Cervical Disk Arthroplasty in a Collegiate Football Player.

Introduction: While the body of research investigating anterior cervical disk fusion (ACDF) for symptomatic cervical disk herniations in high-level athletes is large, evidence for cervical disk replacement (CDR) is sparse. The amount of patients able to return to sport after an ACDF is estimated to be 73.5%, causing surgeons to search for alternatives with better outcomes in this population. This case report describes the successful treatment of a symptomatic collegiate American football player with C6-C7 disk herniation and C5-C6 central canal stenosis. Case Report: This is a 21-year-old American football safety who underwent a C5-6 and C6-7 cervical disk arthroplasty. Three weeks postoperatively, the patient demonstrated nearly complete resolution of weakness, full resolution of radiculopathy, and normal cervical range of motion in all planes. Conclusion: The CDR may be considered as an alternative to the ACDF in the treatment of high-level contact athletes. Compared to the ACDF, CDR has been shown in prior studies to decrease the long-term risk of adjacent segment degeneration. Future studies comparing ACDF to CDR in the high-level contact sport athlete population are needed. CDR appears to be a promising surgical intervention for symptomatic patients in this population.

Return to Football after a Cervical Disk Arthroplasty: A Case Report.

Introduction: Symptomatic cervical spine disk hernations in high-level athletes are traditionally treated with anterior cervical disk fusion (ACDF) after failed conservative management. Unfortunately, an ACDF comes with decreased mobility and only a return to sport 73.5% of the time. In high-level athletes, mobility and range of motion can be critical to their long-term success. This case report will discuss the successful treatment of a C6-C7 disk herniation with a cervical disk replacement (CDR). Case Report: This is a 23-year-old football player whom had a left paracentral C6-C7 disk herniation causing foraminal stenosis. He had significant triceps muscle wasting and weakness and he was not able to participate in football secondary to his symptoms. After failing 6 weeks of conservative, he underwent a CDR. At 8 weeks postoperatively, he was cleared for football and return to sport without complications. Conclusion: The CDR provides high-level athletes the ability to return to contact sports safely. In this unique case, we present a division one football player with a symptomatic cervical herniated disk that was treated with a CDR and return to sport without any limitations or complications. The CDR was able to treat symptoms, improve strength and motion, and ultimately allow the player to return to football. More studies need to be performed, but ultimately CDR in athletes can get them back on the field, improve their cervical range of motion, and decrease their risk of adjacent segment disease in the long run when compared to the cervical fusion.

"Clinical triad" findings in pediatric Klippel-Feil patients.

BACKGROUND: It has been propagated that patients with Klippel-Feil syndrome (KFS) exhibit "clinical triad" findings (CTFs), known as a short neck, low posterior hairline, and limited cervical range of motion (ROM). However, the literature has noted that up to 50 % of KFS cases may not present with such findings and the reasoning behind such assertions remains speculative. As such, the following study addressed the association between CTFs to that of congenitally-fused cervical segments and other risk factors in KFS patients. METHODS: We conducted a retrospective clinical study based on prospectively collected radiographic data. Thirty-one KFS patients at a single institution were assessed. Radiographs were used to evaluate the location and extent of congenitally-fused segments (spanning the occiput (O) to the first thoracic vertebra (T1)), as well as examining coronal and sagittal cervical alignments based on the Samartzis et al. KFS classification. Clinical records were evaluated to account for the initial clinical assessment of CTFs. Patients were further stratified into two groups: Group 1 included patients noted to have any CTFs, while Group 2 included patients who had no such findings. RESULTS: There were 12 males and 19 females (mean age at initial consultation: 9.7 years). No evidence of any of the CTFs was shown in 35.5 % of patients, whereas 38.7, 16.2 and 9.7 % were determined to have one, two or all three criteria, respectively. Limited cervical ROM was the most common finding (64.5 % of patients). In Group 1, 25 % had a short neck, 30 % a low posterior hairline, and 100 % exhibited limited cervical ROM. Group 1 had a mean of 3.9 fused cervical segments, whereas Group 2 had a mean of 2.5 fused cervical segments (p = 0.028). Age, sex-type, occipitalization and alignment parameters did not significantly differ to Group-type (p > 0.05). In Group 1, based on the Samartzis et al. Types I, II, and III, 16.7, 73.3, and 80.0 % of the patients, respectively, had at least one CTF. CONCLUSIONS: Complete CTFs were not highly associated during the clinical assessment of young KFS patients. However, KFS patients with extensive, congenitally-fused segments (i.e. Samartzis et al. Type III) were significantly more likely to exhibit one of the components of the CTF, which was predominantly a limited cervical ROM. Clinicians managing young pediatric patients should not rely on the full spectrum of CTFs and should maintain a high-index of suspicion for KFS, in particular in individuals that exhibit associated spinal findings, such as congenital scoliosis.

