Spondyloepiphyseal Dysplasia Clinical Presentation

Updated: Dec 11, 2017
  • Author: Shital Parikh, MD; Chief Editor: Jeffrey D Thomson, MD  more...
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Presentation

History

Spondyloepiphyseal dysplasia congenita

Wynne-Davies and Hall identified two clinical groups of spondyloepiphyseal dysplasia (SED) congenita, differentiated by the magnitude of skeletal involvement and severity of coxa vara of the hip. [23] This distinction can be made in patients aged 3-4 years. Patients with mild coxa vara fall just below the third percentile of height. Those with severe coxa vara have adult height of 90-120 cm. The hands and feet are normal in length, in striking contrast to the proximal (rhizomelia) and middle segments (mesomelia) of the limbs, which are extremely short.

Cervical myelopathy may result from atlantoaxial instability. Symptoms include delayed motor development, decreased endurance, progressive weakness, hypotonia, sleep apnea, and alterations in respiration. Respiratory insufficiency may develop secondary to thoracic dysplasia. Sensations tend to be maintained for a considerable period.

Neurologic findings are often greater on one side than the other because the cervical cord often is displaced to one side. Some children may have a triad of findings including odontoid hypoplasia, atlantoaxial instability, and spinal cord compression; symptoms often begin when they are aged 5-10 years. Gait problems are often attributed to the hip and knee deformities, and the diagnosis of the cervical deformities may be delayed. Cervical kyphosis may be present in some patients.

Spinal deformities, such as thoracolumbar scoliosis, kyphosis, and kyphoscoliosis, are common in these patients. These deformities occur much earlier, progress more quickly, and are more rigid than those in idiopathic conditions. Spinal cord compression and spastic paraparesis can occur, primarily with kyphosis or kyphoscoliosis.

Patients with hip deformities (coxa vara, avascular necrosis (AVN)-like changes in the capital femoral epiphysis) may present with hip pain or decreased walking tolerance. They are prone to premature osteoarthritis. Some patients may have valgus deformities of the knee in addition to coxa vara of the hip. These patients frequently have knee pain and increased laxity of the medial collateral ligament. Some patients have clubfeet. [24, 25]

Spondyloepiphyseal dysplasia tarda

Children with SED tarda appear normal at birth and develop clinical manifestations of trunk or hip when older than 4 years. Some patients experience mild growth retardation in childhood. Mild disproportionate trunk shortening occurs, but many patients achieve an adult height of more than 153 cm. Thus, true dwarfism may not be present.

Atlantoaxial instability may be present, and patients may present with neurologic deficits or symptoms. Scoliosis or thoracic kyphosis with exaggerated lumbar lordosis may develop. Patients may present with back pain or stiffness. [26]

Patients may present with hip pain and stiffness in the first or second decade of life. Progressive symptomatic osteoarthritis of the hips and knees may be seen. Angular deformities of the lower extremities are mild.

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Physical Examination

Spondyloepiphyseal dysplasia congenita

The diagnosis can be made at birth. Newborn infants are short, with disproportionate involvement of the trunk. In certain cases, patients who are assessed in the neonatal period and in their first year of life may not demonstrate short stature according to clinical height measurements and growth charts, though the diagnosis may be evident by clinical features and radiographic abnormalities.

Generally, in patients with SED congenita, the outstretched fingers reach the knee region instead of midthigh because of the short trunk, even in the neonate. The head-to-pubis (upper segment) measurements are reduced to approximately 75% of normal value, whereas the pubis-to-heel (lower segment) measurements are reduced to approximately 60-80% of normal value. [7, 23]

Adult height ranges from 90 to 167.5 cm. Height charts have been developed for SED congenita. The hands and feet are normal in length, in striking contrast to proximal and middle segments of the limbs, which are extremely short.

Motor development may be delayed. Intelligence is usually unaffected.

Head circumference is normal, but the face is flat, with wide-set eyes. Cleft palate is common. The neck is short, and a pectus carinatum deformity may be present in combination with a barrel-shaped chest.

Os odontoideum or odontoid hypoplasia may lead to atlantoaxial instability. Throughout growth and development, the neurologic status must be assessed in these patients to detect any deficits. [27]  The signs suggestive of spinal cord compression include pyramidal tract signs—namely, spasticity, hyperreflexia, Babinski sign, and clonus. Motor weakness may be present; however, sensory examination findings are usually normal. Gait may be abnormal and should be evaluated.

Increased incidence of lumbar lordosis and associated hip flexion contractures are observed even in the newborn period. The abdomen is protuberant. Thoracic scoliosis or kyphosis may become evident in adolescence. Single- and double-curve patterns have been noted. Thoracic kyphosis may be severe, measuring up to 130°. Kyphosis or kyphoscoliosis can be rigid and severe.

Coxa vara of varying severity is almost universal. A waddling gait may be apparent. Coxa vara may be associated with progressive dislocation if ligamentous laxity is present. The delayed ossification of the capital femoral epiphysis predisposes the hip to deformation with flattening, lateral extrusion, hinge abduction, and premature osteoarthritis. Often, a valgus alignment of the knees may develop, associated with overgrowth of the medial femoral condyle. Genu varum may also occur, albeit rarely. Clubfeet may be present in some patients.

Associated ocular anomalies include myopia with retinal detachment (>50%) and cataracts. [28]  Other ocular manifestations include buphthalmos, secondary glaucoma, and strabismus; however, the corneas are clear.

Other associated conditions include deafness and abdominal or inguinal hernia. A rare form of SED congenita is associated with nephrotic syndrome.

Spondyloepiphyseal dysplasia tarda

In SED tarda, appearance is normal at birth. True dwarfism may not be present. Patients exhibit normal achievement of motor and cognitive milestones. Mild disproportionate trunk shortening occurs. In some patients, the condition remains unrecognized until the adolescent years, when hip pain or scoliosis develops. The diagnosis is suggested in males with disproportionately short stature in adolescence or adulthood and with a relatively short trunk and barrel-shaped chest. Upper-to-lower body segment ratio is usually about 0.8. Arm span typically exceeds height by 10-20 cm.

Atlantoaxial instability may occur secondary to odontoid hypoplasia or os odontoideum. The upper cervical spine should be assessed and a neurologic examination should be performed. [29]  Scoliosis or kyphosis with an exaggerated lumbar lordosis may be present. The curves are similar to those observed in patients with adolescent idiopathic scoliosis. These curves may progress and become severe enough to require treatment.

Epiphyseal involvement in patients with SED tarda is primarily in the shoulders, hips, and knees. Involvement is symmetrical bilaterally. Changes in the hip may mimic bilateral Legg-Calve-Perthes disease. Varying degrees of coxa magna, flattening, extrusion, and subluxation may be present. Osteoarthritis of the hip is a common sequela.

Nephrotic syndrome has been reported in association with SED tarda. [30]

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Complications

Common conditions associated with SED include the following:

  • Neck instability
  • Spinal deformities such as scoliosis, kyphosis, or lordosis
  • Ocular abnormalities such as myopia or retinal detachment
  • Hearing deficits
  • Hip deformities, including coxa vara and capital femoral epiphyseal involvement
  • Equinovarus foot
  • Degenerative joint disease of the hips, knees, or shoulders
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