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CASE REPORT
Year : 2014  |  Volume : 9  |  Issue : 2  |  Page : 142-144
 

Rare association of spondylo costal dysostosis with split cord malformations type II: A case report and a brief review of literature


1 Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
2 Department of Genetics, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India

Date of Web Publication21-Aug-2014

Correspondence Address:
Aneel Kumar Puligopu
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.139320

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   Abstract 

Spondylo costal dysostosis (SCD) is a genetic skeletal disorder characterized by a variety of costo-vertebral malformations. SCD with type I split cord malformation (SCM) have been reported in the literature. We report an unusual association of SCD with type II SCM. Imaging studies revealed multiple vertebral segmentations, rib malformations, spina bifida and low lying cord with type II SCM at the D12-L3 level. She underwent detethering of the cord. To the best of our knowledge, this is the first report of the association of SCD with type II SCM.


Keywords: Jarcho-Levin syndrome, split cord malformation, spondylo costal dysostosis


How to cite this article:
Srinivas BH, Puligopu AK, Sukhla D, Ranganath P. Rare association of spondylo costal dysostosis with split cord malformations type II: A case report and a brief review of literature. J Pediatr Neurosci 2014;9:142-4

How to cite this URL:
Srinivas BH, Puligopu AK, Sukhla D, Ranganath P. Rare association of spondylo costal dysostosis with split cord malformations type II: A case report and a brief review of literature. J Pediatr Neurosci [serial online] 2014 [cited 2018 Jun 23];9:142-4. Available from: http://www.pediatricneurosciences.com/text.asp?2014/9/2/142/139320



   Introduction Top


Spondylo costal dysostosis (SCD) is a rare genetic skeletal disorder characterized clinically by short trunk dwarfism, chest wall deformity and scoliosis, and radiographically by multiple segmentation defects of the vertebrae and asymmetric rib malformation (rib fusion, misalignment and/or abnormal rib number). [1] Additional anomalies such as neural tube defects, genitourinary tract malformations have been reported. [2],[3],[4] Split cord malformations (SCMs) are classified based on the midline septum and the dural sleeve into type 1 and type 2. To the best of our knowledge, this is the first case report of an association of type II SCM with SCD.


   Case Report Top


An 8-year-old girl presented to our hospital with 1-month history of pain in the mid back, paresthesias over both lower limbs and urinary incontinence. The cognitive and language developmental milestones were normal. She was the second offspring of nonconsanguineous parents, her two male siblings were normal and there was no history of similar deformities in any of her family members. At birth, she had an abdominal wall defect below the left subcostal region which closed spontaneously over a period of 6 months.

Physical examination revealed thoracic cage asymmetry, thoracic kyphoscoliosis and discoloration of the skin in the left subcostal region. There were no other dysmorphic features or obvious external malformations. Her anthropometric measurements were as follows: height 124 cm (25 th centile), arm span 124 cm, upper segment: lower segment ratio 0.88:1 and head circumference 51 cm (50 th centile). On neurological examination, power was 4 ± 5 in both the lower limbs, deep tendon reflexes were sluggish, plantar response was equivocal on the right side and extensor on the left and superficial sensations were decreased below the D11 level by 20%. Her higher mental functions, cranial nerve examination and upper limb motor and sensory functions were normal.

Thoracic and lumbar radiographs showed thoracic scoliosis with convexity toward the right, multiple vertebral segmentation anomalies at the D8-D12 level including hemivertebra at D8 and butterfly vertebra at D10, multiple levels of spina bifida at D8-L2 and L3-S1 levels and rib anomalies including irregular fusion of the lower ribs with absent ribs on the left side [Figure 1]. Magnetic resonance imaging of the dorsolumbar spine with screening of the whole spine showed diplomyelia from D12 to L3 without any bony spur. The two hemicords were asymmetric and were surrounded by a single dural tube. There was evidence of low lying cord extending up to L3 level and multiple levels of spina bifida involving the lower dorsal and lumbosacral region [Figure 2].
Figure 1: Computed tomography dorsal spine showing hemivertebra at D8, butterfly vertebra at D10 and absent ribs on left side

