Extreme proximal junctional kyphosis-a complication of delayed lambdoid suture closure in Hajdu-Cheney syndrome: a case report and literature review

PURPOSE

To describe the manifestations, surgical treatment, and potential complications of Hajdu-Cheney syndrome (HCS), and the management of these complications.

METHODS

The clinical presentation, management and outcome of HCS with severe osteoporosis and open skull sutures is presented, together with a literature review.

RESULTS

A 20-year-old female with HCS underwent posterior occipitocervical fusion for symptoms of progressive basilar invagination. Because of delayed lambdoid suture closure, the stiff fusion construct lead to increased suture distraction, most notably in the upright (suture-open) position, with relief in the supine (suture-closed) position. This was successfully remedied with extension of the fusion construct anteriorly over the skull vertex to the frontal bones.

CONCLUSIONS

In patients with HCS and other conditions with delayed suture closure, the surgeon must be cognizant of the presence of mobility at the suture lines, and consider extending the fusion construct anteriorly over the skull vertex up to the frontal bones. Because of significant osteoporosis in these syndromes, multiple fixation points and augmentation with bone graft are important principles.

Hajdu-Cheney Syndrome, a Disease Associated with NOTCH2 Mutations

Notch plays an important function in skeletal homeostasis, osteoblastogenesis, and osteoclastogenesis. Hajdu-Cheney syndrome (HCS) is a rare disease associated with mutations in NOTCH2 leading to the translation of a truncated NOTCH2 stable protein. As a consequence, a gain-of-NOTCH2 function is manifested. HCS is inherited as an autosomal dominant disease although sporadic cases exist. HCS is characterized by craniofacial developmental defects, including platybasia and wormian bones, osteoporosis with fractures, and acro-osteolysis. Subjects may suffer severe neurological complications, and HCS presents with cardiovascular defects and polycystic kidneys. An experimental mouse model harboring a HCSNotch2 mutation exhibits osteopenia secondary to enhanced bone resorption suggesting this as a possible mechanism for the skeletal disease. If the same mechanisms were operational in humans, anti-resorptive therapy could correct the bone loss, but not necessarily the acro-osteolysis. In conclusion, HCS is a devastating disease associated with a gain-of-NOTCH2 function resulting in diverse clinical manifestations.

Basilar impression in osteogenesis imperfecta: can it be treated with halo traction and posterior fusion?

Basilar impression (BI) and hydrocephalus complicating osteogenesis imperfecta (OI) is usually treated by anterior transoral decompression and posterior fixation. Nevertheless, it may be questioned if posterior fusion following axial halo traction is adequate in patients with symptomatic BI complicating OI. We report on a case with progressive symptomatic hydrocephalus and BI complicating OI that was successfully treated by halo traction followed by posterior occipitocervical fusion. However, after a symptom free interval of 2 years the patient suffered from recurrence of symptomatic hydrocephalus needing additional ventriculoperitoneal (VP) shunt placement. In conclusion, posterior fusion without additional VP shunt placement may not be effective in the long term for ameliorating symptoms and signs and halting progressive hydrocephalus in BI complicating OI.

Endoscopic transoral surgery for craniovertebral junction anomalies

✓Craniovertebral junction (CVJ) anomalies continue to be challenging for neurosurgeons because of the complex anatomy of this region. To date, microsurgical decompression via a transoral route is the standard treatment for anteriorly located compressive lesions of the cervicomedullary junction (CMJ). The results obtained by minimizing surgical trauma are fewer complications, shorter hospital stays, and reduced overall psychological burden. Endoscopic surgery is becoming a leading modality in minimally invasive neurosurgical treatment.

The authors performed surgery in 11 patients with irreducible osseous dislocations resulting from CVJ abnormality during a 2-year period. Anterior CMJ decompression was achieved in all patients by performing neuroendoscopically controlled transoral excision of bone and soft tissues. The surgical technique and results will be discussed. The use of the endoscope offers several advantages in cases requiring a transoral approach to the lower clivus and atlantoaxial region. The use of minimally invasive endoscopic techniques has the potential to reduce the need for a wider cranial base opening and to decrease postoperative complications.

[Paget's disease as a cause for symptomatic basilar impression--a case report and review of the literature]

INTRODUCTION

We report a case of a 52-years old women with Paget's disease. A secondary symptomatic basilar impression was observed, causing quadriparesis, bulbar palsy and ataxia

CLINICAL PRESENTATION

We report a case of a 52-year old woman with history of/periodic headache. In the last 6 months the complaints became more intensive and continuous. Additionally quadriparesis, disphagia, hoarsness and gait instability occurred. A cranial form of Paget's disease was found and a secondary basilar impression with compression of the cerebellum and brain stem was proven. A median suboccipital decompression and C1 laminectomy were performed. The occipital bone was thick, porous, with lacunas full of blood, causing unusually intensive hemorrhage. The postoperative period was uneventful with resolution of the preoperative symptomatology.

