Letters to the Editor
Occipito-Vertebral Dissociation in Connection with Extensive Cervical Spine Malsegmentation in a Boy with Möbius Syndrome
Read
811
Timeswas read the article
236
Total PDF
575
Total HTML
Share statistics
array:24 [ "pii" => "S1807593222025480" "issn" => "18075932" "doi" => "10.1590/S1807-59322009001000016" "estado" => "S300" "fechaPublicacion" => "2009-10-01" "aid" => "20222548" "copyright" => "CLINICS" "copyrightAnyo" => "2009" "documento" => "simple-article" "crossmark" => 0 "licencia" => "https://creativecommons.org/licenses/by-nc/3.0/" "subdocumento" => "cor" "cita" => "Clinics. 2009;64:1034-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:19 [ "pii" => "S1807593222025492" "issn" => "18075932" "doi" => "10.1590/S1807-59322009001000017" "estado" => "S300" "fechaPublicacion" => "2009-10-01" "aid" => "20222549" "copyright" => "CLINICS" "documento" => "simple-article" "crossmark" => 0 "licencia" => "https://creativecommons.org/licenses/by-nc/3.0/" "subdocumento" => "cor" "cita" => "Clinics. 2009;64:1037-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letters to the Editor</span>" "titulo" => "Oral Intraneural Perineurioma. Report of Two Cases" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1037" "paginaFinal" => "1039" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f3-cln_64p1037" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 508 "Ancho" => 2044 "Tamanyo" => 467933 ] ] "descripcion" => array:1 [ "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">A</span> - Onion-bulb-like structures composed of central Schwann cells and axons surrounded by circumferential proliferation of spindle-shaped perineurial neoplastic cells (hematoxylin and eosin, original magnification x200). <span class="elsevierStyleBold">B</span> - Perineurial cells immunoreactive for epithelial membrane antigen encircle negative Schwann cells and axons (original magnification x200). <span class="elsevierStyleBold">C -</span> Immunoexpression of S-100 protein in the myelin sheath and Schwann cells, surrounded by perineurial cells that were negative for S-100 protein(original magnification x200)</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Lília Alves Rocha, Sílvia Maria Paparotto Lopes, Alan Roger dos Santos Silva, Márcio Ajudarte Lopes, Pablo Agustin Vargas" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Lília Alves" "apellidos" => "Rocha" ] 1 => array:2 [ "nombre" => "Sílvia Maria Paparotto" "apellidos" => "Lopes" ] 2 => array:2 [ "nombre" => "Alan Roger" "apellidos" => "dos Santos Silva" ] 3 => array:2 [ "nombre" => "Márcio Ajudarte" "apellidos" => "Lopes" ] 4 => array:2 [ "nombre" => "Pablo Agustin" "apellidos" => "Vargas" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222025492?idApp=UINPBA00004N" "url" => "/18075932/0000006400000010/v1_202212060817/S1807593222025492/v1_202212060817/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1807593222025479" "issn" => "18075932" "doi" => "10.1590/S1807-59322009001000015" "estado" => "S300" "fechaPublicacion" => "2009-10-01" "aid" => "20222547" "copyright" => "CLINICS" "documento" => "simple-article" "crossmark" => 0 "licencia" => "https://creativecommons.org/licenses/by-nc/3.0/" "subdocumento" => "cor" "cita" => "Clinics. 2009;64:1031-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letters to the Editor</span>" "titulo" => "Fatal Bronchovascular Fistula after a Single Lung Transplantation: A Case Report" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1031" "paginaFinal" => "1033" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f3-cln_64p1031" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 745 "Ancho" => 994 "Tamanyo" => 112994 ] ] "descripcion" => array:1 [ "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Autopsy examination of the bronchovascular fistula orifice through the pulmonary artery</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marcos Naoyuki Samano, Juliana Akemi Saka, Marlova Luzzi Caramori, Paulo Manuel Pêgo-Fernandes, Fabio Biscegli Jatene" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Marcos Naoyuki" "apellidos" => "Samano" ] 1 => array:2 [ "nombre" => "Juliana Akemi" "apellidos" => "Saka" ] 2 => array:2 [ "nombre" => "Marlova Luzzi" "apellidos" => "Caramori" ] 3 => array:2 [ "nombre" => "Paulo Manuel" "apellidos" => "Pêgo-Fernandes" ] 4 => array:2 [ "nombre" => "Fabio Biscegli" "apellidos" => "Jatene" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222025479?idApp=UINPBA00004N" "url" => "/18075932/0000006400000010/v1_202212060817/S1807593222025479/v1_202212060817/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letters to the Editor</span>" "titulo" => "Occipito-Vertebral Dissociation in Connection with Extensive Cervical Spine Malsegmentation in a Boy with Möbius Syndrome" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1034" "paginaFinal" => "1036" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Ali Al Kaissi, Klaus Klaushofer, Franz Grill" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Ali Al" "apellidos" => "Kaissi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">I</span>" "identificador" => "afI-cln_64p1034" ] ] ] 1 => array:3 [ "nombre" => "Klaus" "apellidos" => "Klaushofer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">I</span>" "identificador" => "afI-cln_64p1034" ] ] ] 2 => array:4 [ "nombre" => "Franz" "apellidos" => "Grill" "email" => array:1 [ 0 => "ali.alkaissi@osteologie.at" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">II</span>" "identificador" => "afII-cln_64p1034" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Ludwig-Boltzmann Institute of Osteology, Hanusch Hospital of WGKK and AUVA Trauma Center Meidling, 4th Medical Department, Hanusch Hospital Vienna – Vienna, Austria" "etiqueta" => "I" "identificador" => "afI-cln_64p1034" ] 1 => array:3 [ "entidad" => "Orthopaedic Hospital of Speising, Paediatric Department - Vienna, Austria. Tel.: 00 43 1 91021 86924" "etiqueta" => "II" "identificador" => "afII-cln_64p1034" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f2-cln_64p1034" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1064 "Ancho" => 993 "Tamanyo" => 81027 ] ] "descripcion" => array:1 [ "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Sagittal MRI imaging revealing <span class="elsevierStyleItalic">discontinuity of the cervical ligaments</span>. Note the disruption of the anterior atlanto-occipital ligament, which connects the lower anterior clivus with the anterior aspect of the body of C2, <span class="elsevierStyleItalic">as visualized by the superior continuation of the anterior longitudinal ligament.