Management of Cervical Instability as a Complication of Neurofibromatosis Type 1 in Children: A Historical Perspective With a 40-Year Experience

Abstract

Study DesignLiterature review with supplementary case examples. ObjectivesThe objective of this article was to review neurofibromatosis type 1 (NF1) and the associated spinal pathology with a focus on the disorder’s manifestations in the immature cervical spine. Summary of Background DataNF1 is one of the most common inheritable genetic disorders. The disorder is associated with spinal deformities, long bone dysplasia, and osteoporosis. The manifestations of NF1 in the cervical spine commonly include instability secondary to kyphosis, neurofibromas, and dural ectasia. MethodsLiterature relevant to the evaluation and management of NF1 in the cervical spine was reviewed using the PubMed/NCBI database with a focus on recent clinical studies. The review was supplemented with a historical perspective and patient cases. ResultsThe prevalence of NF1 cervical spine lesions is difficult to define because many patients may be asymptomatic. Symptoms of cervical kyphosis can include pain or nerve deficits but some have a surprisingly high tolerance for deformity and may have frank dislocation of one vertebral body over another (spondyloptosis) with few associated symptoms. Cervical radiographs should be obtained in patients requiring traction, surgery, or intubation, and those with neck pain or symptoms that suggest spinal neurofibromas. Patients with progressive symptoms should be offered surgery. Careful planning is required because many patients will have small, dysplastic vertebral bodies, thin posterior elements, plexiform neurofibromas, or dural ectasia. The decision to use preoperative traction will vary from patient to patient. Combined anterior-posterior fusion is recommended for most cases of severe symptomatic kyphosis, and the fusion should extend from parallel to parallel vertebrae (or six or more levels). Anterior or posterior fusion alone may be an alternative for skeletally mature patients with smaller, flexible curves. ConclusionsSpinal deformity is the most common musculoskeletal manifestation of NF1. Cervical lesions are frequently asymptomatic, but patients with thoracolumbar scoliosis, dystrophic features, or a history of laminectomy should have the cervical spine carefully evaluated. For severe and progressive kyphotic deformities, most authors recommend a period of traction followed by a combined anterior-posterior fusion that is instrumented from parallel to parallel vertebra (or six or more levels). Close follow-up is very important because complications and progression are frequent.