Klippel–Feil syndrome

Klippel-Feil syndrome
Classification and external resources
Specialty	medical genetics
ICD-10	Q76.1
ICD-9-CM	756.16
OMIM	118100 214300
DiseasesDB	7197
eMedicine	orthoped/408
MeSH	D007714

Klippel–Feil syndrome is a rare disease, initially reported in 1884 by Maurice Klippel and André Feil from France,^[1] characterized by the congenital fusion of any two of the seven cervical vertebrae.^[2]:578 The syndrome occurs in a heterogeneous group of patients unified only by the presence of a congenital defect in the formation or segmentation of the cervical spine. Klippel-feil results in limited movement of the neck. Klippel–Feil syndrome is sometimes identified by shortness of the neck, but not all people with this disorder have a visibly shortened neck. Some people with the syndrome have a very low hairline.^[3] In 1919, André Feil in his PhD thesis,^[4] suggested another classification of the syndrome encompassing not only deformation of the cervical spine but also deformation of the lumbar and thoracic spine.

Signs and symptoms

Numerous associated abnormalities of other organ systems may be present. This heterogeneity requires comprehensive evaluation of all patients and treatment regimes that can vary from modification of activities to extensive spinal surgeries. Furthermore, it is unclear whether Klippel–Feil syndrome is a unique disease, or if it is one part of a spectrum of congenital spinal deformities. Klippel–Feil syndrome is usually diagnosed after birth.

The most common sign of the disorder is restricted mobility of the neck and upper spine. A short neck and low hairline at the back of the head may occur in some patients.

Associated abnormalities may include:

• scoliosis^[5] (side-to-side curvature of the spine), which is abnormal curving of the spine. The spine sometimes appears as a “C” or an “S”.
• spina bifida, when the spinal canal and the back bone do not close completely during birth.
• anomalies of the kidneys and the ribs,
• cleft palate^[5] (hole in the roof of the mouth),
• dental problems^[5][6] (late dentition, high-risk of caries, oligo- and hypodontia),
• respiratory problems,
• heart malformations,^[5]
• short stature,
• Duane syndrome,
• Approximately 35% of patient's with Klippel–Feil syndrome will also have a congenital elevation of the scapula known as Sprengel's Deformity^[7]

The disorder also may be associated with abnormalities of the head and face, skeleton, sex organs, muscles, brain and spinal cord, arms, legs, fingers and heart defects. These heart defects often lead to a shortened life expectancy, the average being 35–45 years of age among males and 40–50 among females. This condition is similar to the heart failure seen in gigantism.^[8]

In 2011, a study identifying the occurrence of symptoms of 100 patients was published.^[9]

Genetics

Genetic genealogy has identified a specific location of a gene on a chromosome for Klippel-Feil Syndrome. Mutations in the GDF6 and GDF3 genes have also been identified to cause the disease. Although some people with Klippel–Feil syndrome do not have identified mutations in the GDF6 or GDF3 genes. In this case, the cause of the condition in these individuals is unknown. GDF6 and GDF3 genes provide the body with instructions for making proteins involved in regulating the growth and maturation of bone and cartilage. These proteins actively regulate cell growth in embryonic and adult tissue. GDF6 specifically is involved in the formation of vertebral bones, among others, and establishing boundaries between bones in skeletal development while GDF3 is involved with bone and cartilage growth. Mutations cause reductions in these functional proteins but, it is unclear exactly how a shortage in these proteins leads to incomplete separation of the vertebrae in people with Klippel–Feil syndrome.^[10] However, when the GDF6 gene was knocked out in mice, the result was the fusion of bones.^[11] Only by identifying the link between the genetic etiology and the phenotypic pathoanatomy of Klippel–Feil syndrome will we be able to rationalize the heterogeneity of the syndrome.

These mutations can be inherited in two ways:

• Autosomal dominant inheritance, where one copy of the altered gene in each cell is sufficient to cause the disorder, is especially associated with C2-C3 fusion.^[10]
• Autosomal recessive inheritance, where both copies of a gene contain mutations, is especially associated with C5-C6 fusion.^[10]
• Another autosomal dominant form (mapped on locus 8q22.2) known as Klippel–Feil syndrome with laryngeal malformation has been identified. It is also known as Segmentation syndrome 1.^[12][13]

Classification

In 1912, Maurice Klippel and Andre Feil independently provided the first descriptions of Klippel–Feil syndrome. They described patients who had a short, webbed neck; decreased range of motion (ROM) in the cervical spine; and a low hairline. Feil subsequently classified the syndrome into 3 categories:

• Type I — Fusion of C2 and C3 with occipitalization of the atlas. Further complications were later reported by McRae in 1953. Flexion and extension is concentrated within the C1 and C2. As with aging, an odontoid can become hypermobile, which narrows the spinal cord and brain stem.
• Type II — Long fusion below C2 with an abnormal occipital-cervical junction. Similar to the C2-C3 fusion of McRae and could be reviewed as a more elaborate variation. Flexion, extension, and rotation are all concentrated in the area of the abnormal odontoid or poorly developed ring of C1 which cannot withstand the effects of aging. Difference in pattern from the patient with a long fusion and a normal C1-C2 articulation, is that C1-C2 can live a normal life expectancy.
• Type III — A single open interspace between two fused segments. Cervical spine motion is concentrated at single open articulation. This hypermobility may lead to instability or degenerative osteoarthritis. This pattern can be recognized as the cervical spine is often seen to be at an angle or hinge at this open segment.