Cervical scoliosis in the Klippel-Feil patient.

STUDY DESIGN: Retrospective study. OBJECTIVE: This study addressed in patients with Klippel-Feil syndrome (KFS), the role of congenitally fused cervical patterns, risk factors, and cervical symptoms associated with cervical scoliosis. SUMMARY OF BACKGROUND DATA: KFS is an uncommon condition, characterized as improper segmentation of one or more cervical spine segments with or without associated spinal or extraspinal manifestations. "Scoliosis" is potentially the most common manifestation associated with KFS. However, the role of congenitally fused cervical patterns along with additional potential risk factors and their association with cervical scoliosis, and its relationship with cervical spine-related symptoms remain largely unknown. METHODS: Plain radiographs were utilized to assess the location of congenitally fused cervical segments (O-T1), degree of coronal cervical alignment, and any additional cervical and thoracic spine abnormalities. The classification scheme, as proposed by Samartzis et al of congenitally fused cervical patterns (Types I-III) in KFS patients, was utilized and additional fusion and region-specific patterns were assessed. Patients with coronal cervical alignments of 10° or greater were regarded scoliotic. Patient demographics and the presence of cervical spine-related symptoms were also assessed. RESULTS: Thirty KFS patients were assessed (mean age, 13.5 yr). The mean coronal cervical alignment was 18.7° and scoliosis was noted in 16 patients. Patients that exhibited congenital fusion of the mid and lower cervical spine region, had multiple, contiguous congenitally fused segments (Type III), and associated vertebral malformations (e.g., hemivertebrae) were highly associated with the presence of cervical scoliosis (P < 0.05). Ten patients exhibited cervical spine-related symptoms; however, no statistically significant difference was noted between the presence of symptoms and coronal cervical alignment (P = 0.815) and cervical scoliosis (P = 0.450). CONCLUSION: The study noted a prevalence of cervical scoliosis to occur in 53.3% of young KFS patients. Such patients that exhibited congenital fusion of the mid and lower cervical spine region, had multiple, contiguous congenitally fused segments (Type III), and associated vertebral malformations (e.g., hemivertebrae) were highly associated with the presence of cervical scoliosis. However, in young KFS patients, the presence of cervical scoliosis may not be associated with the manifestation of cervical spine-related symptoms.

The extent of fusion within the congenital Klippel-Feil segment.

STUDY DESIGN: Retrospective radiographic review. OBJECTIVE: To evaluate in patients with Klippel-Feil syndrome (KFS) the presence and extent of specific fusion patterns across involved cervical segments and their association with age-specific parameters. SUMMARY OF BACKGROUND DATA: While the radiographic hallmark of KFS is characterized by congenital fusion of at least one cervical motion segment, the relation between age and the extent of segmental congenital fusion remains speculative. METHODS: A radiographic review of 31 patients with KFS at a single institution. Plain radiographs were used to assess fusion across the vertebral segment as entailing the anterior elements, posterior elements, or complete segment from O-T1. Age-specific stratifications were also performed. RESULTS: A mean of 3.7 fused segments and a sum of 116 fused segments were noted. From C2-T1, complete fusion of the involved segment represented 77.8% at 10 years or older, 87.5% at 15 years or older, 91.7% at 16 years or older, 95.7% at 17 years or older, 86.5% who were skeletally mature, and 100% at adulthood. Similar trends were not noted for segments of O-C2. In absence of complete segmental fusion, the posterior elements exhibited a higher incidence of fusion than the anterior elements. Statistically significant differences between anterior/posterior to complete segmental fusion with respect to different age markers entailed segments of C2-C3, C4-C5, and C6-C7 (P < 0.05). CONCLUSION: This study provides some insight into the potential developmental aspects of the extent of segmental fusion of the cervical spine in patients with KFS. In older patients, complete fusion of involved fused segments was more prevalent in regards to C2-T1; however, such an observation was not noted for segments from O-C2. In the absence of complete segmental fusion, fusion of the posterior elements was more often noted than fusion of the anterior elements. Awareness of the varied phenotypic expression of segmental fusion patterns of the cervical spine in patients with KFS underlines theimportance of thorough evaluation of the cervical spine to assess the presence and extent of segmental fusion to facilitate in the identification of neurologic risk factors.

