The clinical presentation of patients with Klippel-Feil syndrome is variable because of presence of other syndromes and anomalies. In many cases, the discovery of Klippel-Feil syndrome is an incidental finding. In general individuals with involvement of the upper cervical spine present much earlier than those with involvement of the lower spine.

A very common finding on examination is a short neck with limited range of motion. Most patients have difficulty rotating the neck. In some patients there is also loss of cervical spine flexion and extension. A low hairline may be seen in about 50% of patients. Other features of the disorder include presence of facial asymmetry and torticollis. About 20% of individual present with mild to moderate neurological deficit so a proper neurological exam is indicated. Besides paresthesias, some individuals may have muscle weakness and atrophy [5] [6].

The neurological deficits result from spinal stenosis, fusion anomalies and or unstable fusions of the vertebral joint and may include:

• Synkinesia
• Paresthesia
• Radiculopathy
• Myelopathy
• Torticollis
• Craniosynostosis

Skeletal anomalies include:

• Fused ribs
• Hypermobility of craniocervical junction
• Scoliosis
• Sprengel deformity is seen in about 1/4th of patients
• Congenital limb anomalies

Renal abnormalities include:

• Renal ectopia
• Double collecting system
• Bilateral tubular ectasia
• Horseshoe kidney
• Absence of kidney

Cardiovascular anomalies

• Atrial septal defects

ENT anomalies 

• Hearing defects
• Structural defects of the ear

Indications for Surgery

• Not all patients with Klippel-Feil syndrome need treatment. Because the syndrome can present with diverse features that vary from mild to severe, the individual must be thoroughly worked up. The indications for surgery include presence of symptoms, instability of cervical spine, rate of progression of the deformity, location of the deformity and patient preferences. The presence of neurological symptoms is generally a strong indication for surgery [7] [8] [9].
• Other indications include instability of the cervical spine and/or neurologic problems.
• There are some individuals who present early in the teenage years with severe cervical and thoracic spine deformity that is deforming and progressive. Some of these patients may require cervical spine fusion to prevent progression of the disease.
• Some individuals may have congenital scoliosis or may develop compensation which may progress and worsen the symptoms. These individuals often require surgery to prevent the deformity and symptoms.

Contraindications

There are no absolute contraindications for surgery, but good clinical judgment is required before recommending surgery. It is vital that the surgeon assess the patient thoroughly and also take into account presence of any other co-existing disorder or syndrome. The patient must also be medically and physically fit to undergo surgery. If the patient has an underlying congenital heart defect, it must be corrected prior to surgery on the spine. The patient must be fully worked up before undertaking any surgery.

• Pain

  […] by jacksmom2018 Rib pain on left side Hi all. I've been experiencing rib pain on the left side under... by Guest Rib pain on left side Hi all. [mdjunction.com]

  I take medications for nerve pain, but the pain persists throughout my upper body, as well as other neurological symptoms that make every day a roller coaster. [globalgenes.org]

  Practical Pain Management. Philadelphia: Lippincott Williams & Wilkins, 2002. Print. [physio-pedia.com]

  Cervical deep muscle strengthening has been shown to improve the stability of the hypermobile cervical spine and also help to decrease mechanical stress applied around the spine, thereby alleviating pain[3]. [patient.info]

• Atrial Septal Defect

  In our case we have had registered a nonrestrictive atrial septal defect and corrective surgical intervention at age 18 months in the Santa Rosa Children's Hospital (USA) has been done successfully. [ncbi.nlm.nih.gov]

  In the region of fosa ovale restrictive secundum atrial septal defect was presented with a predominantly right-to-left shunt. [heighpubs.org]

  A cardiac sonogram demonstrated a secundum atrial septal defect. [nature.com]

  Our patient had a history of the corrected atrial septal defect, and an incidentally detected right ectopic kidney. [mjdrdypu.org]

  septal defects ENT anomalies Hearing defects Structural defects of the ear Indications for Surgery Not all patients with Klippel-Feil syndrome need treatment. [symptoma.com]

• Coarctation of the Aorta

  Although congenital heart and lung defects are infrequent, some abnormalities such as cor triatriatum, coarctation of the aorta, total anomalous pulmonary venous connection, or lung agenesis have been reported. [ncbi.nlm.nih.gov]

  Patent ductus arteriosus, mitral valve prolapse, bicuspid aortic valve, and coarctation of the aorta leading to perioperative heart failure can also be present 4,7,9. [scielo.br]