A classification scheme for Klippel–Feil syndrome was proposed in 1919 by Andre Feil, which accounted for cervical, thoracic, and lumbar spine malformations.^[14]

However, recently, Dino Samartzis and colleagues in 2006 proposed 3 classification-types that specifically addressed the cervical spine anomalies and their associated cervical spine-related symptoms, with additional elaboration on various time-dependent factors regarding this syndrome.^[15]

Treatment

Treatment for Klippel–Feil syndrome is symptomatic and may include surgery to relieve cervical or craniocervical instability and constriction of the spinal cord, and to correct scoliosis.

Failing non-surgical therapies, spinal surgery may provide relief. Adjacent segment disease and scoliosis are two examples of common symptoms associated with Klippel–Feil syndrome, and they may be treated surgically. The three categories treated for types of spinal cord deficiencies are massive fusion of the cervical spine (Type I), the fusion of 1 or 2 vertebrae (Type II), and the presence of thoracic and lumbar spine anomalies in association with type I or type II Klippel–Feil syndrome (Type III).

Adjacent segment disease can be addressed by performing cervical disc arthroplasty using a device such as the Bryan cervical disc prosthesis.^[16] The option of the surgery is to maintain range of motion and attenuate the rate of adjacent segment disease advancement without fusion.^[17] Another type of arthroplasty that is becoming an alternate choice to spinal fusion is Total Disc Replacement. Total disc replacement objective is to reduce pain or eradicate it.^[18] Spinal fusion is commonly used to correct spinal deformities such as scoliosis. Arthrodesis is the last resort in pain relieving procedures, usually when arthroplasties fail.

Prognosis

The heterogeneity of the Klippel–Feil syndrome has made it difficult to outline the diagnosis as well as the prognosis classes for this disease. Because of this, it has complicated the exact explanation of the genetic etiology of the syndrome.

The prognosis for most individuals with KFS is good if the disorder is treated early on and appropriately. Activities that can injure the neck should be avoided, as it may contribute to further damage. Other diseases associated with the syndrome can be fatal if not treated, or if found too late to be treatable.^[19]

Epidemiology

The prevalence of Klippel–Feil syndrome is unknown due to the fact that there was no study done to determine the true prevalence.^[20]

Although the actual occurrence for the KFS syndrome is unknown, it is estimated to occur 1 in 40,000 to 42,000 newborns worldwide. In addition, females seem to be affected slightly more often than males.^[10]

Notable cases

A case of a child in Switzerland was discovered in a necropolis dated between 4500 and 4000 BC.^[21]

In 2009, archaeologists excavating at a Neolithic site of the Đa Bút culture of northern Vietnam discovered the remains of a young man around age 25, "Burial 9", living between 2000 BC and 1500 BC with Klippel–Feil syndrome, who had apparently been supported by his subsistence-level community for at least a decade before his death.^[22][23][24]

The 18th Dynasty Egyptian pharaoh Tutankhamun is believed by some to have suffered from Klippel–Feil syndrome,^[25] though others dispute this claim.^[26]

A more recent case is the English cricketer Gladstone Small.^[27]

