Prevalence of vertebral pars defects (spondylolysis) in a population with osteogenesis imperfecta

Unraveling the Link of Altered TGFβ Signaling with Scoliotic Vertebral Malformations in Osteogenesis Imperfecta: A Comprehensive Review

Osteogenesis Imperfecta (OI) is a genetic disorder caused by mutations in genes responsible for collagen synthesis or polypeptides involved in the formation of collagen fibers. Its predominant skeletal complication is scoliosis, impacting 25 to 80% of OI patients. Vertebral deformities of the scoliotic curves in OI include a variety of malformations such as codfish, wedged-shaped vertebrae or platyspondyly, craniocervical junction abnormalities, and lumbosacral spondylolysis and spondylolisthesis. Although the precise pathophysiology of these spinal deformities remains unclear, anomalies in bone metabolism have been implicated in the progression of scoliotic curves. Bone Mineral Density (BMD) measurements have demonstrated a significant reduction in the Z-score, indicating osteoporosis and a correlation with the advancement of scoliosis. Factors such as increased mechanical strains, joint hypermobility, lower leg length discrepancy, pelvic obliquity, spinal ligament hypermobility, or vertebrae microfractures may also contribute to the severity of scoliosis. Histological vertebral analysis has confirmed that changes in trabecular microarchitecture, associated with inadequate bone turnover, indicate generalized bone metabolic defects in OI. At the molecular level, the upregulation of Transforming Growth factor-β (TGFβ) signaling in OI can lead to disturbed bone turnover and changes in muscle mass and strength. Understanding the relationship between spinal clinical features and molecular pathways could unveil TGFβ -related molecular targets, paving the way for novel therapeutic approaches in OI.

Staphylococcal enterotoxin C as a novel strategy for treating lumbar spondylolysis in adolescents: Description of technique

Lumbar spondylolysis is one of the most common causes of low back pain and primarily affects children and adolescents. Traditional posterior lumbar fixation and interbody fusion surgery has always been the most effective method to treat spondylolysis. However, traditional surgical management has limitations of large trauma, complex operation, high cost, postoperative biomechanical deterioration, and resulting complications. In order to avoid the trauma and complications of surgical treatment, and reduce the cost of treatment. Based on the successful clinical experience of using staphylococcal enterotoxin C (SEC) to treat nonunion after a limb fracture, we identified a minimally invasive method to effectively treat lumbar spondylolysis. A novel minimally invasive therapeutic approach is presented herein of an SEC injection guided by C-arm fluoroscopy to treat lumbar spondylolysis. We describe a novel technique applied in a patient with lumbar spondylolysis, who showed significantly improved low back pain symptoms and a computed tomography scan, including osseous fusion of the bilateral isthmus at L4 after SEC therapy. This is the first reported case description of using an SEC injection to treat lumbar spondylolysis with a successful clinical outcome.

Utility of ultrasonography in the diagnosis of lumbar spondylolysis in adolescent patients

BACKGROUND

This study aims to investigate the utility of the Doppler effect on ultrasonography for the diagnosis of very early- and early-stage lumbar spondylolysis in adolescent patients.

METHODS

In total, 76 adolescent patients with acute and subacute low back pain were prospectively enrolled, with 46 having lumbar spondylolysis and the remaining 30 having low back pain without spondylolysis. MRI and/or computed tomograms scans revealed very early- and early-stage lumbar spondylolysis. Furthermore, positive Doppler findings in ultrasonography around the area from the facet joint to the laminae were investigated.

RESULTS

There were no significant differences in age (p > 0.99) and body mass index (p = 0.11) between cases with and without spondylolysis. Very early- and early-stage spondylolysis were observed in 27.6% and 72.4% of patients, respectively. Positive power Doppler was 91.3% and 33.3% in cases with and without spondylolysis, respectively, which was significantly higher in spondylolysis (p < 0.001). The sensitivity and specificity of this positive power Doppler were 91.4% and 66.7%, respectively. Furthermore, the rate of positive power Doppler was significantly higher in early-stage spondylolysis (p = 0.02), with 75.0% and 97.6% sensitivity in very early- and early-stage spondylolysis, respectively.

CONCLUSIONS

A positive Doppler effect on ultrasonography is effective for screening very early- and early-stage spondylolysis in adolescent patients in an outpatient clinic.

Osteogenesis Imperfecta: A Pediatric Orthopedic Perspective

Osteogenesis imperfecta is a genetically and phenotypically heterogeneous disorder related to a defect or deficiency in the production of type I collagen. It is characterized by brittle bones, fractures, spine and extremity deformity, and a host of extraskeletal manifestations. Type I collagen is present in bone, tendons, ligaments, skin, dentin, and the sclera of the eye and other connective tissues. Osteogenesis imperfecta includes a multitude of disease manifestations that may be present at birth or develop over time and vary depending on the severity of the disease. This article describes the disease presentation and management considerations from a pediatric orthopedic perspective.

