"Clinical triad" findings in pediatric Klippel-Feil patients

Klippel-Feil syndrome: Should additional examination be conducted?

PURPOSE

Klippel-Feil syndrome (KF) is a rare disease defined as single or multi-level cervical vertebra fusion. KF could be accompanied by other spinal anomalies or isolated, and in which case necessity of whole spine screening is not clearly known. KF is investigated in terms of prevalence, gender distribution, fusion types, and frequency of accompanying anomalies according to types of KF.

METHODS

Approval from our hospital's ethics committee was received for this single-center, retrospective study. Considering the exclusion criteria among the 40,901 cervical spine MRIs, 40,450 patients were included in the study. It was re-evaluated for KF, fusion level, classification, cervical scoliosis, and other musculoskeletal and spinal anomalies.

RESULTS

125 (0.309%) of 40,450 patients is diagnosed with KF, which is more common in women (P < 0.001). Single fused segment 106 (84.8%), multilevel fused segments 8 (6.4%), contiguous fused segments 11 (8.8%) are observed. Upper level KF is detected in 13 (10.4%) patients. The frequency of additional anomaly is significantly higher in upper level KF compared to other level fusions (P < 0.001, Chi-square t). The cervical scoliosis is diagnosed 34 (27%). In KF patients with scoliosis, the frequency of additional anomalies was significantly higher (P < 0.001, Chi-square t).

CONCLUSION

Klippel-Feil prevalence is 0.309%, it is frequently observed in women, and at C2-C3 level. Additional anomalies are especially associated with 'contiguous fused segments' and 'upper level' types. Klippel-Feil with scoliosis is an indicator of increased risk for associated anomalies, and examination of the whole spine is recommended.

Klippel-Feil Syndrome With Isolated Facial Dysmorphism: A Clinical Conundrum With Resemblance to Adenoid Facies

Klippel-Feil syndrome (KFS) is a triad comprising cervical spine fusion, a low posterior hairline, and constrained neck movement. This triad is not universally present. The most frequent accompaniment is Sprengel's scapula deformity. According to the Feil classification, Class 1 (C1) is an immense fusion of many cervical vertebrae, Class 2 (C2) is a fusion of one or two vertebrae only, and Class 3 (C3) is coupled with thoracic and lumbar spinal vertebral fusion in addition to the fusion of the cervical vertebrae. Clarke's categorization of KFS includes other associated anomalies. The different classification systems for KFS have been made by the different specialists to whom patients may present, which include orthopedic surgeons, neurosurgeons, orthodontists, faciomaxillary surgeons, cardiologists, and pediatricians. This anomaly being rare and the lack of universally accepted classification may lead to confusion regarding the identification of the syndrome, especially the Clarke Type 3 with isolated facial dysmorphism may go undiagnosed. We report a case with KFS-Clarke Type 3 with isolated facial dysmorphism and Feil Type 2 with the fusion of C2-C3 cervical vertebrae, detected as an incidental radiologic finding, and initial impression of adenoid facies. Hence, this case also highlights the contrasting features between the facial dysmorphism of Clarke Type 3 KFS and adenoid facies.

Klippel-Feil Syndrome Associated with Renal and Cardiac Anomalies in an Infant: A Case Report

Klippel-Feil syndrome is a rare congenital bone disorder characterised by a triad of short neck, low posterior hairline and limited lateral bending of the neck with an annual incidence of 1 in 40,000 live births. It has remained an obscure term in the medical literature because of its variability in presentation and wide spectrum of anomalies involving multiple organ systems. It is unusual to find a case that has all three classical triad features. Here, we present a case of a 9-month-old infant who manifests not only all three classical triad features associated with Klippel-Feil syndrome but also demonstrates the presence of congenital heart disease, scoliosis, and renal ectopia. An early comprehensive evaluation of a suspected case is essential for diagnosis and counselling which impacts its prognosis, helps minimize social stigma and affords parents the opportunity to consider cosmetic surgery as an option, should they choose to pursue it.

Keywords

case reports; congenital; heart diseases; Klippel-Feil syndrome; scoliosis.

Transmandibular Cervical Corpectomy for Persistent Spinal Cord Compression in a Patient With Klippel-Feil Syndrome: A Technical Note and Systematic Review

BACKGROUND

Few studies have described a transmandibular approach for decompression in a patient with Klippel-Feil syndrome (KFS) for cervical myelopathy.