2008 Young Investigator Award: The role of congenitally fused cervical segments upon the space available for the cord and associated symptoms in Klippel-Feil patients.

STUDY DESIGN: A prospective radiographic and retrospective clinical chart review. OBJECTIVE: This study evaluated the role of congenitally fused cervical segments in relation to the space available for the cord (SAC) and associated cervical spine-related symptoms (CSS) in patients with Klippel-Feil Syndrome (KFS). SUMMARY OF BACKGROUND DATA: KFS is a developmental disorder presenting with congenital fusion of at least 2 cervical vertebrae. The effects of congenitally fused cervical segments in relation to the SAC and associated symptoms in KFS patients remain speculative and have not been thoroughly addressed in the literature. METHODS: At a single institution, a prospective radiographic and clinical evaluation of 29 KFS patients was conducted. Based on plain radiographs, assessment of the SAC consisted of the posterior atlantodens interval, the midvertebral body SAC (C2-C7), and the interbody SAC (C2-C3-C7-T1). Vertebral body width (VBW) from C2 to C7 and the presence of occipitalization (O-C1) were also noted. Torg ratios were obtained at each level. Demographics, medical history, and the presence of CSS were noted based on clinical chart review. RESULTS: Ten males and 19 females were reviewed (mean age, 13.4 years). A significant correlation was noted between the overall VBWs to the number of fused segments, age, and skeletal maturity (P < 0.05), but not to sex-type, O-C1, and SAC levels (P > 0.05). In the presence of a fused segment, individualized SAC levels tended to have greater canal dimensions and cephalad/caudal VBWs were less. Cephalad and caudal Torg ratios in relation to a segment were greater in all fused segments, and with 4 or greater fused segments (P < 0.05). Number of levels fused, sex-type, skeletal maturity, and O-C1 were not significantly associated with the presence of symptoms (P > 0.05). Symptomatic patients had smaller VBWs than nonsymptomatic patients (P = 0.027) and an overall decrease in SAC at the interbody disc level, primarily at C6-C7 (P > 0.05). Smaller Torg ratios were noted in symptomatic patients, specifically myelopathic patients. CONCLUSION: Congenital fusion in KFS may arrest the normal vertebral development, which may affect appositional bone growth. Such effects on the VBW could potentially contribute to an increase in the SAC. Such a development may delay neurologic compromise stemming from the congenital fusion process and subsequent degenerative manifestations.

Superior odontoid migration in the Klippel-Feil patient.

