ehlers- danlos syndrome update 2011
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Ehlers- Danlos Syndrome Update 2011. What We Know – And What We Don’t Know Clair A. Francomano , M.D. Overview. Classification Pain Neurologic Complications Autonomic dysfunction Chiari malformation Occult tethered cord Increased intracranial pressure - PowerPoint PPT PresentationTRANSCRIPT
Ehlers-Danlos SyndromeUpdate 2011
What We Know – And What We Don’t Know
Clair A. Francomano, M.D.
Overview
• Classification• Pain• Neurologic Complications
– Autonomic dysfunction– Chiari malformation– Occult tethered cord– Increased intracranial pressure
• Immune Function, including autoimmunity• Mast Cell Disease• Drug Metabolism
Classification – Types of Ehlers Danlos Syndrome
• Classical type – Joint hypermobility– Skin involvement (soft, stretchy, translucent)
• Hypermobile type– Joint hypermobility– Minimal skin involvement
• Vascular type– Aneurysms (typically medium-sized arteries in the
abdominal cavity)
EDS Classification, cont.
• Kyphoscoliosis type– friable, hyperextensible skin, thin scars, and easy
bruising – generalized joint laxity– severe muscle hypotonia at birth– progressive scoliosis, present at birth or within the first
year of life; – scleral fragility and increased risk of rupture of the globe
• Arthrochalasia type• Dermatosporaxis type
EDS Classification, continued
• Arthrochalasia type (VII A and B)– severe generalized joint hypermobility with recurrent
subluxations– congenital, bilateral hip dislocation – tissue fragility with widened atrophic scars – kyphoscoliosis– stretchy skin– caused by defects in type I collagen processing
• Dermatosporaxis type (VIIC)
Classification - Questions
• Is there a better way to classify the various types of EDS?
• Skin involvement is extremely variable, even within families (some members of a family may appear to have classical, others hypermobile type). As of now the assessment is highly subjective. Is there a good way to quantitate skin involvement?
• How does the joint and skin involvement change with age?
Classification - Questions
• From a clinical perspective, there appear to be additional subtypes of EDS.– EDS with Marfan-like habitus (tall, thin, difficulty putting
on weight). This subgroup resembles MASS phenotype. Is there a biological basis for this resemblance?
– Classical type “with vascular features” – persons with EDS who have cerebral aneurysms, cardiovascular features such as septal aneurysm, and others
– Families with overlap between EDS and other connective tissue conditions such as osteogenesis imperfecta, Stickler syndrome and Marfan syndrome
Genes
• Classical type– Type V collagen, alpha 1 or alpha 2 genes (50%)– Unknown (50%)
• Hypermobile type– Unknown
• Vascular type– Type III collagen, alpha 1 gene (100%)
Questions
• We know that about half the people with Classical EDS have alterations in one of the two type V collagen genes. What are the other genes causing the classical type?
• What genes cause the hypermobile type of EDS?
These are not strictly academic questions. Gene identification will help us understand the fundamental biology underpinning these disorders, and may lead to rational approaches to treatment
Help is On the Way – Whole Genome Sequencing
• The cost of DNA sequencing has been cut by about 6 orders of magnitude over the past 10 years (from $1 billion to $10-15,000 per genome)
• NIH is about to fund Centers for whole genome sequencing, specifically to find unknown genes causing Mendelian disorders
Pain in EDS
• Myopathic• Neuropathic• Single most common cause for referral
• Comprehensive, multidisciplinary approach is needed for management
• We need much more information about optimal strategies for pain
Autonomic Dysfunction In EDS
• Postural Orthostatic Tachycardia syndrome (POTS)
• Neurally Mediated Hypotension• Gastrointestinal motility issues• Temperature instability• Sleep disturbances
Autonomic Dysfunction in EDSOpen Questions
• Is this a primary neurologic problem?• Is autonomic dysfunction always secondary to
impingement of the brainstem or upper cervical spinal cord?
• Does stabilization of the craniocervical junction improve autonomic dysfunction?
• How can we improve the GI motility issues?