Complex spine deformities in young patients with severe osteogenesis imperfecta: current concepts review

The severity of osteogenesis imperfecta (OI), the associated reduced quality and quantity of collagen type I, the degree of bone fragility, ligamentous laxity, vertebral fractures and multilevel vertebral deformities all impair the mechanical integrity of the whole spinal architecture and relate to the high prevalence of progressive kyphoscoliotic deformities during growth. Bisphosphonate therapy may at best slow down curve progression but does not seem to lower the prevalence of deformities or the incidence of surgery. Brace treatment is problematic due to pre-existing chest wall deformities, stiffness of the curve and the brittleness of the ribs which limit transfer of corrective forces from the brace shell to the spine. Progressive curves entail loss of balance, chest deformities, pain and compromise of pulmonary function and eventually require surgical stabilization, usually around puberty. Severe vertebral deformities including deformed, small pedicles, highly brittle bones and chest deformities, short deformed trunks and associated issues like C-spine and cranial base abnormalities (basilar impressions, cervical kyphosis) as well as deformed lower and upper extremities are posing multiple peri- and intraoperative challenges. Hence, an early multidisciplinary approach (anaesthetist, pulmonologist, paediatric orthopaedic spine surgeon) is mandatory. This paper was written under the guidance of the Spine Study Group of the European Paediatric Orthopaedic Society. It highlights the most pertinent information given in the current literature and various practical aspects on surgical care of spine deformities in young OI patients based on the personal experience of the contributing authors.

Surgical Treatment With Pedicle Screws of Scoliosis Associated With Osteogenesis Imperfecta in Children

STUDY DESIGN

Retrospective study.

OBJECTIVE

To assess results of posterior instrumented fusion using pedicle screws in 12 children with osteogenesis imperfecta (OI) with spinal deformity at a single institution from 2001 to 2012.

SUMMARY OF BACKGROUND DATA

This is the first case series of OI patients who underwent non-cement augmented screw-rod instrumented fusion published in the literature.

METHODS

Of a total of 54 children with spinal deformity associated with OI, 12 (22.2%) were submitted to posterior spinal fusion with pedicle screws (80% density) because of severe spinal deformity. Here we reported the results in seven females and five males.

RESULTS

Five thoracic (41.7%), five double (thoracic and lumbar 41.7%), and two lumbar (16.7%) curves were considered. The mean number of fused levels was 11.8 (range: 5 to 16). Mean age at surgery was 13 years 8 months. Mean follow-up was 7 years 11 months (range: 3 years 7 months to 16 years 1 month). The mean preoperative scoliosis angle was 75.6°, whereas the postoperative angle was 31.4° (58.5% correction rate). The mean preoperative kyphosis angle was 57.4° and the postoperative angle was 42.3°. We observed one superficial infection, one dural tear, and three cases of proximal junctional kyphosis; two patients required one revision surgery each (2 years and 4 months postoperatively on average).

CONCLUSIONS

To our knowledge, this is the first case series published in the literature regarding OI with instrumented fusion with non-cement augmented pedicle screws exclusively in children with spinal deformity. We found that posterior spinal fusion with the screw-rod system in OI deformity in children is feasible and reliable, and has acceptable clinical and imaging results in the long-term follow-up.

LEVEL OF EVIDENCE

Level IV.

The Spine in Patients With Osteogenesis Imperfecta

Osteogenesis imperfecta is a genetic disorder of type I collagen. Although multiple genotypes and phenotypes are associated with osteogenesis imperfecta, approximately 90% of the mutations are in the COL1A1 and COL1A2 genes. Osteogenesis imperfecta is characterized by bone fragility. Patients typically have multiple fractures or limb deformity; however, the spine can also be affected. Spinal manifestations include scoliosis, kyphosis, craniocervical junction abnormalities, and lumbosacral pathology. The incidence of lumbosacral spondylolysis and spondylolisthesis is higher in patients with osteogenesis imperfecta than in the general population. Use of diphosphonates has been found to decrease the rate of progression of scoliosis in patients with osteogenesis imperfecta. A lateral cervical radiograph is recommended in patients with this condition before age 6 years for surveillance of craniocervical junction abnormalities, such as basilar impression. Intraoperative and anesthetic considerations in patients with osteogenesis imperfecta include challenges related to fracture risk, airway management, pulmonary function, and blood loss.

