the craniocervical junction and cervical spine
TRANSCRIPT
Neurological Complications of EDS: Instability the craniocervical junction and cervical spine
Fraser C. Henderson Sr
Chief ,Neurosurgery Luminis Health, DCH,MD
Director, The Metropolitan Neurosurgery Group
Staff, University of Maryland Capital Region MC
Disclosures
◼ Scientific Board, Computational BioDynamics, LLC
◼ Inventor: Stress Injury Analysis Computer Simulation Model For Human Central Nervous System. Henderson. U.S. Patent # 6,980,922 doi 12/27/2005
◼ Inventor: Theory, method and Device for Determination of Abnormal Brainstem stress and subsequent neurological deficit. Henderson:
U.S. patent # 8858470 doi 01/29/2007
◼ Inventor : Mathematical Relationship of Strain, Neurological Dysfunction and Abnormal Behavior Resulting from Neurological Dysfunction of the Brainstem: Henderson FC, Newman JW:
U.S. Patent # 8556939 doi 01/08/2008
◼ Inventor : Craniospinal Fusion Method and Apparatus: Henderson US Patent # 8,182,511 doi 5/29/2012
◼ Consultant , Life Spine , Inc
26 y.o. woman, formerly a vocalist
◼ Masters in music at Cambridge◼ MVA 2009, bedrest since then◼ Headache (8/10) and diffuse joint pains◼ Nausea◼ Memory and cognition problems◼ Visual blurring, photosensitivity, hyperacusis◼ Dizziness, episodes of syncope, POTS◼ Weakness, imbalance, incoordination◼ Unstable joints with frequent subluxation◼ unable to walk > 20 feet◼ Urinary urgency , incontinence
Chiari Malformation Type 1, Basilar invagination, Atlantoaxial instability, cervical segmental instability
Ligamentous laxity results in deformation of the nervous system in EDS
Van Depaepe A, Malfait F: , Clin Genet : 82: 1–11, 2012Voermans et al, Annals of Neurol, 2009
In assessing for the potential of basilar invagination and craniospinal instability : 3 radiological metrics
• Clivo-axial angle, CXA
• Grabb,Mapstone,Oakes measurement pB-C2
• Harris’ measurement, BAI
The Consensus Statement, Chiari Syringomyelia Foundation Multi-disciplinary Colloquium Craniocervical Hypermobility Francisco, Oct 19th, 2013
Clinical research common data elements (CDEs):Radiological metrics standardization for craniocervical instability.https://commondataelements.ninds.nih.gov/CM.aspx#66=Data_Standards.Updated 2016.Adopted by the NIH/NINDS CommonDataEquivalents 2018
flexion/ extension CT or MRI recommended where possible
1. Clival-axial angle (CXA)
< 135◦>150 ◦
PATHOLOGICALNORMAL
Ventral brainstem compression – if the Grabb-Oakes measurement >9mm
Harris measurement Abnormal >12mm
Normally, the basion pivots over the mid odontoid, translational movement is < 1 mm
Weisel, Rothman, 1979 Werne, 1957 Fl White and Punjabi 1980 Fielding 1957 Menezes, 1990 Henderson 2017,2018
>1 mm translation between cranium and odontoid is Pathological (White,Panjabi,1990)
Harris measurement BAI = 12mm Harris measurement BAI = 7mm
Chronic Craniocervical instability translation >1 mm is pathological
Indications for cranio-cervical fusion stabilization
• exhausted non-operative treatment
• surgery is a last option
• disabling headache/neck pain >7/10
• Cervical medullary syndrome
• neurological deficits
• pathological radiological metrics
The cervical medullary syndrome
HeadachesDizziness, vertigo, tinnitus ImbalanceGait changesSensori-motor deficits Visual and auditory deficitsDysarthria, dysphagia , chokingAltered breathing , sleep apneaNausea, emesissyncope
Consensus conference , CSF, San Francisco, 2013
Operative Procedure
• SSEPs• Limited suboccipital
decompression, no duroplasty• Screw fixation per Goel• rib harvest T7 for fusion• Cut time 3 hours• EBL average <100ml
Craniocervical fusion stabilization
Iliac crest allograft soaked with bone marrow aspirate, incorporated into aperture of occipital plate
Hospital outcomes
◼ surgical cohort= 50 surgical patients non-surgical comparison cohort =22