OBJECTIVE

To describe the transmandibular approach in a KFS patient with cervical myelopathy and to perform a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

METHODS

A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Embase and PubMed databases were searched from January 2002 to November 2022 for articles examining patients with KFS undergoing cervical decompression and/or fusion for cervical myelopathy and/or radiculopathy were included. Articles describing compression due to nonbony causes, lumbar/sacral surgery, nonhuman studies, or symptoms only from basilar invagination/impression were excluded. Data collected were sex, median age, Samartzis type, surgical approach, and postoperative complications.

RESULTS

A total of 27 studies were included, with 80 total patients. Thirty-three patients were female, and the median age ranged from 9 to 75 years. Forty-nine patients, 16 patients, and 13 patients were classified as Samartzis Types I, II, and III, respectively. Forty-five patients, 21 patients, and 6 patients underwent an anterior, posterior, and combined approach, respectively. Five postoperative complications were reported. One article reported a transmandibular approach for access to the cervical spine.

CONCLUSION

Patients with KFS are at risk of developing cervical myelopathy. Although KFS manifests heterogeneously and may be treated through a variety of approaches, some manifestations of KFS may preclude traditional approaches for decompression. Surgical exposure through the anterior mandible may prove an option for cervical decompression in patients with KFS.

The tilts, twists, and turns of torticollis

PURPOSE OF REVIEW

The purpose of this review is to outline the most recent understanding of torticollis in the pediatric population.

RECENT FINDINGS

It is important to diagnose the underlying condition of torticollis early in childhood, as some conditions that cause torticollis may result in major developmental delays in early motor milestones. Recent studies have highlighted that many of the rarer causes of torticollis are often misdiagnosed as congenital muscular torticollis, suggesting that physicians should pay close attention to the results of clinical and radiographic examinations when patients present with torticollis.

SUMMARY

Congenital muscular torticollis is the most common cause of torticollis. Other, less common causes of torticollis include vertebral abnormalities, ocular torticollis, gastrointestinal disorders, soft tissue infections of the neck, posterior fossa tumors, and benign paroxysmal torticollis. Although rare, these differential diagnoses should be considered during a clinical work-up for a patient who presents with torticollis.

Prevalence and Risk Factors of Surgical Treatment for Klippel–Feil Syndrome

Background

Recently, there have been some reports on surgical treatment for Klippel–Feil syndrome, but the prevalence and risk factors of surgery have not been well evaluated. This study sought to find the prevalence and potential risk factors of surgical treatment.

Methods

A retrospective radiographic review of 718 Klippel–Feil syndrome patients seen at Peking University Third Hospital from January 2010 to October 2017 was performed. Parameters included age, gender, deformity, cervical instability, Samartzis classification, and surgical treatment. Based on the surgical treatment they received, patients were divided into a surgery group and a non-surgery group. Prevalence and possible risk factors of surgical treatment were assessed.

Results

A total of 718 Klippel–Feil syndrome patients, including 327 men and 391 women, with an average age of 46.8 years were enrolled. According to the Samartzis classification scheme, 621 cases (86.5%) were classified as type I, 48 cases (6.7%) were classified as type II, and 49 cases (6.8%) were classified as type III, respectively. The most commonly fused segments were C2–3 (54.9%) and C5–6 (9.3%). Of all 718 patients, 133 (18.5%) patients underwent surgical treatment, mainly via the posterior approach (69.9%). The clinical factors included age, gender, deformity, instability, and Samartzis classification. Men were more likely to require surgical treatment (p < 0.001). Patients with instability (p < 0.001) or patients with deformity (p = 0.004) were also more likely to undergo surgery. All three of these variables were included in the binary regression analysis. Finally, gender (p < 0.001) and unstable joints (p < 0.001) were identified to be independently associated with surgical treatment. Gender was the most important risk factor with men being 2.39 times more likely to have surgical treatment, while patients with instability were 2.31 times more likely to receive surgery.

Conclusion

The prevalence of patients with Klippel–Feil syndrome requiring surgery was 18.5%, with the majority undergoing posterior cervical surgery. Gender and instability were indemnified as independent risk factors leading to surgical treatment.

Klippel-Feil Syndrome: Clinical Presentation and Management

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Klippel-Feil syndrome (KFS) is a rare multisystem constellation of findings with congenital cervical fusion as the hallmark. The etiology is not fully understood.