• Protein S Deficiency

  Our patient had pulmonary thromboembolism, the cause for which was identified to be congenital protein S deficiency. Protein S deficiency is an inherited coagulopathy which can manifest clinically as thromboembolic phenomena. [mjdrdypu.org]

• Heart Disease

  Echocardiography is indicated when congenital heart disease is suspected. MANAGEMENT Treatment is mainly symptomatic. Affected patients should avoid contact sports and any exercise that might exacerbate instability of the cervical spine. [contemporarypediatrics.com]

  Other commonly associated anomalies include scoliosis, renal abnormalities, Sprengel deformity, deafness, synkinesia and congenital heart disease. The most common heart disease variant was ventricular septal defect. [ai-online.info]

  Br Heart J 1976; 38:1220–1. PubMed CrossRef Google Scholar 15. Forney WR, Robinson SJ, Pascoe DJ. Congenital heart disease, deafness and skeletal malformations: a new syndrome? J Pediatr 1966; 68:14–26. PubMed CrossRef Google Scholar 16. [link.springer.com]

  (aplasia in 33%) deafness (30%) congenital heart disease / cardiovascular (5-30%) synkinesis (mirror motions) brainstem abnormalities congenital cervical stenosis basilar invagination atlantoaxial instability (~50%) adjacent level disease (100%) degeneration [orthobullets.com]

  All patients were at risk of having other serious anomalies such as Sprengel's deformity, hearing impairment, synkinesia and congenital heart disease. [clinicaltrials.gov]

• Hypertension

  Renovascular hypertension (RVHT) and RAS. [biomed.uninet.edu]

  Pulmonary function testing revealed a restrictive defect, but transthoracic echocardiography was normal without pulmonary hypertension. We planned a combined spinal-epidural technique; however, only the epidural technique was obtained. [ncbi.nlm.nih.gov]

  Hypertension in South Africa adults: results from the Demographic and Health Survey, 1998. Journal of Hypertension 2001;19:1717-1725. 16. Spence JD. Treatment options for renovascular hypertension. Expert Opin Pharmacother 2002 Apr;3(4):411-416. 17. [ispub.com]

• Tachycardia

  When she was turned prone she developed persistent tachycardia, hypotension and ST segment changes despite fluids, pressors and inotropes. [ncbi.nlm.nih.gov]

  RYR2, SCN10A, SCN1B, SCN2B, SCN3B, SCN4B, SCN5A, SEMA3A, SLMAP, SNTA1, TECRL, TRDN, TRPM4 Del Dup NGS Cardiac valvular dysplasia, X-linked FLNA Del Dup NGS Cartilage-hair hypoplasia RMRP Sanger Del Dup NGS Catecholaminergic polymorphic ventricular tachycardia [ctgt.net]

  Tachycardia can sometimes be associated with these symptoms. [doi.org]

• Hearing Impairment

  Less common associations include congenital limb deficiencies, craniosynostosis, ear abnormalities and hearing impairment, and craniofacial abnormalities. [patient.info]

  […] of which 30% were deaf. 9 In 1974, Hensinger et al found 36% of patients in their study had hearing loss. 10 A review by Helmi and Pruzansky in 1980 suggested hearing impairment was present in 24% of KFS patients, although in their own seven cases, five [adc.bmj.com]

• Hearing Problem

  Five declined to be tested and, of these, three had no reported problem; two did have hearing problems and previous audiological data were obtained. No reply was received from seven patients, four of whom reported no problem. [adc.bmj.com]

  […] palate (see entry Cleft Lip and/or Palate); fusion of two or more ribs; problems with movements including when one side of the body is moved, the other side wanting to do exactly the same (otherwise known as mirror movements); and hearing problems (see [contact.org.uk]

• Torticollis

  […] other findings high scapula (Sprengel Deformity) jaw anomalies partial loss of hearing torticollis scoliosis Imaging Imaging recommended views AP, lateral, and odontoid views findings basilar invagination is seen on lateral view defined as dens elevation [orthobullets.com]

  Range of motion should be increased in cases of torticollis and Sprengel's deformity. Scoliosis strengthening/stretching techniques (see here) and breathing exercises. A home exercise program.[6] KFS cannot be resolved with physical therapy. [physio-pedia.com]

  Increases the apparent width of the neck Referred to as pterygium colli Torticollis and facial asymmetry Due to contracture of the sternocleidomastoid muscle or bony abnormalities. [boneandspine.com]

• Limitation of Neck Movement

  GupteChaitanya HawaldarMaggi Vettiyatil Medicine 2016 Klippel-Feil syndrome is a rare condition also known as synostosis of cervical spine that consists of the triad of symptoms such as short neck, limitation of neck movements, and low posterior hairline [semanticscholar.org]