CONCLUSION

In cases with Paget's disease a secondary basilary impression with ensuing cerebellar and brain stem compression may be observed. Decompressive suboccipital craniectomy may be a therapeutic option. The surgical team should be prepared for an excessive hemorrhage from the porous occipital bone.

Spontaneous regression of syringomyelia in Hajdu-Cheney syndrome with severe platybasia. Case report

Hadju-Cheney syndrome (HCS) is a rare autosomal-dominant disorder with variable expressivity. It is characterized by facial dysmorphism, premature tooth loss, osteolysis of distal phalanges, and skull abnormalities. In some cases, progressive platybasia can occur and can lead to Chiari malformation with an obstruction of cerebrospinal fluid flow. To the best of the authors' knowledge, only five cases of HCS-associated syringomyelia have been reported in the literature. Because of the rarity of this association, little is known about its natural history. The authors present the case of a 16-year-old boy affected by HCS. On initial magnetic resonance (MR) imaging, a severe basilar invagination with Chiari malformation and cervicothoracic syringomyelia was documented. The syringomyelia had no clinical manifestations. A repeated MR image demonstrated a spontaneous resolution of the syrinx with no changes in the tonsil or the platybasia. The regression of the syringomyelia was confirmed by a control MR imaging examination performed after a 2-year period. No changes in the patient's clinical conditions were found during the follow-up period. This is the first case of spontaneous regression of the syringomyelia despite a severe platybasia in HCS. It did not appear correlated to a modification of the tonsil's structure or position. This observation illustrates one possible evolution of syringomyelia in the natural history of HCS and raises the question of the potential mechanisms involved in the spontaneous drainage of the syringomyelic cavity.

Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation

Object. The author discusses the successful preliminary experience of treating selected cases of basilar invagination by performing atlantoaxial joint distraction, reduction of the basilar invagination, and direct lateral mass atlantoaxial plate/screw fixation.

Methods. Twenty-two patients with basilar invagination—in which the odontoid process invaginated into the foramen magnum and the tip of the odontoid process was above the Chamberlain, McRae foramen magnum, and Wackenheim clival lines—were selected to undergo surgery. In all patients fixed atlantoaxial dislocations were documented.

The 16 male and six female patients ranged in age from 8 to 50 years. A history of trauma prior to the onset of symptoms was documented in 17 patients. Following surgery, the author observed minimal-to-significant reduction of basilar invagination and alteration in other craniospinal parameters resulting in restoration of alignment of the tip of the odontoid process and the clivus and the entire craniovertebral junction in all patients. In addition to neurological and radiological improvement, preoperative symptoms of torticollis resolved significantly in all patients. The minimum follow-up period was 12 months and the mean was 28 months.

Conclusions. Joint distraction and firm lateral mass fixation in selected cases of basilar invagination is a reasonable surgical treatment for reducing the basilar invagination, restoring craniospinal alignment, and establishing fixation of the atlantoaxial joint.

Combined anterior and posterior approach for managing basilar invagination associated with type I Chiari malformation

Ventral brainstem compression is common in patients with basilar invagination associated with type I Chiari malformation. The aim of this study was to investigate the reliability of a combined one-session anterior-posterior surgical approach for these patients. Nine patients underwent transoral odontoidectomy, posterior foramen magnum decompression, occipitocervical fixation, and bone grafting. All but two patients had ventral and dorsal operations in one surgical sitting. One of these two individuals had previously undergone posterior decompressive surgery at another hospital, but his condition had deteriorated rapidly afterward. The mean follow-up time was 19 months (range, 14-30 months). There was no mortality and no significant morbidity in this series. All but one of the patients showed significant improvement in their symptoms. Chiari malformations have a surprisingly high association with basilar invagination, and patients may have symptoms in both conditions. If there is a marked anterior compression, anterior transoral and posterior decompression, fusion, and instrumentation is an optimal strategy for treating patients with basilar invagination associated with type I Chiari malformation.