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Recent studies have indicated that KFS is more prevalent than previously described.

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Hypermobility in the nonfused segments may lead to adjacent segment disease and potential disc herniation and myelopathy after minor trauma.

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Most patients with KFS are asymptomatic and can be managed nonoperatively. Surgical treatment is reserved for patients presenting with pain refractory to medical management, instability, myelopathy or radiculopathy, or severe adjacent segment disease.

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Patients with craniocervical abnormalities and upper cervical instability should avoid contact sports as they are at increased risk for spinal cord injury after minor trauma.

Perioperative management of a child with Klippel–Feil syndrome and severe uncorrected aortic stenosis undergoing cervical spine stabilization

Severe stenotic aortic valve poses serious anesthetic challenges because of the fixed cardiac output and complex hemodynamics. The challenges magnify in the presence of a difficult airway which not only puts the airway at risk but also disturbs the hemodynamics, which can negatively impact the patient outcome. Moreover, prone positioning, intraoperative hemodynamics, recovery, and extubation are equally challenging for management. This case report highlights the perioperative management of a child with severe uncorrected aortic stenosis and Klippel–Feil syndrome posted for cervical spinal stabilization under anesthesia.

Congenital Cervical Hemivertebrae and Block Vertebrae in a 43-Year-Old Male

Congenital deformities of the spine are a consequence of anomalous vertebral development in the embryo and may be identified at birth or remain unnoticed until adulthood. Minor bony malformations of all types occur in up to 12% of the general population and are usually not apparent. In contrast, congenital spinal malformations that result in progressive spinal deformity are relatively rare. Klippel-Feil syndrome is a complex heterogeneous entity that results in cervical vertebral fusion and sometimes can occur associated to hemivertebra. We present a case of a 43-year-old male who presented to the emergency department after a fall. The patient had severe cervicalgia and generalized loss of active movement and sensation on his limbs. On physical examination, the patient presented reduced cervical range of motion and tetraplegia. Cervical magnetic resonance imaging revealed complete atlanto-occipital assimilation, left C3 hemivertebra with partial fusion in the right lateral portion of C2 and C4. Finally, there was a C5-C6 fusion. Surgical cervical stabilization was attempted but the procedure was aborted due to lack of space for placing the anterior plate safely. During hospitalization, the patient wore a cervical collar and started a rehabilitation program including muscle strengthening, balance, and gait training. The rehabilitation treatment led to a favorable clinical evolution. At discharge, the patient maintained a slight deficit of strength in his left upper and lower extremities, but he was functionally autonomous and was able to walk with a walker.

Klippel-Feil Syndrome: Pathogenesis, Diagnosis, and Management

Klippel-Feil syndrome (KFS), or congenital fusion of the cervical vertebrae, has been thought to be an extremely rare diagnosis. However, recent literature suggests an increased prevalence, with a high proportion of asymptomatic individuals. Occurring as a sporadic mutation or associated with several genes, the pathogenesis involves failure of cervical somite segmentation and differentiation during embryogenesis. Most commonly, the C2-C3 and C5-C6 levels are involved. KFS is associated with other orthopaedic conditions including Sprengel deformity, congenital scoliosis, and cervical spine abnormalities, as well as several visceral pathologies. There are several classification systems, some based on the anatomic levels of fusion and others on its genetic inheritance. Management of patients with KFS primarily involves observation for asymptomatic individuals. Surgical treatment may be for neurologic complaints, correction of deformity, concomitant spinal anomalies, or for associated conditions and varies significantly. Participation in sports is an important consideration. Recommendations for contact sports or activities depend on both the level and the number of vertebrae involved in the fusion. A multidisciplinary team should be involved in the treatment plan and recommendations for complex presentations.

Klippel-Feil syndrome cases from Slovakia

OBJECTIVE

This study analyzes two probable cases of Klippel-Feil syndrome (KFS) from the region of modern Slovakia and provides an overview of possible cases reported in 'grey' literature.

MATERIALS

Two adult skeletons with probable KFS from Vráble-Veľké Lehemby and Radoľa-Koscelisko.

METHODS

Macroscopic analysis was performed using standard osteological methods.

RESULTS

The two analyzed skeletons represent probable cases of KFS; one from the Neolithic, and one from the Middle Ages. Additional cases of potential KFS have been indicated within the 'grey' literature.