  On airway examination, she had short, webbed neck and limited neck extension and flexion movements and a low-lying posterior hair line (Figure 1). [apicareonline.com]

• Short Neck

  The clinical triad of low posterior hairline, short neck, and limited range of neck motion in a patient with fused multiple cervical vertebrae isdiagnostic of Klippel-Feil syndrome. [contemporarypediatrics.com]

  This condition leads to a characteristic appearance of a short neck, low hairline, facial asymmetry, and limited neck mobility. The anomalies can lead to chronic headaches, a limited range of neck motion, and neck muscle pain. [physio-pedia.com]

  The 'clinical triad' findings, which are short neck, low posterior hairline and a limited cervical range of motion, only occur in around 50% of people with KFS[2]. [patient.info]

  The short neck and its immobility and instability present a significant challenge for endotracheal intubation. [ncbi.nlm.nih.gov]

• Nystagmus

  A long list of associated features includes torticollis, facial asymmetry, scoliosis and kyphosis; difficulty in breathing and swallowing, cleft palate, micrognathia, mental retardation, deafness, strabismus, nystagmus, spastic quadriplegia, synkinesis [whonamedit.com]

  Restricted Cervical ROM Patients with extensive fusions present earlier Cosmetic deformity Instability/Hypermobility at unfused levels Cord compression in congenitally anomolous, narrow canal in young adults -Arnold Chiari Malformation Ataxia Dizziness Nystagmus [wheelessonline.com]

  Brain stem and cranial nerve deficits include Internuclear ophthalmoplegia (ipsilateral weakness of eye adduction plus contralateral horizontal nystagmus in the abducting eye with lateral gaze) Downbeat nystagmus (fast component downward) Hoarseness Dysarthria [msdmanuals.com]

• Paresthesia

  Besides paresthesias, some individuals may have muscle weakness and atrophy. [symptoma.com]

  A 38-year-old female presented with acute unsteadiness, along with a tendency to lean to the left side while walking or sitting, and paresthesia in the right lower limb and trunk, at 2 days before admission. [ncbi.nlm.nih.gov]

  (Sprengel's deformity) is also frequently encountered (58%) as well as scoliosis (57%) Deafness (49%), neck bent to one side (46%), sleep disturbances (44%), severe and abnormal repetitive fatigue (41%) as well as paresthesia of the arms or hands (39% [thomasjolleyds.blogspot.com]

  The tip of the dens should lie below this line. 15 Figure 15: 31 year-old woman presenting with left upper extremity paresthesias. [radsource.us]

• Vertigo

  We present a case of a 43-year-old female with headaches, progressive paresthesias of the upper extremities, and vertigo. Ultrasonography could not visualize the left internal carotid artery (ICA). [ncbi.nlm.nih.gov]

  Case Report A 14-year-old boy with known KFS clinically presented with repetitive episodes of severe occipital headache, vertigo, and nausea combined with neck and shoulder discomfort, which lasted for weeks. [ajnr.org]

  Symptoms may include Intermittent syncope Drop attacks Vertigo Confusion or altered consciousness Weakness Visual disturbance Syringomyelia (cavity in the central part of the spinal cord) is common in patients with Chiari malformation. [msdmanuals.com]

• Neck Stiffness

  In our case, the anomaly of the vertebrae resulted in neck stiffness, which may have contributed to injury of the scalp skin due to engagement with the uterine wall during foetal development. [medicaljournals.se]

  On examination the child was irritable, small for his age, with a head tilt to the left, neck stiffness and restricted mobility. Neurological examination revealed bilateral early papilloedema, truncal ataxia and difficulty in sitting upright. [neurologyindia.com]

  She is healthy overall, with her only complaint being intermittent neck stiffness. On evaluation you note limited cervical range of motion and a subtle webbed appearance to the neck. Cervical radiographs are ordered as seen in Figures A & B. [orthobullets.com]

  Typical age of onset of spine related neurological symptoms is between 10 and 11 years of age. 14 Type I patients with a single fused segment have predominantly axial symptoms of neck/headache, neck pain, and neck stiffness. [now.aapmr.org]

  Axial symptoms of neck/headache, neck pain, and neck stiffness are the predominant symptoms in symptomatic KFS patients and are largely noted in Type I patients who present with a single fused cervical segment [ 4 ]. [pulsus.com]