References

1. Klippel M, Feil A (1912). "Un cas d'absence des vertebres cervicales. Avec cage thoracique remontant jusqu'a la base du crane (cage thoracique cervicale)". Nouv Iconog Salpetriere 25: 223–250.
2. Andrews, James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0-7216-2921-0.
3. "Klippel-Feil Syndrome". HONselect.
4. Feil A (1919). "These de medicine, Paris. L'absence et la diminution des vertèbres cervicales (étude clinique et pathogénique) ; le syndrome de réduction numérique cervicales.".
5. Paradowska, Szeląg, Sławecki (2007). "Klippel−Feil Syndrome – Review of the Literature" (PDF). Dent. Med. Probl. Retrieved 2015-09-30.
6. de Lima, Marina de Deus Moura; Ortega, Karem Lopez; Araújo, Luis Carlos Arias; Soares, Marcelo Melo; de Magalhães, Marina Helena Cury Gallottini (2009-12-01). "Dental team management for a patient with Klippel-Feil syndrome: case report". Special Care in Dentistry: Official Publication of the American Association of Hospital Dentists, the Academy of Dentistry for the Handicapped, and the American Society for Geriatric Dentistry 29 (6): 244–248. doi:10.1111/j.1754-4505.2009.00101.x. ISSN 1754-4505. PMID 19886936.
7. Farsetti P, Weinstein SL, Caterini R, De Maio F, Ippolito E (May 2003). "Sprengel's deformity: long-term follow-up study of 22 cases". J Pediatr Orthop B 12 (3): 202–10. doi:10.1097/01.bpb.0000049568.52224.1e. PMID 12703036. Sarwark, JF; LaBella, CR, eds. (2010). Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide. Elk Grove Village IL: American Academy of Pediatrics. pp. 231–4.
8. McGaughran JM, Kuna P, Das V (October 1998). "Audiological abnormalities in the Klippel-Feil syndrome". Arch. Dis. Child. 79 (4): 352–5. doi:10.1136/adc.79.4.352. PMC 1717726. PMID 9875048.
9. Longpre D. http://www.klippel-feil.info/document/klippelfeilsymptoms2011.pdf
10. at NLM Genetics Home Reference
11. Tassabehji M, Fang ZM, Hilton EN, et al. (August 2008). "Mutations in GDF6 are associated with vertebral segmentation defects in Klippel-Feil syndrome". Hum. Mutat. 29 (8): 1017–27. doi:10.1002/humu.20741. PMID 18425797.
12. Online 'Mendelian Inheritance in Man' (OMIM) Klippel-Feil Syndrome 1, Autosomal Dominant; KFS1 -118100
13. http://rarediseases.info.nih.gov/GARD/Disease.aspx?diseaseID=6838
14. Feil A. L'absence et la diminuaton des vertebres cervicales (etude cliniqueet pathogenique); le syndrome dereduction numerique cervicales. Theses de Paris; 1919.
15. Samartzis DD, Herman J, Lubicky JP, Shen FH (2006). "Classification of congenitally fused cervical patterns in Klippel-Feil patients: epidemiology and role in the development of cervical spine-related symptoms". Spine 31 (21): E798–804. doi:10.1097/01.brs.0000239222.36505.46. PMID 17023841.
16. Goffin J, Casey A, Kehr P, et al. (September 2002). "Preliminary clinical experience with the Bryan Cervical Disc Prosthesis". Neurosurgery 51 (3): 840–5; discussion 845–7. doi:10.1227/00006123-200209000-00048. PMID 12188968.
17. Papanastassiou ID, Baaj AA, Dakwar E, Eleraky M, Vrionis FD (March 2011). "Failure of cervical arthroplasty in a patient with adjacent segment disease associated with Klippel-Feil syndrome". Indian J Orthop 45 (2): 174–7. doi:10.4103/0019-5413.77139. PMC 3051126. PMID 21430874.
18. Phillips FM, Garfin SR (September 2005). "Cervical disc replacement". Spine 30 (17 Suppl): S27–33. doi:10.1097/01.brs.0000175192.55139.69. PMID 16138062.
19. Cathy C. Cartwright; Donna C. Wallace (3 May 2007). Nursing care of the pediatric neurosurgery patient. pp. 205–. ISBN 978-3-540-29703-1. Retrieved 25 December 2010.
20. Angeli, E., Wagner, J., Lawrick, E., Moore, K., Anderson, M., Soderland, L., & Brizee, A. (2010, May 5). General format title. Retrieved from http://owl.english.purdue.edu/owl/resource/560/01/
21. http://www.klippel-feil.info/histoire.html
22. "Oldest Known Paralyzed Human Discovered". Retrieved 2014-01-18.
23. Tilley, Lorna; Oxenham, Marc F (March 2011). "Survival against the odds: Modeling the social implications of care provision to seriously disabled individuals". International Journal of Paleopathology 1 (1): 35–42. doi:10.1016/j.ijpp.2011.02.003. Retrieved 12 April 2015.
24. Gorman, James (2012-12-17). "Ancient Bones That Tell a Story of Compassion" (17 December 2012, New York edition, D1). The New York Times. The New York Times. Retrieved 12 April 2015.
25. "Tutankhamun shows his face 80 years after tomb is opened". The Telegraph. London. Retrieved 2007-07-12.
26. Boyer RS, Rodin EA, Grey TC, Connolly RC (2003). "The skull and cervical spine radiographs of Tutankhamen: a critical appraisal". AJNR. American journal of neuroradiology 24 (6): 1142–7. PMID 12812942.
27. Hughes, Simon (1997-09-05). "Small gains from wealth of partners". Cricinfo. Retrieved 2007-12-13.

This article incorporates information in the public domain prepared by the National Institute of Neurological Disorders and Stroke.

External links

• Klippel–Feil syndrome at DMOZ