Orthopaedic Considerations for the Adult With Osteogenesis Imperfecta

Osteogenesis imperfecta is a heritable group of collagen-related disorders that affects up to 50,000 people in the United States. Although the disease is most symptomatic in childhood, adults with osteogenesis imperfecta also are affected by the sequelae of the disease. Orthopaedic manifestations include posttraumatic and accelerated degenerative joint disease, kyphoscoliosis, and spondylolisthesis. Other manifestations of abnormal collagen include brittle dentition, hearing loss, cardiac valve abnormalities, and basilar invagination. In general, nonsurgical treatment is preferred for management of acute fractures. High rates of malunion, nonunion, and subsequent deformity have been reported with both closed and open treatment. When surgery is necessary, surgeons should opt for load-sharing intramedullary devices that span the entire length of the bone; locking plates and excessively rigid fixation generally should be avoided. Arthroplasty may be considered for active patients, but the procedure frequently is associated with complications in this patient population. Underlying deformities, such as malunion, bowing, rotational malalignment, coxa vara, and acetabular protrusio, pose specific surgical challenges and underscore the importance of preoperative planning.

Imaging Findings and Evaluation of Metabolic Bone Disease

Bone is a dynamic organ of the endoskeleton, playing an important role in structural integrity, mineral reservoirs, blood production, coagulation, and immunity. Metabolic bone disease encompasses a broad spectrum of inherited and acquired disorders that disrupt the normal homeostasis of bone formation and resorption. For patients affected by these processes, radiologic imaging plays a central role in diagnosis, monitoring treatment, and risk stratification. Radiologists should be familiar with the diseases, intimately aware of the imaging findings, and possessive of multimodality expertise to wisely guide the best practice of medicine. The purpose of this paper is to review the imaging features and characteristics of the most common types of metabolic bone disease with highlights of clinically relevant information so that readers can better generate appropriate differential diagnoses and recommendations. For this review, a thorough literature search for the most up-to-date information was performed on several key types of metabolic bone disease: osteoporosis, osteomalacia, rickets, scurvy, renal osteodystrophy, hyperparathyroidism, Paget’s disease, osteogenesis imperfecta, acromegaly, and osteopetrosis. Although they all affect the bone, these diseases have both shared characteristic features that can be discerned through imaging.

Current Evidence Regarding the Etiology, Prevalence, Natural History, and Prognosis of Pediatric Lumbar Spondylolysis: A Report from the Scoliosis Research Society Evidence-Based Medicine Committee

STUDY DESIGN

Structured literature review.

OBJECTIVES

To assess the current state of evidence as a first step in the development of practice guidelines for pediatric spondylolysis.

SUMMARY OF BACKGROUND DATA

Progress in published medical knowledge, changes in societal expectations, and developments in health care economics have led medical organizations to develop evidence-based documents and products.

METHODS

A comprehensive literature search for pediatric spondylolysis was performed with the assistance of a medical librarian. The authors reviewed citations and abstracts. Abstracts were reviewed for exclusions and data from included studies were analyzed by committee. A total of 44 articles provided the best available evidence for the questions of etiology, prevalence, natural history, and prognosis: 9 were graded as level I evidence, 23 were level II, 3 were level III, and 9 were level IV. No level V studies were included in the final list.

RESULTS

There is good evidence that pediatric lumbar spondylolysis is an acquired fracture of the pars interarticularis that can occur unilaterally or bilaterally. Evidence shows that when chronic, bilateral pars defects develop, 43% to 74% of patients will progress to grade 1 or 2 spondylolisthesis. In addition, unilateral, incomplete, and early lesions can obtain bony union. With or without bony union or spondylolisthesis, short-term symptom resolution is the norm. Long-term prognosis is less clear, but there is fair evidence that most patients will have lumbar symptoms compared with the general population. There is also fair evidence that some patients will develop significant symptoms as adults and will undergo surgical treatment. There is insufficient knowledge to predict which patients will continue to do well in the long term with conservative or no treatment and which patients will develop symptoms significant enough to warrant early intervention.

CONCLUSIONS

The current medical literature provides fair to good evidence for clinically relevant questions regarding the etiology, prevalence, natural history, and prognosis of pediatric spondylolysis.

Update on the evaluation and treatment of osteogenesis imperfecta

Osteogenesis imperfecta (OI) is a heritable bone fragility disorder that presents with a wide clinical phenotype spectrum: from perinatal lethality and severe deformities to very mild forms without fractures. Most cases of OI are due to autosomal dominant mutations of the type I collagen genes. A multidisciplinary approach with rehabilitation, orthopedic surgery, and consideration of medical therapy with bisphosphonates underpins current management. Greater understanding of the pathogenesis of OI may lead to novel, therapeutic approaches to help improve clinical symptoms of children with OI in the future.