• Hyperreflexia

  In addition, some individuals may develop increased reflex reactions (hyperreflexia); weakness or paralysis of one side of the body (hemiplegia) or of the legs and the lower part of the body (paraplegia); or impairment of certain nerves that emerge from [rarediseases.org]

  Neurologic symptoms developing later in life are due to development of degenerative disc disease, instability and spinal stenosis at adjacent segments. 2 Patients may present with neck or radicular pain, slowly progressive or acute myelopathy, ataxia, hyperreflexia [radsource.us]

• Blood work is not useful for making a diagnosis of Klippel-Feil syndrome. However, patients who undergo surgery need to have a complete blood count, electrolytes, renal function, coagulation profile and urine analysis.
• Lateral and AP X-rays of the spine are often done to assess the cervical spine. If there is instability of the cervical spine, flexion-extension images are also obtained. To detect other possible spine anomalies, X-rays of the entire spinal column must be obtained. Rib and chest wall X-rays are also necessary to look for rib anomalies such as fusion.
• The two imaging tests of choice to fully assess the patient with Klippel-Feil syndrome are CT scan and MRI. These imaging tests also enable 3D reconstruction and can be invaluable in interpreting the anatomical defects. CT scan is also useful for planning of surgery.
• Patients with neurological deficits may benefit from an MRI, which is far more superior in assessing spinal stenosis.
• In patients with suspected renal involvement, ultrasound is preferred to intravenous pyelography.
• Echocardiogram is performed to rule out any heart or valvular defects
• Since children with Klippel-Feil syndrome have hearing deficits, an audiologist consult is necessary to determine degree of hearing deficit.

• Cervical Spine X-Ray

  Relevant diagnostic work-up included craniogram, cervical spine x-ray, computed tomography (CT) of the brain and craniocervical junction, magnetic resonance imaging of the brain, electroencephalography, ophthalmologic examination, urinary tract ultrasonography [ncbi.nlm.nih.gov]

  All routine investigations including echocardiography were within normal limits, except fused cervical spines at upper and lower levels with failure of complete segmentation on cervical spine x-ray films (Figure 2). [apicareonline.com]

  A lateral cervical spine X-ray (image B) demonstrates cervical fusion (arrow A’) but not the extent of spinal canal narrowing, and thus magnetic resonance imaging or computed tomography better informs preoperative airway assessment. [pubs.asahq.org]

• Ventricular Hypertrophy

  A 2-dimensional echocardiography revealed left ventricular hypertrophy, mild pulmonary hypertension, and normal right ventricular function. A working diagnosis of Klippel–Feil syndrome with pulmonary thromboembolism was made. [mjdrdypu.org]

  An electrocardiogram showed tight atrial and ventricular hypertrophy. Chest X-ray showed cardiomegaly. Transthoracic echo cardiography showed confluence of the all pulmonary veins above left atrium and draining together to the right atrium. [heighpubs.org]

Medical therapy has a minimal role in patients with Klippel-Feil syndrome. Because the disorder is not common, it is highly recommended that patients are referred to specialists because the general physician may not be aware of the different anomalies that can occur. If any type of urological or renal abnormality is suspected, consultation with a nephrologist and or urologist is recommended. Similarly, all heart defects need to be referred to a cardiologist and/or a cardiac surgeon. Because of the high incidence of ear problems, consultation with an ENT surgeon and audiologist is recommended. These specialists may help with the investigation, monitoring and follow up of the patient. Nerve impingement may present with pain and paresthesias which may require non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsants and analgesics.

Surgical therapy

Surgical therapy is necessary in some patients with Klippel-Feil syndrome. Because the disorder presents with fusion of the spine, the growth potential of a child can sometimes be impaired. In other cases, the cervical spine fusion can be progressive and lead to both a cosmetic and neurological deficits. Other individuals may have cervical spine instability which may lead to paralysis if not promptly treated. Other indications for surgery include constant and worsening pain and ongoing neurological deficits. The type of surgery for Klippel Feil syndrome is variable. If the patent has spinal stenosis, it may require decompression and fusion; others patients may require fusion if there is vertebral instability.

Preoperative details

Prior to undertaking surgery, the patient must be thoroughly assessed to ensure that he/she is fit for surgery. CT scans are generally obtained to determine the site of surgery and extent.

The prognosis of patients with Klippel-Feil syndrome depends on the severity of the disorder and presence of any other syndromes. All patients must be followed for life, since the disorder is often progressive. A multidisciplinary approach to care is required to avoid the morbidity of the disorder. Because the disorder is not common, patients should be referred to orthopedic or neurosurgeons who specialize in spinal and craniofacial defects. Even when surgery is performed, complications are not uncommon and can be serious. The complications of spinal surgery vary from paresthesia, paralysis, spinal fluid leak, infections, hematoma and even death. Mild cases of Klippel-Feil syndrome have a good prognosis but those with multiorgan involvement have a guarded prognosis.