◼ mean hospital LOS = 4 days
◼ no intra-operative complications
◼ 6 unplanned reoperations related to poor wound healing, of which 1 underwent revision of fusion
At follow-up, surgical cohort reported taking less pain medication (p-value = 0.001)
Pre-post surgery symptom improvement)
NEUROLOGICAL ▪ Dizziness /
lightheadedness▪ Presyncope ▪ syncope▪ Headache▪ Neck pain▪ Concentration
difficulties ▪ Nausea / vomiting ▪ Incoordination
CONSTITUTIONAL • Fatigue
MUSCULOSKELETAL• Joint pain • Neck pain on bumpy
roads • Muscle pain at rest
Symptoms reaching statistical significance p<0.001
pre-post surgery symptom improvement
NEUROLOGICAL ▪ Vertigo ▪ Dystonias▪ Memory loss▪ Double vision▪ Photosensitivity▪ Facial numbness▪ Leg weakness▪ Arm weakness▪ Speech difficulty▪ phonosensitivity
MUSCULOSKELETAL• Cramps, stiff muscles• Pain in legs while
walking
GASTROINTESTINAL • Abdominal pain• Bloating• Constipation• Heartburn, GERD• Diarrhea
DYSAUTONOMIAstatistical significance ( p < 0.05)lpitations• Chest tight, pain at
rest• Chest pain on
exertion• Short breath at night• Short breath at rest• Fingers change color
(Raynaud-like phenomena)
• Heat intolerance• Elevated
temperature
Karnofsky Performance Score
p-value = 0.044
p-value = 0.033
70 Cares for self; unable to carry on normal activity or to do active work.
60 Requires occasional assistance, but is able to care for most of his personal needs.
50 Requires considerable assistance and frequent medical care.
40 Disabled; requires special care and assistance.
Patients reported high satisfaction with their surgery.
“In looking back, I would still choose to have the cranio-cervical surgery.”
Atlanto-axial instability
Alar ligament incompetence is a cause of AAI
• rotational movement (23-39°) restricted by contralateral alar ligament
• “.. overstretching or rupture of the alar ligaments can result in rotary hypermobility or instability”
- Harold HoffmanDvorak JRI, Panjabi M, Gerber M, Wichmann W. CT Functional diagnostics of the Rotary Instability of Upper Cervical Spine , Spine ,1987
86% of patients RA exhibit anterioratlantoaxial subluxation (AAS) stroke and sudden death due vertebrobasilar insufficiency Anterior AAS is the most common form (80%)
BUT in EDS the subluxation is lateral
AAI dx by open mouth views on DMX or CT
Lateral translation
Alar ligament incompetence demonstrated by stressing the alar ligaments with rotation of the cervical spine
neck rotated to left, angle subtended by C1 upon C2
Therefore , the C1-C2 angle is 45 °
N N
>80% facet subluxation = unstable
UNSTABLE
>80% loss of facet overlap
Atlanto-dental interval normal
Unilateral facet subluxation
facet joint not subluxed
Mechanical deformative stress
Altered vertebro-basilar circulation
Indications for C1C2 fusion stabilization
• Occipital neuralgia• Posterior circulation sx - altered vision - pre-syncope or syncope• intermittent dysesthesias • Nausea• Tinnitus• Impaired memory and
concentration
• Tenderness over C1C2• Hyperreflexia• Diffuse hypoesthesia to
pinprick• Dysdiadochokinesia,
unsteady gait, Romberg• Imaging of subluxation -
- neck rotation - lateral tilt - Impaired vertebral artery flow
Occipital Neuralgia
• Severe suboccipital h/ache
• misdiagnosed as tension headache or migraine
• worse with neck movement, extension , bumpy ride
• neurological exam intact
Fusion with structural allograft infused with bone marrow
Treatment requires careful positioning of screws for stabilization
P =0.003 P < 0.003
Headache and neck pain
Statistically significant improvement in Syncope , presyncope and lightheadedness
P = 0.008
P= 0.018
Karnofsky performance scale
Overall improvement in 65%, no significant improvement in 35%
EDS: premature DDD and osteoarthritis
• Early-onset of cervical spine DDD and osteoarthritic changes
Grahame R. Clinical conundrum. Br J Rheumatol.1989 ;28:320.
