health.

RESULTS

Nineteen percent of patients diagnosed under the Berlin criteria failed to meet the Ghent standard. Dural ectasia was the second most common major diagnostic manifestation, and screening for dural ectasia established the diagnosis of Marfan syndrome in 23% of patients under the Ghent criteria.

CONCLUSIONS

Some patients are appropriately excluded from the diagnosis of Marfan syndrome by the Ghent criteria. Determination of dural ectasia is valuable in the diagnosis of Marfan syndrome.

Dural ectasia is associated with back pain in Marfan syndrome

STUDY DESIGN

A cross-sectional age- and sex-matched study comparing the prevalence and size of dural ectasia in two groups of patients with Marfan syndrome. Group I comprised patients with moderate to severe back pain and Group II comprised patients without back pain.

OBJECTIVES

To determine whether the presence and size of dural ectasia is associated with back pain in patients with Marfan syndrome.

SUMMARY OF BACKGROUND DATA

Dural ectasia is present in more than 60% of patients with Marfan syndrome. Moderate to severe back pain is present in more than 50% of patients with Marfan syndrome. Most cases of significant low back pain in patients with Marfan syndrome do not have a clear cause. It would be useful for the clinician to know whether dural ectasia may be a cause of back pain in patients with Marfan syndrome with no other source.

METHODS

Thirty two volunteers aged 30-50 with Marfan syndrome were enrolled as age- and sex-matched pairs with significant back pain (Group I) and without back pain (Group II). A completed questionnaire, physical examination, and magnetic resonance image of the lumbosacral spine were obtained. Dural volume caudal to L5 was calculated from the magnetic resonance data by specially designed software.

RESULTS

Dural ectasia was present in 76% of the patients in Group I, and 41% of the patients in Group II. The proportion of patients with dural ectasia was significantly higher in Group I. Furthermore, the mean dural volume was significantly higher in Group I, and a significant correlation between dural volume and Oswestry pain score was noted.

CONCLUSIONS

The presence and size of dural ectasia are associated with back pain in the Marfan syndrome. However, a high prevalence of dural ectasia (41%) exists even in patients with Marfan syndrome without back pain. The mere presence of dural ectasia therefore does not necessarily mean the patient will be symptomatic even though the two are associated.

Dural ectasia in the Marfan syndrome: MR and CT findings and criteria

PURPOSE

To create criteria for detecting dural ectasia on MR or CT images in adult Marfan patients.

METHODS

Images were analyzed using a workstation. Parameters that predicted dural ectasia were included in our criteria.

RESULTS

Major criteria include: (1) width of dural sac below L5 > width above L4; (2) anterior sacral meningocele. Minor criteria include: (1) L5 nerve root sleeve diameter > 6.5 mm and (2) S1 scalloping > 3.5. Dural ectasia exists if 1 major or 2 minor criteria are present.

CONCLUSION

MR and CT diagnose dural ectasia with high specificity and sensitivity. Our criteria accurately diagnose dural ectasia in adult Marfan patients.

Importance of dural ectasia in phenotypic assessment of Marfan's syndrome

BACKGROUND

Early identification of Marfan's syndrome is fundamental in the prevention of aortic dilatation, but the wide phenotypic expression of the disorder makes the clinical diagnosis very difficult. Dural ectasia has been classified as a major diagnostic criterion; however, its prevalence is not known. We aimed to identify the true prevalence of dural ectasia in Marfan's syndrome, and to investigate its relation to aortic pathology.

METHODS

A magnetic-resonance-imaging (MRI) study of the thoracic aorta and of the lumbosacral spine was done in an inclusive series of 83 patients with Marfan's syndrome to assess the presence and degree of dural ectasia and aortic involvement; 12 patients were younger than 18 years. 100 individuals who underwent MRI of the lumbar spine for routine clinical indications represented the control group; none of them had any potential causes for dural ectasia.

FINDINGS

Dural ectasia was identified in 76 (92%) patients and none of the control group. The severity of dural ectasia was related to age; the mean (SD) age of patients with mild dural ectasia was 26 years (14) whereas that of those with severe disease (meningocele) was 36 years (9) (p=0.038). 11 of 12 patients younger than 18 years had dural ectasia. No association was found between aortic dilatation and dural ectasia.

INTERPRETATION

Dural ectasia is a highly characteristic sign of Marfan's syndrome, even at an early age.