Osteogenesis imperfecta at the beginning of bone and joint decade

Osteogenesis imperfecta (OI), or brittle bone disease, is a heritable disorder characterized by increased bone fragility. Four different types of the disease are commonly distinguished, ranging from a mild condition (type I) to a lethal one (type II). Types III and IV are the severe forms surviving the neonatal period. In most cases, there is a reduction in the production of normal type I collagen or the synthesis of abnormal collagen as a result of mutations in the type I collagen genes. These classic forms of OI are described in this review. There are instances, however, where alterations in bone matrix components, other than type I collagen, are the basic abnormalities of the OI. Recently, three such discrete types have been identified by histomorphometric evaluation (types V and VI) and linkage analysis (Rhizomelic OI). They provide evidence for the as yet poorly understood complexity of the phenotype-genotype correlation in OI. We also discuss bisphosphonates treatment as well as fracture management and surgical correction of deformities observed in the patients with OI. However, ultimately, strengthening bone in OI will involve steps to correct the underlying genetic mutations that are responsible for this disorder. Thus, we also describe different genetic therapeutic approaches that have been tested either on OI cells or on available OI murine models.

Spectrum of occipitoatlantoaxial injury in young children

OBJECT

Injuries of the occipitoatlantoaxial (Oc-C2) region are the predominant form of cervical injury in children younger than 10 years of age. Magnetic resonance (MR) imaging can be used to visualize directly the traumatic ligamentous and soft-tissue abnormalities of the Oc-C2 region. A retrospective review was undertaken to examine the spectrum of pediatric Oc-C2 injuries seen on MR imaging, their correlation with plain x-ray film and computerized tomography findings, and their clinical course.

METHODS

Seventy-one consecutive children younger than 10 years of age underwent cervical MR imaging for evaluation of traumatic injury. Magnetic resonance imaging was used to document abnormalities in 23 children; 20 of these injuries involved the Oc-C2 region. Abnormalities in the Oc-C2 region included disruptions of the musculature, apical ligament, atlantooccipital joint(s), tectorial membrane, and spinal cord. A spectrum of injury with progressive involvement of these structures was seen, ranging from isolated muscular injury to the multiple soft-tissue and ligamentous disruptions with craniocervical dislocation. Involvement of the tectorial membrane was the critical threshold in the transition from stable to unstable injury. Analysis of plain x-ray films revealed that a novel interspinous C1-2:C2-3 ratio criteria of greater than or equal to 2.5 was predictive of tectorial membrane abnormalities on MR imaging, with 87% sensitivity and 100% specificity. In patients with tectorial membrane abnormalities who underwent immobilization alone, interim platybasia was demonstrated on follow-up MR images. Conclusions. A progressive spectrum of distinct Oc-C2 injuries can occur in young children; the tectorial membrane is a critical stabilizing ligamentous structure in the Oc-C2 complex; and tectorial membrane abnormalities may be identified by a C1-2:C2-3 ratio of greater than or equal to 2.5.

Basilar invagination as a sequela of multisystem Langerhans' cell histiocytosis

We report the presence of basilar invagination, an unexpected and previously undescribed abnormality of the skull base, in 7 of 38 long-term survivors of multisystem Langerhans' cell histiocytosis. The abnormality is acquired, but its pathogenesis is uncertain.

Neurofibromatosis, stroke and basilar impression. Case report

Neurofibromatosis type 1 (NF1) can virtually affect any organ, presenting most frequently with "cafe au lait" spots and neurofibromas. Vasculopathy is a known complication of NF1, but cerebrovascular disease is rare. We report the case of a 51-year-old man admitted to the hospital with a history of stroke four months before admission. On physical examination, he presented various "cafe au lait" spots and cutaneous neurofibromas. Neurologic examination demonstrated right-sided facial paralysis, right-sided hemiplegia, and aphasia. Computed tomography scan of head showed hypodense areas in the basal ganglia and centrum semiovale. Radiographs of cranium and cervical spine showed basilar impression. Angiography revealed complete occlusion of both vertebral and left internal carotid arteries, and partial stenosis of the right internal carotid artery. A large network of collateral vessels was present (moyamoya syndrome). It is an uncommon case of occlusive cerebrovascular disease associated with NF1, since most cases described in the literature are in young people, and tend to spare the posterior cerebral circulation. Basilar impression associated with this case may be considered a pure coincidence, but rare cases of basilar impression and NF1 have been described.