CONCLUSIONS

The study shows that KFS was present in prehistoric eastern Central Europe. The few cases of ancient rare diseases may be a result of past and present bioarcheological research, and many cases are hidden within 'grey' literature. A re-examination of older datasets is vital.

SIGNIFICANCE

The described cases from modern Slovakia contributes to a limited list of archaeological cases, thus widening our knowledge about the occurrence of this rare condition throughout Europe in the past.

LIMITATIONS

The state of past and present osteo-archaeological research in eastern Central Europe, poor preservation of some remains, and lack of pathognomonic features associated with KFS.

SUGGESTIONS FOR FURTHER RESEARCH

Systematic review of older skeletal assemblages and 'grey' literature.

Prenatal diagnosis of Sprengel's deformity in a patient with Klippel-Feil Syndrome

We present a case of Klippel-Feil Syndrome, a congenital skeletal defect where multiple cervical vertebral bodies are fused. Klippel-Feil Syndrome has multiple associated anomalies, with a notable one being Sprengel's deformity. In this case, the patient was given a diagnosis of Klippel-Feil Syndrome prenatally after suspected cervical vertebrae fusion and Sprengel's deformity were seen on both fetal magnetic resonance imaging (MRI) and ultrasound. Prenatal diagnosis of Sprengel's deformity has been reported once in the literature. In this report, we present imaging findings of Sprengel's deformity seen in association with Klippel-Feil Syndrome using a combination of fetal ultrasound and MRI.

Comparative proteomics analysis for identifying the lipid metabolism related pathways in patients with Klippel-Feil syndrome

Background

Klippel-Feil syndrome (KFS) represents the rare and complex deformity characterized by congenital defects in the formation or segmentation of the cervical vertebrae. There is a wide gap in understanding the detailed mechanisms of KFS because of its rarity, heterogeneity, small pedigrees, and the broad spectrum of anomalies.

Methods

We recruited eight patients of Chinese Han ethnicity with KFS, five patients with congenital scoliosis (CS) who presented with congenital fusion of the thoracic or lumbar spine and without known syndrome or cervical deformity, and seven healthy controls. Proteomic analysis by data-independent acquisition (DIA) was performed to identify the differential proteome among the three matched groups and the data were analyzed by bioinformatics tools including Gene Ontology (GO) categories and Ingenuity Pathway Analysis (IPA) database, to explore differentially abundant proteins (DAPs) and canonical pathways involved in the pathogenesis of KFS.

Results

A total of 49 DAPs were detected between KFS patients and the controls, and moreover, 192 DAPs were identified between patients with KFS and patients with CS. Fifteen DAPs that were common in both comparisons were considered as candidate biomarkers for KFS, including membrane primary amine oxidase, noelin, galectin-3-binding protein, cadherin-5, glyceraldehyde-3-phosphate dehydrogenase, peroxiredoxin-1, CD109 antigen, and eight immunoglobulins. Furthermore, the same significant canonical pathways of LXR/RXR activation and FXR/RXR activation were observed in both comparisons. Seven of DAPs were apolipoproteins related to these pathways that are involved in lipid metabolism.

Conclusions

This study provides the first proteomic profile for understanding the pathogenesis and identifying predictive biomarkers of KFS. We detected 15 DAPs that were common in both comparisons as candidate predictive biomarkers of KFS. The lipid metabolism-related canonical pathways of LXR/RXR and FXR/RXR activation together with seven differentially abundant apolipoproteins may play significant roles in the etiology of KFS and provide possible pathogenesis correlation between KFS and CS.

Klippel–Feil Syndrome with Multiple Cervical Anomalies Discovered Following Trauma

The approach to the upper cervical spine is a challenge for surgeons, not only for its complex anatomy but also for the great variety of pathologies. Klippel–Feil syndrome (KFS) is a congenital disease characterized by the fusion of two or more cervical segments and is associated with various musculoskeletal and vascular malformations. However, there is no consensus on the type of surgery, approach, level of fixation or fusion. We report the case of a KFS, associated with multiple anatomical variants, who suffered a traumatic cervical injury and underwent surgical treatment.

The mutational burden and oligogenic inheritance in Klippel-Feil syndrome

Background

Klippel-Feil syndrome (KFS) represents a rare anomaly characterized by congenital fusion of the cervical vertebrae. The underlying molecular etiology remains largely unknown because of the genetic and phenotypic heterogeneity.