Klippel-Feil syndrome type 1 is caused by heterozygous mutation in the GDF6 gene on chromosome 8q22, autosomal recessive Klippel-Feil syndrome type 2 is caused by mutation in the MEOX1 gene on chromosome 17q21, and autosomal dominant Klippel-Feil syndrome type 3 occurs due to mutation in the GDF3 gene on chromosome 12p13. The syndrome is known to present in patients with other syndromes such as Goldenhar syndrome, fetal alcohol syndrome and anomalies of the extremities. 

Recent data indicates that perhaps there is a systemic insult (eg. vascular interruption) to the fetus during pregnancy which may explains its systemic features and occurrence with other syndrome. So far the role of the environment or medications has not been studied.

The exact incidence of Klippel-Feil syndrome is not known because not all people with the disorder come to medical attention. The disorder is rare and not usually encountered in everyday medical practice. The majority of patients with Klippel Feil syndrome present as children. The disorder occurs in both genders and can affect all races. Analysis of spine films from two relatively large studies indicate that the incidence may vary from 0.7 to 1%. The severity of the defect does vary greatly and may occur in the presence of several other syndromes.

The pathophysiology of Klippel-Feil syndrome is not well understood. Because the disorder affects the spine and other organs, it is suspected that a systemic insult may be the cause. More recent data suggest that interruption of blood supply to critical organs in the fetus may be a possible explanation for the pathology. The “injurious” agent appears to affect predominantly the cervical spine, heart and the urogenital systems.

It is not possible to prevent Klippel-Feil syndrome. However, once the diagnosis is made, it is important that the individual follow up closely with the specialist. The disorder is often progressive and can suddenly become symptomatic. When treated early, whether medically or surgically, the prognosis for most patients is good. For patients with fused vertebrae, physical therapy may help improve the range of motion. Patients with unstable vertebral segments should avoid all sports until the disorder is surgically fixed.

Patients with Klippel-Feil syndrome should be told to avoid contact sports or any other type of activity where there is risk of injury to the head or neck area. The reason is that there have been several cases of traumatic tetraplegia even after minor trauma in patients with unstable cervical spine segments.

Klippel-Feil syndrome is a rare congenital anomaly that presents with a triad of short webbed neck, limited range of motion of the cervical spine and a low hair line. The disorder may occur isolated or in association with numerous other syndromes. Besides the spine anomaly, one may also observe anomalies of the urogenital system and heart. Klippel-Feil syndrome is not a common disorder and most physicians are unlikely to encounter it in their everyday practice. Several classifications have been developed to describe the severity of the syndrome and its pathology, which include the following:

• Type I – Extensive fusion of the cervical spine. This is usually a single level fusion.
• Type II – More than one vertebrae is fused.
• Type III – The is extensive spinal cord involvement, including presence of thoracic and lumbar spine anomalies.

In Klippel-Feil syndrome the defect in the spine is most commonly found between cervical segments C1-C3. Any anomaly here is likely to cause symptoms whereas lesions lower then C4 are less likely to cause symptoms. Overall at least 1/4th of patients with Klippel-Feil syndrome develop symptoms with in the first ten years of life. The rest tends to develop symptoms in the second to third decade of life [1] [2] [3] [4].

Klippel-Feil syndrome is a rare disorder that presents with fusion of the cervical spine. The affected individual will have a very short neck, with difficulty performing rotational movements of the neck. The condition may occur in combination with several other skeletal anomalies, including scoliosis and fusion of the ribs. The exact cause of Klippel-Feil syndrome is unknown. The disorder can present with varied features but the most prominent are a short neck, inability to turn the head and low hairline. While most affected individuals have no symptoms, others may present with neurological problems like numbness or pain in the extremities. The treatment depends on the severity of the condition and other associated defects. Surgery is often required when the disease is progressive and the cervical spine is unstable.

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8. Stallmer ML, Vanaharam V, Mashour GA. Congenital cervical spine fusion and airway management: a case series of Klippel-Feil syndrome. J Clin Anesth. 2008 Sep;20(6):447-51
9. Samartzis D, Kalluri P, Herman J, Lubicky JP, Shen FH. 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. Spine (Phila Pa 1976). 2008 Jun 1;33(13):1442-50