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Figure 2: Magnetic resonance imaging of the dorso lumbar spine showing diplomyelia from D12 to L3 without bony spur

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The patient underwent D11 to L3 laminectomy. Intraoperatively, two hemicords with a single dural tube were noted and no bony or fibrous septum was found. Thick arachnoidal adhesions were found between the two hemicords, which were released. Primary dural closure was performed, and sectioning of thick fatty filum terminale was done. Post operatively, the patient did not have new neurological deficits, her scoliosis showed mild improvement and she is on follow-up.


   Discussion Top


The first report of congenital malformation syndrome involving vertebral segmentation defects and rib anomalies was published by Jarcho and Levin in 1938 and was termed the Jarcho-Levin syndrome. [5],[6] Since then, the term has been loosely used for all genetic costo vertebral malformations. Subsequent studies have now made it evident that congenital costo vertebral malformations can be of two distinct subtypes: the SCD and the spondylo thoracic dysostosis (STD). [7] Patients with SCD have intrinsic rib malformations (broadening, fusion, missing ribs, abnormal orientation, bifurcation, irregularity of shape and size) in addition to multiple vertebral segmentation defects as in our case. [8] Those with STD have multiple vertebral anomalies with posterior fusion of the ribs giving a "fan" like configuration of the ribs and "crab" like appearance of the thorax and do not have intrinsic rib malformations. [9] The vertebral defects in both SCD and STD include decreased number of vertebrae with segmentation and formation defects like block vertebrae, hemi vertebrae, butterfly vertebrae, missing vertebra and fused vertebrae. All cases of STD and majority of SCD have an autosomal recessive pattern of inheritance and, therefore, have a 25% risk of recurrence in siblings. Prenatal diagnosis can be offered to parents of affected children through either targeted mutation analysis in the fetal DNA or through targeted fetal anomaly scanning at 18-23 weeks gestation, to prevent birth of further affected children in the family. [10],[11] Clinically children with SCD will have scoliosis and respiratory difficulties due to mechanical restriction. Aggressive neonatal management, treatment of pneumonia and ventilator care if necessary are required. Chest wall reconstructions have also been performed. [1],[12] Management of scoliosis requires bracing, hemivertebra excision, convex hemiepiphysiodesis, spinal instrumentation and thoracoplasty with a vertical expansion prosthetic titanium rib. [13]

Neural tube defects such as spina bifida, meningocoele, myelomeningocoele, and SCMs etc., have been reported in association with Jarcho-Levin syndrome in literature. [14] Although spina bifida appears to be a commonly associated finding in Jarcho-Levin syndrome, association of SCMs is uncommon and until date only six cases of split cord malformations with Jarcho-Levin syndrome have been reported in the literature. [15],[16],[17],[18],[19],[20] All these reported cases had SCM type I in which the two hemicords are surrounded by two separate dural sheaths and separated by a bony spur. Our case is unique in that it is the first report of an association of a type II SCM with SCD. Surgical management is indicated in type I SCM whereas fully preserved cases of type II SCM can be followed conservatively.


   Conclusion Top


Identification of costo vertebral malformations and classifying them can be helpful in genetic counseling of the parents and predict prognosis. Management strategies and prognosis differ according to the type of SCM.

 
   References Top

1.Cornier AS, Ramirez N, Carlo S, Reiss A. Controversies surrounding Jarcho-Levin syndrome. Curr Opin Pediatr 2003;15:614-20.  Back to cited text no. 1
    
2.Campbell RM Jr. Spine deformities in rare congenital syndromes: Clinical issues. Spine (Phila Pa 1976) 2009;34:1815-27.  Back to cited text no. 2
    
3.Young S, Reyes MG, Uzoaru IL, Harris V. Arnold-Chiari malformation in Jarcho-Levin syndrome. J Child Neurol 1989;4:229-30.  Back to cited text no. 3
    