Methods

We consecutively recruited a Chinese cohort of 37 patients with KFS. The clinical manifestations and radiological assessments were analyzed and whole-exome sequencing (WES) was performed. Additionally, rare variants in KFS cases and controls were compared using genetic burden analysis.

Results

We primarily examined rare variants in five reported genes (GDF6, MEOX1, GDF3, MYO18B and RIPPLY2) associated with KFS and detected three variants of uncertain significance in MYO18B. Based on rare variant burden analysis of 96 candidate genes related to vertebral segmentation defects, we identified BAZ1B as having the highest probability of association with KFS, followed by FREM2, SUFU, VANGL1 and KMT2D. In addition, seven patients were proposed to show potential oligogenic inheritance involving more than one variants in candidate genes, the frequency of which was significantly higher than that in the in-house controls.

Conclusions

Our study presents an exome-sequenced cohort and identifies five novel genes potentially associated with KFS, extending the spectrum of known mutations contributing to this syndrome. Furthermore, the genetic burden analysis provides further evidence for potential oligogenic inheritance of KFS.

Klippel-Feil Syndrome With Auxiliary Anterior Cervical Meningomyelocele and Thoracic Syringomyelia: A Case Report

STUDY DESIGN

Case report.

OBJECTIVE

Since this is the first ever case of a male patient with Klippel-Feil syndrome (KFS) with anterior cervical meningomyelocele and syringomyelia. All four previously reported cases were female patients. This makes this case unique.

SUMMARY OF BACKGROUND DATA

KFS with auxiliary anterior cervical meningomyelocele is a rare entity. To the best of our knowledge so far only four cases are reported.

METHODS

A 22-year-old male patient was presented to neurology outpatient department with 2-year history of left hand paresthesia and progressive weakness. The diagnostic evaluation showed KFS with auxiliary anterior cervical meningomyelocele and thoracic syringomyelia.

RESULTS

Patient was sent to neurosurgery department for intervention. After discussing the possible risks and complications of intervention he opted for conservative therapy and declined the surgery.

CONCLUSION

The paucity of data is the key reason for any recommended protocol for management of such patients but the available literature recommends neurosurgical intervention in symptomatic patients.

LEVEL OF EVIDENCE

5.

Demographics, presentation and symptoms of patients with Klippel-Feil syndrome: analysis of a global patient-reported registry

INTRODUCTION

Klippel-Feil syndrome (KFS) occurs due to failure of vertebral segmentation during development. Minimal research has been done to understand the prevalence of associated symptoms. Here, we report one of the largest collections of KFS patient data.

METHODS

Data were obtained from the CoRDS registry. Participants with cervical fusions were categorized into Type I, II, or III based on the Samartzis criteria. Symptoms and comorbidities were assessed against type and location of fusion.

RESULTS

Seventy-five patients (60F/14M/1 unknown) were identified and classified as: Type I, n = 21(28%); Type II, n = 15(20%); Type III, n = 39(52%). Cervical fusion by level were: OC-C1, n = 17(22.7%), C1-C2, n = 24(32%); C2-C3, n = 42(56%); C3-C4, n = 30(40%); C4-C5, n = 42(56%); C5-C6, n = 32(42.7%); C6-C7, n = 25(33.3%); C7-T1, n = 13(17.3%). 94.6% of patients reported current symptoms and the average age when symptoms began and worsened were 17.5 (± 13.4) and 27.6 (± 15.3), respectively. Patients reported to have a high number of comorbidities including spinal, neurological and others, a high frequency of general symptoms (e.g., fatigue, dizziness) and chronic symptoms (limited range of neck motion [LROM], neck/spine muscles soreness). Sprengel deformity was reported in 26.7%. Most patients reported having received medication and invasive/non-invasive procedures. Multilevel fusions (Samartzis II/III) were significantly associated with dizziness (p = 0.040), the presence of LROM (p = 0.022), and Sprengel deformity (p = 0.036).

CONCLUSION

KFS is associated with a number of musculoskeletal and neurological symptoms. Fusions are more prevalent toward the center of the cervical region, and less common at the occipital/thoracic junction. Associated comorbidities including Sprengel deformity may be more common in KFS patients with multilevel cervical fusions. These slides can be retrieved under Electronic Supplementary Material.