Klippel-Feil syndrome (KFS) is an uncommon condition noted primarily as congenital fusion of two or more cervical vertebrae. Superior odontoid migration (SOM) has been noted in various skeletal deformities and entails an upward/vertical migration of the odontoid process into the foramen magnum with depression of the cranium. Excessive SOM could potentially threaten neurologic integrity. Risk factors associated with the amount of SOM in the KFS patient are based on conjecture and have not been addressed in the literature. Therefore, this study evaluated the presence and extent of SOM and the various risk factors and clinical manifestations associated therein in patients with KFS. Twenty-seven KFS patients with no prior history of surgical intervention of the cervical spine were included for a prospective radiographic and retrospective clinical review. Radiographically, McGregor's line was utilized to evaluate the degree of SOM. Anterior and posterior atlantodens intervals (AADI/PADI), number of fused segments (C1-T1), presence of occipitalization, classification-type, and lateral and coronal cervical alignments were also evaluated. Clinically, patient demographics and presence of cervical symptoms were assessed. Radiographic and clinical evaluations were conducted by two independent blinded observers. There were 8 males and 19 females with a mean age of 13.5 years at the time of radiographic and clinical assessment. An overall mean SOM of 5.0 mm (range = -1.0 to 19.0 mm) was noted. C2-C3 (74.1%) was the most commonly fused segment. A statistically significant difference was not found between the amount of SOM to age, sex-type, classification-type, AADI, PADI, and lateral cervical alignment (P > 0.05). A statistically significant greater amount of SOM was found as the number of fused segments increased (r = 0.589; P = 0.001) and if such levels included occipitalization (r = 0.616; P = 0.001). A statistically significant greater amount of SOM was also found with an increase in coronal cervical alignment (r = 0.413; P = 0.036). Linear regression modeling further supported these findings as the strongest predictive variables contributing to an increase in SOM. A 7.20 crude relative risk (RR) ratio [95% confidence interval (CI) = 1.05-49.18; risk differences (RD) = 0.52] was noted in contributing to a SOM greater than 4.5 mm if four or more segments were fused. Adjusting for coronal cervical alignment greater than 10 degrees , five or more fused segments were found to significantly increase the RR of a SOM greater than 4.5 mm (RR = 4.54; 95% CI = 1.07-19.50; RD = 0.48). The RR of a SOM greater than 4.5 mm was more pronounced in females (RR = 1.68; 95% CI = 0.45-6.25; RD = 0.17) than in males. Eight patients (29.6%) were symptomatic, of which symptoms in two of these patients stemmed from a traumatic event. However, a statistically significant difference was not found between the presence of symptoms to the amount of SOM and other exploratory variables (P > 0.05). A mean SOM of 5.0 mm was found in our series of KFS patients. In such patients, increases in the number of congenitally fused segments and in the degree of coronal cervical alignment were strongly associated risk factors contributing to an increase in SOM. Patients with four or greater congenitally fused segments had an approximately sevenfold increase in the RR in developing SOM greater than 4.5 mm. A higher RR of SOM more than 4.5 mm may be associated with sex-type. However, 4.5 mm or greater SOM is not synonymous with symptoms in this series. Furthermore, the presence of symptoms was not statistically correlated with the amount of SOM. The treating physician should be cognizant of such potential risk factors, which could also help to indicate the need for further advanced imaging studies in such patients. This study suggests that as motion segments diminish and coronal cervical alignment is altered, the odontoid orientation is located more superiorly, which may increase the risk of neurologic sequelae.

Symptomatic cervical disc herniation in a pediatric Klippel-Feil patient: the risk of neural injury associated with extensive congenitally fused vertebrae and a hypermobile segment.

STUDY DESIGN: A case report. OBJECTIVE: To report the occurrence of a herniated cervical disc following a high-impact activity in a pediatric Klippel-Feil patient who presented with spinal cord compression, myelopathy, and myelomalacia requiring posterior instrumented fusion followed by an anterior discectomy and fusion at the hypermobile nonfused segment. SUMMARY OF BACKGROUND DATA: The primary hallmark of Klippel-Feil syndrome (KFS) is the presence of at least one congenitally fused cervical segment. Studies have reported the potential risk of cervical injury from hypermobility associated with the nonfused cervical segment in KFS. The manifestation of a cervical disc herniation in the pediatric KFS patient is rare. To the authors' knowledge, the development of a symptomatic cervical herniated disc attributed to mechanical fatigue following a high-impact activity has not been addressed in the literature with respect to the pediatric KFS patient having extensive cervical fusion and a hypermobile segment. METHODS: A 16.8-year-old KFS boy with occipitalization of C1 and fusion of C2-C3 and C4-T1 presented with myelopathy, severe cord compression, and myelomalacia stemming from a left-sided herniated cervical disc at C3-C4 with onset following an 8-foot high rooftop jump. On radiographic evaluation, the patient's C3-C4 segment was hypermobile. RESULTS: The patient was operatively managed via a same-day combined posterior-anterior procedure. The posterior aspect of the procedure entailed a posterior lateral mass plate-screw fixation at C3-C4 with autologous iliac crest bone fusion. Anteriorly, a discectomy was performed at C3-C4 with application of an interbody tricortical autograft. After surgery, the patient wore a halo vest for 3 months, followed by a soft collar for an additional 3 months. On final follow-up at 39 months, the patient was asymptomatic with no instrumentation-related complications, fusion of the posterior graft-bed and anterior interbody graft was noted, and cervical alignment was maintained. CONCLUSIONS: A hypermobile segment in the pediatric KFS patient is a risk factor that may lead to cord compression. A symptomatic herniated cervical disc may develop from an excessive mechanical load stress in a pediatric KFS patient with multiple fused segments. In such a patient, a same-day combined posterior-anterior procedure provides cord decompression and stabilizes the spine with a favorable outcome.