Transmaxillary anterior decompressions in patients with severe basilar impression

Severe basilar impression leads to an upward translocation of the upper cervical spine and clivus into the foramen magnum and is a diagnosis best made with computed tomography or magnetic resonance imaging scans. Basilar impression may be a primary condition or secondary to bone softening disorders. Symptoms relating to direct neuraxial compression, obstruction to cerebral spinal fluid outflow, and vascular compromise all have been described. Management depends on the exact nature of the abnormality seen, but it is now firmly accepted that those with anterior neuraxial compression should have an anterior decompression. The severe basilar impression and craniofacial abnormalities seen in osteogenesis imperfecta together with the progressive nature of the condition have led to the development of a specific surgical response, the open door maxillotomy combined with a contoured loop fixation of the cervical spine. Little is known of the long term outcome of severe basilar impression, and long term studies undertaken by centers familiar with the condition and its management are required if definitive care is to be delivered to these patients.

Traumatic basilar impression: case report

A very rare case of traumatic basilar impression is reported. The patient, a 57-year-old man, was hit on the head vertically in the parietal region. X ray of the cervical spine and computed tomography (CT) scans showed intracranial indentation of the atlas and the odontoid process with a depressed fracture around the foramen magnum. There are no previous reports about this type of fracture.

The spine in osteogenesis imperfecta: a review of treatment

Progressive spinal deformity can be an anathma for indivudials with osteogenesis imperfecta. Scoliosis or khyphosis develop indolently, being less dramatic than long bone fractures, but once significant deformities evolve, they tend to remain progressive on into adulthood. State of the art spinal fixation systems are of little help in correcting such deformities due to poor bone stock. However, most curves can be arrested by posterior spinal fusion, performed either in situ, or by utilizing basic Harrington type instrumentation with methylmethacylate supplemtation for the hook sites, along with Drummond wires where feasible. Platybasia is yet another issue involving the spine which may be complicated by neurologic deterioration. It has been posulated as a cause of death, but can respond to shunting and brain stem decompression when recognized.

Craniocervical abnormalities in osteogenesis imperfecta: genetic and molecular correlation

Basilar impression (BI) assessed by either plain lateral skull radiograph or computerized tomography (CT) sagittal reconstruction of the craniocervical junction is a common finding occurring in 25% of subjects with osteogenesis imperfecta (OI). It appears to occur with highest frequency in a group of subjects with OI type IV B, i.e. patients with mild/moderate liability to fractures, normal sclerae but dentinogenesis imperfecta. Neurologic signs indicating compression of posterior fossa structures occur predominantly in subjects with BI and OI type IV. Screening is recommended for all patients with OI but particularly OI type IV B.

The operative management of basilar impression in osteogenesis imperfecta

Four patients with osteogenesis imperfecta and neurologically significant basilar impression have been treated over the past 8 years. The experience has resulted in changes in our therapeutic strategy for this particularly difficult problem. These cases are discussed with respect to the disease process, neurological involvement, radiological findings, and modes of surgical therapy. The errors in management as well as the success resulting from our learning experience are described. Currently, we recommend the extensive removal of the anterior bony compression by a transoral approach. This should be followed by a posterior rigid fixation that transfers the weight of the head to the thoracic spine, in an effort to prevent further basilar invagination.

Haemangioma of the skull base producing basilar impression

A patient with an acquired basilar impression, due to a cavernous angioma involving the skull base, is presented. The various causes of acquired basilar impression are reviewed.

Cranio-cervical growth collision: another explanation of the Arnold-Chiari malformation and of basilar impression

Analysis of neuro-cranio-spinal development suggests a cranio-cervical growth conflict as the cause of the Arnold-Chiari malformation and of basilar impression. The ascending course and elongation of the upper cervical nerves associated with the Arnold-Chiari malformation reflects the abnormal, caudo-cranially proceeding growth of the cervical spine. This is the opposite of the normal cranio-caudal direction of growth (which includes the brain) with downward slanting of the cervical nerve roots. The cervical growth reversal is a compensatory event related to the impairment of distal spinal growth at the level of the coexistent myelomeningocele. With the reversal of the cerical growth, the initial descent (uncoiling) of the primordial brain curvatures is compromised owing to the growth-collision with the ascending cervical spine. Their subsequent growth proceeds into the upper cervical spinal canal. The contents of the posterior cranial fossa are actively "sucked up", "devoured" by the latter. In contrast to the adaptively enhanced growth of the early cranio-cervical nervous structures in the Arnold-Chiari malformation, as an answer to the growth-shifts of the encasing skeleton, basilar impression is a postembryonic adaptation of the cervico-cranial skeleton to the inadequate growth of the nervous structures after the latter have lost their growth adaptability. Arnold-Chiari malformation and basilar impression are just two representatives of "osteo-neural growth pathology" encompassing some "dysplastic" disorders of the axial as well as of the limb skeleton such as platyspondyly, scoliosis, Scheuermann's kyphosis, achondroplasia-like conditions, congenital dysplasia of the hip etc.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiofrequency trigeminal rhizotomy in treatment of symptomatic non-neoplastic facial pain