The prevalence of Klippel-Feil syndrome in pediatric patients: analysis of 831 CT scans

Background

To evaluate the prevalence of Klippel-Feil syndrome (KFS) in pediatric patients obtaining cervical CT imaging in the emergency room (ER).

Methods

We evaluated CT scans of the cervical spine of pediatric patients treated in the ER of a Level I Trauma Center from January 2013 to December 2015. Along with analysis of the CT scans for KFS, the following demographics were collected: age, sex, race and ethnicity. Mechanism of injury was also established for all patients. If KFS was present, it was classified using Samartzis classification as type I (single level fusion), type II (multiple, noncontiguous fused segments) or type III (multiple, contiguous fused segments).

Results

Of the 848 cervical CTs taken for pediatric ER patients during the study period, 831 were included. Of these patients, 10 had KFS, a prevalence of 1.2%. According to Samartzis classification, 9 were type I and 1 type III. The average age of patients with KFS was 16.02 years (10-18 years), with 8 males (80%) and 2 females (20%). Three had congenital fusions at vertebral levels C2-C3, two at C3-C4, three at C5-C6, one at C6-C7, and one with multiple levels of cervical fusion.

Conclusions

The prevalence of KFS amongst 831 pediatric patients, who underwent cervical CT imaging over a 3-year period, was 1.2% (approximately 1 in 83). The most commonly fused spinal levels were C2-C3 and C5-C6. The prevalence of KFS in our study was higher than previously described, and thus warrants monitoring.

Association of Klippel-Feil syndrome, Dandy-Walker malformation, spina bifida: A case report

Klippel-Feil syndrome is a congenital malformation characterized by the fusion of at least 2 cervical vertebrae. It may occur in association with other clinical syndromes and disorders.

We describe a case of prenatal diagnosis of a Klippel-Feil syndrome with Dandy-Walker malformation, and spina bifida, proved by ultrasound examination. A postmortem x-ray and autopsy were performed in a female fetus of 16 + 6 weeks of gestation: several malformations have been discovered.

To the best of our knowledge, no similar cases have been reported in the medical literature. This case report underscores the importance of a careful ultrasound screening during pregnancy for an adequate diagnostic and therapeutic management.

The Prevalence of Klippel-Feil Syndrome: A Computed Tomography-Based Analysis of 2,917 Patients

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To determine the prevalence of KFS in asymptomatic patients in New York State.

SUMMARY OF BACKGROUND DATA

Klippel-Feil syndrome (KFS) is characterized by congenitally fused cervical vertebrae and may not be diagnosed clinically because most patients do not have the classic triad of short neck, low posterior hairline, and decreased neck range of motion. KFS may be associated with abnormalities such as congenital scoliosis and deafness, and patients are at higher risk for neurologic injury following cervical spine trauma. The prevalence of KFS has not been evaluated in a large series but is estimated to occur every 40,000 births.

METHODS

A total of 3,534 cervical computed tomography (CT) scans at the emergency department of a level I trauma center were obtained during a one-year period. Duplicate scans and outside hospital imaging were excluded, resulting in 2,917 cervical CT scans for review. Demographic information was collected, and if KFS was present, level(s) fused, Samartzis classification type, and presence of cervical scoliosis and cervical spine fractures were recorded.

RESULTS

The prevalence of KFS was 0.0058% (1 in 172). Of the 17 subjects with KFS, 8 were female and 9 were male. The most commonly fused levels were C5-C6 and C2-C3. All 17 subjects were classified as Samartzis type I, with a single congenitally fused cervical segment. None of the subjects had cervical scoliosis or cervical spine fractures.

CONCLUSIONS

The prevalence of KFS in our series is much higher than previously described. Because clinical diagnosis may not be reliable, it is likely that this condition is underreported and may only be found incidentally on imaging.

LEVEL OF EVIDENCE

Level III.

Klippel-Feil: A constellation of diagnoses, a contemporary presentation, and recent national trends

Background:

Klippel–Feil syndrome (KFS) includes craniocervical anomalies, low posterior hairline, and brevicollis, with limited cervical range of motion; however, there remains no consensus on inheritance pattern. This study defines incidence, characterizes concurrent diagnoses, and examines trends in the presentation and management of KFS.

Methods:

This was a retrospective review of the Kid's Inpatient Database (KID) for KFSpatients aged 0–20 years from 2003 to 2012. Incidence was established using KID-supplied year and hospital-trend weights. Demographics and secondary diagnoses associated with KFS were evaluated. Comorbidities, anomalies, and procedure type trends from 2003 to 2012 were assessed for likelihood to increase among the years studied using ANOVA tests.