4.Roberts AP, Conner AN, Tolmie JL, Connor JM. Spondylothoracic and spondylocostal dysostosis. Hereditary forms of spinal deformity. J Bone Joint Surg Br 1988;70:123-6.  Back to cited text no. 4
    
5.Jarcho S, Levin PM. Hereditary malfor-mations of the vertebral bodies. Bull Johns Hopkins Hosp 1938;62:216-26.  Back to cited text no. 5
    
6.Kulkarni ML, Navaz SR, Vani HN, Manjunath KS, Matani D. Jarcho-Levin syndrome. Indian J Pediatr 2006;73:245-7.  Back to cited text no. 6
    
7.Solomon L, Jimenez RB, Reiner L. Spondylothoracic dysostosis: Report of two cases and review of the literature. Arch Pathol Lab Med 1978;102:201-5.  Back to cited text no. 7
    
8.Suri M, Madhulika, Pemde H, Gupta AK, Verma IC. Jarcho-Levin syndrome. Indian Pediatr 1994;31:1119-22.  Back to cited text no. 8
    
9.Karnes PS, Day D, Berry SA, Pierpont ME. Jarcho-Levin syndrome: Four new cases and classification of subtypes. Am J Med Genet 1991;40:264-70.  Back to cited text no. 9
    
10.Tolmie JL, Whittle MJ, McNay MB, Gibson AA, Connor JM. Second trimester prenatal diagnosis of the Jarcho-Levin syndrome. Prenat Diagn 1987;7:129-34.  Back to cited text no. 10
    
11.Romero R, Ghidini A, Eswara MS, Seashore MR, Hobbins JC. Prenatal findings in a case of spondylocostal dysplasia type I (Jarcho-Levin syndrome). Obstet Gynecol 1988;71:988-91.  Back to cited text no. 11
    
12.Berdon WE, Lampl BS, Cornier AS, Ramirez N, Turnpenny PD, Vitale MG, et al. Clinical and radiological distinction between spondylothoracic dysostosis (Lavy-Moseley syndrome) and spondylocostal dysostosis (Jarcho-Levin syndrome). Pediatr Radiol 2011;41:384-8.  Back to cited text no. 12
    
13.Oskouian RJ Jr, Sansur CA, Shaffrey CI. Congenital abnormalities of the thoracic and lumbar spine. Neurosurg Clin N Am 2007;18:479-98.  Back to cited text no. 13
    
14.Dane B, Dane C, Aksoy F, Cetin A, Yayla M. Jarcho-Levin syndrome presenting as neural tube defect: Report of four cases and pitfalls of diagnosis. Fetal Diagn Ther 2007;22:416-9.  Back to cited text no. 14
    
15.Eller JL, Morton JM. Bizarre deformities in offspring of user of lysergic acid diethylamide. N Engl J Med 1970;283:395-7.  Back to cited text no. 15
    
16.Reyes MG, Morales A, Harris V, Barreta TM, Goldbarg H. Neural defects in Jarcho-Levin syndrome. J Child Neurol 1989;4:51-4.  Back to cited text no. 16
    
17.Giacoia GP, Say B. Spondylocostal dysplasia and neural tube defects. J Med Genet 1991;28:51-3.  Back to cited text no. 17
    
18.Etus V, Ceylan S, Ceylan S. Association of spondylocostal dysostosis and type I split cord malformation. Neurol Sci 2003;24:134-7.  Back to cited text no. 18
    
19.Kansal R, Mahore A, Kukreja S. Jarcho-Levin syndrome with diastematomyelia: A case report and review of literature. J Pediatr Neurosci 2011;6:141-3.  Back to cited text no. 19
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20.Yilmaz MB, Kaymak A, Kurt G, Percin FE, Baykaner K. Spondylocostal dysostosis associated with type I split cord malformation and double nipple on one side: A case report. Turk Neurosurg 2013;23:256-9.  Back to cited text no. 20
    


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    Abstract
   Introduction
   Case Report
   Discussion
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    References
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