Lewkonia RM. Does generalized articular hypermobility predispose to generalized osteoarthritis? Clin Exp Rheumatol.1986 ;4:115–119.
Cervical instability / stretch myelopathy
Physiological tethering through deformity Benzel ,Neurosurg 2007
Henderson et al, Neurosurg 56 :1101-1113, 2005
White and Punjabi, 1990
Cervical Segmental instability C45
NORMAL On standard MRI
Abnormal on dynamic MRI
Symptoms of high cervical instability may mimic some sx of CCI
◼ Headache◼ Nausea◼ Poor memory ,
concentration◼ Change in gait
◼ Neck shoulder pain◼ Interscapular muscle pain
(rhomboid mm)◼ Arm sensory and motor
changes◼ Dyspnea◼ Convergence fatigue
Clinical Instability ≥5 = unstable
2 points each
◼ Sagittal plane displacement > 3.5 mm • sagittal plane angulation > 11 degrees • Spinal cord damage 1 pt each◼ Stenosis Sagittal diameter < 13 mm ◼ Abnormal disc narrowing ◼ Nerve root damage
Headaches due to tethered cord
• 50% tethered cord pts report “ pulling down the back of the head”
• Headache worsens with traction , straight leg raising, neck flexion
• Moderate severe pain
Tethered cord syndrome• Low back pain• Leg weakness, sensory loss , pain• Neurogenic bladder• Sometimes rectal incontinence
• Urodynamic findings• Radiologic findings: fatty filum, low conus
Tethered cord syndrome (may be radiologically occult)
Vascular problems
Potential for vasculopathy
◼ vEDS◼ cEDS 1subtype heterozygous variant of COL1A1, encoding the alpha-1 chain of type I collagen
◼ Classic-like EDS (tenascin X ) ◼ Kyphoscoliotic EDS (kEDS), congenital
hypotonia, rupture or aneurysm of medium-sized arteries.
EDS vascular complications
◼ Dissection of right renal artery
◼ vascular type v EDS (Col 3A1)
◼ Classic –like cl EDS (Tenascin x)heterozygous variant of COL1A1, encoding the alpha-1 chain of type I collagen
◼ Kyphoscoliotic EDS ( kEDS) PLOD 1 or FKBP14 genes
Vertebral artery kinks and carotid dissection
Vertebral artery loops, dissection
Normal VA
Hypercoagulability, sinus thrombosis and decreased venous drainage
Sinus thromboses
◼ left transverse sinus thrombosis
◼ sinus rectus thrombosis◼ SX: Headache,
confusion, personality change, leg weakness, incontinence, coma
◼ Dx: CTA
◼ Treament: Lovenox 1 mg/kg SQ bid
Vascular congestion
• obstruction of venous flow – transverse sinus stenosis - jugular compression• venous congestion • increased bleeding
• Preserve perivertebral venous drainage
◼ Thank you for your attention !!
Acknowledgements
◼ Clair Francomano MD, JHI◼ Myles Koby MD, NIH, Doctors Hospital◼ Peter Rowe MD,JHI◼ Rodney Grahame, Professor of Rheumatology, London Univ◼ Alan Pocinki MD, George Washington University◼ Ed Benzel MD- Prof, Chair Neurosurg ,Cleveland Clinic◼ Robert Gerwin MD Assoc Prof, JHI◼ Alex Vaccaro MD- Prof Neurosurg Ortho, TJU◼ Stephen Mott MD Assoc Prof Peds Neurol, Dartmouth◼ Joel Berry PhD – Prof Chair Mech Eng, Kettering Univ ◼ Mark Alexander MD , Director Neuroradiology Bethesda MRI◼ Jonah Murdoch, MD, GUH,DCH◼ Jessica Adcock BS,MS◼ William Wilson IV, Yale Univ◼ Kelly Tuchman BA, ASN