Results:

Eight hundred and fifty-eight KFS diagnoses (age: 9.49 years; 51.1% females) and 475 patients with congenital fusion (CF) (age: 8.33 years; 50.3% females) were analyzed. We identified an incidence rate of 1/21,587 discharges. Only 6.36% of KFS patients were diagnosed with Sprengel's deformity; 1.44% with congenital fusion. About 19.1% of KFS patients presented with another spinal abnormality and 34.0% presented with another neuromuscular anomaly. About 36.51% of KFS patients were diagnosed with a nonspinal or nonmusculoskeletal anomaly, with the most prevalent anomalies being of cardiac origin (12.95%). About 7.34% of KFS patients underwent anterior fusions, whereas 6.64% of KFS patients underwent posterior fusions. The average number of levels operated on was 4.99 with 8.28% receiving decompressions. Interbody devices were used in 2.45% of cases. The rate of fusions with <3 levels (7.46%) was comparable to that of 3 levels or greater (7.81%).

Conclusions:

KFS patients were more likely to have other spinal abnormalities (19.1%) and nonnervous system abnormalities (13.63%). Compared to congenital fusions, KFS patients were more likely to have congenital abnormalities such as Sprengel's deformity. KFS patients are increasingly being treated with spinal fusion.

Level of Evidence:

III

Concomitant Temporomandibular Joint Ankylosis and Maxillomandibular Fusion in a Child with Klippel- Feil Syndrome: A Case Report

Klippel-Feil syndrome (KFS) is classically characterized by fusion of any of the two of seven cervical vertebrae. It is identified by the presence of a triad of clinical signs including short neck, limitation of head and neck movements and low posterior hairline. Unusual bony malformations leading to facial asymmetry is the most common oral manifestation associated with KFS. Such maxillomandibular fusion can also result in restricted mouth opening in children. It's a challenge to provide complete rehabilitation in such children. This paper presents a report of a type II KFS with both maxillomandibular fusion and temporomandibular joint ankylosis which led to the limited mouth opening in a six-year-old child. Also, the child showed an inadequate development of speech, facial asymmetry and compromised oral health owing to the restricted mouth opening. After thorough investigations, surgery was done which restored limited mouth opening which led to normalizing of speech and oral health.

Anomalous vertebral arteries in Klippel-Feil syndrome with occipitalized atlas: CT angiography

Klippel-Feil syndrome is an uncommon anomaly that may be asymptomatic. Early clinical signs such as restricted neck motion or short neck can be subtle and incorrectly treated as spasms. High incidence of associated craniovertebral junction (CVJ) anomalies such as occipitalized atlas predisposes them to serious neurologic complications requiring invasive procedures and surgeries. However, these often have anomalous vertebral artery course which is more prone to injury during CVJ procedures, and also sparsely known in radiology literature. We demonstrate the importance of computed tomography angiography in preprocedural planning to avoid catastrophic injury to anomalous vertebral artery at CVJ in such case.

Klippel-Feil Syndrome with Sprengel Deformity and Extensive Upper Extremity Deformity: A Case Report and Literature Review

Introduction

Klippel-Feil syndrome (KFS) is a congenital anomaly resulting from fusion of cervical vertebral bodies secondary to the dysregulation of signaling pathways during somite development. It is commonly associated with scoliosis and Sprengel deformity. We present a case of KFS with commonly associated abnormalities as well as deformities that have not yet been reported in the literature.

Case Presentation

A 3-year-old girl presented for further evaluation of a left upper extremity deformity following a negative genetic workup. Upon physical exam and radiographic imaging, the patient was diagnosed with KFS and associated abnormalities including cervical scoliosis, Sprengel deformity, and congenital deformity of the left upper extremity. Deformities of the left upper extremity include radioulnar synostosis, a four-rayed hand, and absent thenar musculature. The Sprengel deformity was corrected surgically with a Woodward procedure.

Discussion

Congenital musculoskeletal deformities can be differentiated based upon spinal and limb embryology. The presence of extraspinal abnormalities not originating from somite differentiation may suggest a severe form of KFS. Important considerations in the workup of the KFS patient include looking for deformities of the shoulder girdle and upper extremities to identify abnormalities for intervention at a young age.