Twenty patients suffering from non-neoplastic symptomatic facial pain underwent percutaneous radiofrequency trigeminal thermo-rhizotomy. Fourteen patients had long-standing severe multiple sclerosis, two patients had intracranial aneurysms, three patients had basilar impression secondary to Paget's disease and developmental malformations of the skull, and one patient was suffering from chronic ocular pain that developed after retinal hemorrhage. Pain paroxysms similar to tic douloureux were present in patients with multiple sclerosis and in those with basilar impression, while continuous aching pain was present in the others. After thermo-rhizotomy, pain disappeared in all patients; however, at 1 to 4 years follow-up examination, a high recurrence rate (40%) was present in the multiple sclerosis group, and the percutaneous procedure was successfully repeated. In the patients with intracranial aneurysm not amenable to direct surgery, and in the other non-neoplastic diseases, complete pain relief was found at 4 years follow-up review.

Birth injury: a possible contributory factor in the aetiology of primary basilar impression

Adult patients with primary basilar impression were four times more likely to have a history of birth injury than a control group. Distortion of basicranial synchondroses during birth is suggested as a possible mechanism and, in association with hindbrain herniation and arachnoid adhesions, may contribute towards the development of syringomyelia.

[Hypogonadism, basillary impression, subluxation of the lenses, and other clinical manifestations in a case of neurofibromatosis (author's transl)]

A case of neurofibromatosis with varied clinical symptoms due to parental consanguinity is reported. The patient presented the following manifestations: mental retardation, curved tibias, kyphoscoliosis, basillary impression with pyramidal syndrome and parkinsonism, subluxation of the lenses, bilateral blindness, and hypogonadism. Subluxation of the lenses and hypogonadism deserve special mention because of the rarity of their presentation in this disease. The hypogonadism was of the hypogonadotrophic type without evidence of pituitary or gonadal tumor. The possible causes of endocrine dysfunction in neurofibromatosis are discussed. The more likely hypothesis explains endocrine dysfunction on the basis of an elongation of the pituitary stem; if such abnormality was caused by gliosis of the optic chiasma, an explanation would be apparent for the bilateral blindness presented by our patient since infancy. The alterations of the nervous, endocrine, and osteoarticular systems, and the ocular manifestations that can be present in von Recklinghausen's disease are also reviewed.

Cervicobasilar relationships

It is prudent to apply several methods of evaluation of cervicobasilar relationships in basilar impression and, in suggestive cases, to use tomographic evaluation for complete study. This discussion reviews normal cervicobasilar relationships and illustrates selected pathologic processes that produce basilar impression.

[Neurologic complications of pagetic basilar impressions and their surgical treatment]

Paget's disease of the skull is the main cause of basilar artery syndromes in the adult. They may cause various neurological symptoms, including signs of ischemia of the spinal cord or medulla, or involvement of the cranial nerves and brain stem and, also, distant symptoms due to hydrocephalus, with various mental disorders including transient, recurrent, coma. The authors discuss 30 cases found in the world literature and 6 unreported personal cases, study the clinical symptoms of these cases of basilar artery compression due to Paget's disease, and the methods of neuro-radiological investigation, and emphasize the interest, in severe forms, of early surgical decompression before the stage of severe neurological complications. Regular supervision of patients with Pagets disease is thus essential to detect at an early stage, decompensation of basilar artery insufficiency in Paget's disease. In late forms, calcitonin may be indicated.

Basilar impression of the skull in patients with adult coeliac disease and after gastric surgery

Chamberlain's, McGregor's and Bull's angle measurements for basilar impression of the skull were made on 22 adult patients with idiopathic steatorrhoea (probable gluten enteropathy), 24 patients who had had previous gastric surgery, and 48 control subjects. For each of the three measurements a value greater than the mean plus two standard deviations was taken as the upper limit of normal. In seven patients with adult steatorrhoea all three measurements were abnormal suggesting basilar impression, while basilar impression was probable in only one patient who had gastric surgery. The trend towards abnormal measurements was significant in the steatorrhoea patients but not in those who had gastric surgery. Basilar impression also was present in patients who did not have rickets or present evidence of osteomalacia. It was argued that this study could support a hypothesis that some cases of primary basilar impression of the skull are secondary to bone softening associated with malabsorption in early life, the evidence of which may have disappeared in adult life.