Anatomy of the Spine
Anatomy of the Spine
Anatomy of the Spine
Anatomy of the Spine
Anatomy of the Craniocervical Junction
Anatomy of the Craniocervical Junction
Pathology of the Spine
Tendons and Ligaments• Ligaments and tendons are made of connective
tissue
• Ligaments connect bone to bone
• Tendons connect muscle to bone
• Tendons are an extension of the strong connective tissue that surrounds all muscles – the fascia
Tendons and Ligaments
Chiari Malformation
Classical EDS – 16 year old female
Tonsillar ectopia Posterior fossa crowding Abnormal long odontoid Pannus formation Loss of height of cervical discs
Multiple Schmorl’s nodes in the T-spine Disc desiccation in multiple levels Tonsillar ectopia without crowding of the posterior fossa Pannus around the odontoid Cervical degenerative disc disease
Hypermobile EDS – 21 year old man
Classical EDS –50 year old woman
High grade multi-level cervical stenosis
Spondylolisthesis
Retroflexed odontoid
Pannus formation
Normal Cord Tethered Cord
Upright MRI in 27 year old female with EDS/CMI
Dural ectasia Degenerative and desiccated discs Herniated discs Type 2 Modic changes Spinal stenosis Spondylolisthesis
52 year old Woman Classical EDS
Left: multi level herniations disc desiccation neural foramina narrowing facet arthrosis
Right top: Severe degenerative disc
disease Herniated discs
Spondylolisthesis
Bottom: Spinal canal stenosis
Dural ectasia Degenerative disc disease
54 yo F
56 yo M
39 yo M
Unilateral facet arthrosis, L4 levelT1 MRI image
16- year old girl with hypermobile EDS
48 yo woman with hypermobile EDS
Annular tears at L4-L5 and L5-S1
Spondylolisthesis at L4-L5 and multi level disc bulges
32 year old woman with classical EDS
Multi-level disc herniations Spinal canal stenosis Neural foramina narrowing Severe facet arthrosis
18-year old man with hypermobile EDS
Eccentric Nucleus Pulposus
19 year old Man 18 year old WomanNormal
Patients with hereditary connective tissue disorders may present with varying degrees of occipitoatlantoaxial hypermobility, resulting in • Symptoms referable to basilar impression • Retro-odontoid pannus formation• Functional cranial settling • Caudal displacement of the cerebellar tonsils
Atrophy of the thoracic spinal cord
Hypermobile EDS – 49 year old woman
Findings on Lumbar Spine MRIs (N=58)Degenerative disc diseasemultiple levels; narrowing of neural foramina
45 78%Herniation and expulsion of discs 30 52%Spinal canal stenosis 10 17%Facet arthrosis 48 83%Dural ectasia 15 26%Eccentric nucleus pulposusyounger age group (<25)
12 21%Dural “cysts” 3 5%Type II Modic changesolder age group (>40)
9 16%Spondylolisthesis 4 7%Annular tears 7 12%
Spine In EDS – What We Know• Degenerative disc disease is extremely
common in classical and hypermobile EDS• Spinal stenosis at the cervical level is seen in
about 1/3 of women over the age of 40• Scoliosis may progress in adults with EDS • Spinal disease causing significant morbidity,
back pain, and neurological symptoms is nearly ubiquitous and frequently causes disability.
Spine in EDS, Cont. • Chiari malformation is associated with EDS in a
significant minority of patients • Pannus formation around the odontoid-
thought to be related to craniocervical instability
• Retroflexed or misshaped odontoid • No age or subtype correlation observed with
craniocervical junction abnormalities
Summary and Recommendations
• Spinal pathology is a major cause of morbidity in Classical and Hypermobile EDS
• Low threshold for MRI investigations is appropriate for EDS patients with complaint of back and neck pain
• Anticipatory guidance is appropriate for avoidance of activities that are known to accelerate disc disease
Spine in EDS –What We Don’t Know
• Why do some patients develop disabling symptoms while others never do?
• Why does seemingly minor trauma induce severe, sometimes life-changing symptoms?
• What is the long-term prognosis for stabilizationsurgeries of the craniocervical junction and spine?
• What is the long-term prognosis of detetheringprocedures for tethered cord?
Immune Issues
• We have seen multiple patients with disorders of the immune system, including both humoral and cellular immunity
• Is there an association, or merely a chance occurrence of two disorders
• Are these related to autonomic dysfunction? Or is there another mechanism at play?
• Why do patients with hereditary disorders of connective tissue seem to be at increased risk of autoimmune conditions?
Mast Cell Disease
• There is a subset of EDS patients who develop symptoms of mast cell disease (flushing, hives, anaphylaxis)
• Is this a chance association or another manifestation of the phenotype?
Drug Metabolism
• Many EDS patients do not metabolize drugs as expected.
• Many patients have reported that they are slow to respond to the “caine” derivatives in the dental office – need multiple injections; wears off very slowly
• Metabolism of many drugs either prolonged or accelerated
• What can we learn from these observations about the underlying disorder(s)?
Thanks to
• Dr Nazli McDonnell • Dr. Fraser Henderson • Dr. Alan Pocinki• Dr. Robert Gerwin• Ms. Jessica Adcock• All my patients and their families