Craniospinal abnormalities and neurologic complications of osteogenesis imperfecta: imaging overview

Osteogenesis imperfecta is a rare genetic disorder that leads to progressive skeletal deformities due to deficits in type I collagen, the main pathophysiologic effect of the disease. In addition, it may lead to a wide range of associated neurologic abnormalities: The central nervous system is usually involved because of softening of bone at the base of the skull, with resultant upward migration of the upper cervical spine and odontoid process into the skull base. Upward migration of the spine may cause compression of the brainstem, mechanical impingement of the spinal canal with restriction of cerebrospinal fluid circulation, and impingement of the cranial nerves. Osteogenesis imperfecta also may directly involve neurovascular structures, leading to cavernous fistulas of the carotid artery, dissection of the cervical arteries, and cerebral aneurysms. The brain parenchyma is frequently affected by the disease, with manifestations including cerebral atrophy, communicating hydrocephalus, and cerebellar hypoplasia. The imaging features of the disorder vary as widely as its clinical manifestations, depending on the severity of disease. Severe forms accompanied by debilitating skeletal fractures and progressive neurologic impairments may lead to perinatal death, whereas milder asymptomatic forms might cause only a modest reduction in life span. The most important advance in medical therapy for osteogenesis imperfecta has been the introduction of bisphosphonate therapy to slow the resorption of bone in patients with moderate to severe forms of the disease (ie, type III or IV). In some patients, neurosurgery may be necessary to correct the effects of severe basilar invagination by the odontoid process.

The incidence of spondylolysis and spondylolisthesis in children with osteogenesis imperfecta

BACKGROUND

Spondylolysis and spondylolisthesis are common abnormalities of the lumbar spine. The incidence of these diagnoses is recognized in the healthy population. However, their incidence in osteogenesis imperfecta (OI) patients is less well defined.

METHODS

This is a retrospective radiographic review of patients treated in the OI clinic from a single institution. Lateral radiographs were reviewed on all available patients to assess the incidence of spondylolysis and spondylolisthesis in this patient population. The morphology of the pedicle and pars interarticularis was also evaluated to identify any abnormalities or dysplasia of these structures.

RESULTS

One hundred ten of the 139 patients treated in the OI clinic met the inclusion criteria for this study. Of these patients, 79% (87 of 110) were ambulatory. The overall incidence of spondylolysis in this pediatric OI population was found to be 8.2% (9 of 110) at an average age of 7.5 years. The incidence of spondylolisthesis was 10.9% (12 of 110) at an average age of 6.5 years with 75% (3 of 12) being isthmic type and 25% (3 of 12) dysplastic. The combined incidence of spondylolysis and spondylolisthesis was 19.2%. Incidentally, the pedicle length was noted to be elongated in 40.0% (44 of 110) of this OI population.

CONCLUSIONS

This study found that the incidence of spondylolysis in a group of children with OI was much higher than in the normal pediatric population, which has been reported to be 2.6% to 4.0%. This incidence was also found to be higher than previously reported incidence of spondylolysis in OI patients (5.3%). The incidence of spondylolisthesis was also found to be much higher than that of the normal pediatric population (4.2%). It is important to recognize this higher incidence of these abnormalities and to anticipate future associated symptoms and potential worsening listhesis that can clinically affect the lifestyles of these children and potentially require surgical treatment. The clinical significance of these findings will necessitate long-term follow-up.

Incidence and etiology of lumbar spondylolysis: review of the literature

BACKGROUND

Lumbar spondylolysis is a defect of the pars interarticularis known to occur as a stress fracture. Its incidence varies considerably depending on ethnicity, sex, and sports activity. However, there are few literature reviews describing its incidence in different ethnic groups or in people who engage in different sports.

METHODS

We reviewed the most relevant articles on spondylolysis published in scientific journals. First, we focused on its incidence in various ethnic groups distributed by sex, the familial occurrence, and in patients with relevant diseases. Second, we focused on the incidence of spondylolysis in relation to the sports practiced by the patients. Although placing special emphasis on the incidence of lumbar spondylolysis in the general population in Japan, we also reviewed the Japanese and English literature to investigate its incidence among those who engage in different sports.

RESULTS

The incidence of lumbar spondylolysis in the general Japanese population was 5.9%. Most studies report that the incidence in higher in male subjects than in female subjects. We found that Japanese rugby and judo players were prone to suffer lumbar spondylolysis, at an incidence of about 20%. However, the incidence for Japanese professional soccer and baseball players was much higher, at 30%, which was more than five times the incidence in the general Japanese population.

CONCLUSIONS

The incidence of lumbar spondylolysis varies depending on ethnicity, sex, family history, relevant disease, and sports activity.