</span> In addition, disruption of the anterior longitudinal ligament is evident (arrow-b). Note the dislocated atlas (arrow-c) and compression of the <span class="elsevierStyleItalic">dura mater</span> space. Line (d) represents the Wachenheim-clivus line (a method to evaluate craniocervical abnormalities). The line is drawn along the posterior aspect of the clivus, toward the odontoid process (OP). In normal subjects, the line is tangential to the posterior aspect of the OP. In contrast, in our patient, this line intersects the anterior aspect of the OP</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Möbius<a class="elsevierStyleCrossRef" href="#bib1">1</a> syndrome has drawn attention to patients with congenital, non-progressive bilateral facial and abducens palsies. Anomalies of other cranial nerves, such as the hypoglossal (XII), craniofacial, or orofacial nerves, and limb malformations are often encountered in association with Möbius syndrome. The etiology and pathogenesis of Möbius syndrome are still controversial. Patients with Möbius syndrome are generally asymptomatic, but increasing age and injury may precipitate symptoms. Though most cases are sporadic, a few families with hereditary Möbius syndrome have been described.<a class="elsevierStyleCrossRef" href="#bib1">1</a>–<a class="elsevierStyleCrossRef" href="#bib4">4</a><span class="elsevierStyleItalic">Vertebral abnormalities are not a well-known feature in patients with Möbius syndrome. None the less,</span> fusion of one or more contiguous segments results from the embryological failure in normal spine segmentation.<a class="elsevierStyleCrossRef" href="#bib5">5</a></p><p id="para20" class="elsevierStylePara elsevierViewall">This phenomenon is most likely the result of a decreased local blood supply during the third to eighth week of fetal development.<a class="elsevierStyleCrossRef" href="#bib6">6</a></p><p id="para30" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In patients with vertebral fusion premature</span> degenerative changes at adjoining motion segments are common, as this condition results in greater biomechanical stress in adjoining segments. Discal tears, rupture of transverse ligaments, fractures of the odontoid process and spondylosis are common consequences. Injuries to the atlanto-occipital region can range from complete atlanto-occipital or atlanto-axial dislocation to nondisplaced occipital condyle avulsion fractures.<a class="elsevierStyleCrossRef" href="#bib7">7</a>–<a class="elsevierStyleCrossRef" href="#bib10">10</a> In the present case study, we detected pre- and postnatal injuries by analyzing the details of cervical spine ligamental and osseous disruptions by MRI imaging. The combination of occipito-vertebral dissociation (distraction-separation) associated with extensive cervical spine malsegmentation can be considered as a novel syndromic variant associated with Möbius syndrome.</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CLINICAL REPORT</span><p id="para40" class="elsevierStylePara elsevierViewall">A 5-year-old boy was referred to the orthopedic department for clinical evaluation. He was the first child of healthy, non-consanguineous parents. At birth, his growth parameters were around the 50<span class="elsevierStyleSup">th</span> percentile. Maternal history was non-contributory (no history of spontaneous or elective abortions and/or prenatal exposure to misoprostol). Congenital facial diplegia was noted at birth together with ligamentous hyperlaxity and poor sucking, which led to feeding and choking problems. His subsequent development was slow. Walking was achieved at the age of 18 months, albeit with difficulty. Speech and language were significantly retarded, as were coordination skills. Conductive hearing loss was attributed to enlarged tonsils.</p><p id="para50" class="elsevierStylePara elsevierViewall">Examination at the age of 5 years showed growth around the 50<span class="elsevierStyleSup">th</span> percentile, facial diplegia, ptosis, and bilateral abducens nerve palsy with retraction of the bulb on lateral gaze. Limb abnormalities included partial syndactyly of the 2<span class="elsevierStyleSup">nd</span>, 3<span class="elsevierStyleSup">rd</span>, and 4<span class="elsevierStyleSup">th</span> fingers and partial syndactyly of the 3<span class="elsevierStyleSup">rd</span>, 4<span class="elsevierStyleSup">th</span>, and 5<span class="elsevierStyleSup">th</span> toes. The latissmus dorsi, trapezius, and pectoralis muscles were hypoplastic. The lower limbs demonstrated genu valgum (knock-knees). Thoracic kyphosis associated with painful and restricted mobility of the neck was noted. Neurological examination evoked suboccipital and neck pain, and the upper arms were weak. Some limitations were noted in cervical motion, especially with respect to rotation and lateral bending.</p><p id="para60" class="elsevierStylePara elsevierViewall">The cardiologic examination was normal, as were the renal ultrasound scans. Laboratory studies demonstrated normal white and red blood cell and platelet counts and normal calcium, phosphorus, and alkaline phosphatase levels. Urine amino acids and mucopolysaccharides were normal, and the patient had a normal karyotype.</p><p id="para70" class="elsevierStylePara elsevierViewall">In view of the seriousness of the patient’s cervical lesions, exploratory procedures were not recommended and dynamic X-rays were considered as too dangerous to perform. A lateral craniocervical radiograph showed that, throughout the cervical spine, there was extensive fusion of both the anterior and posterior elements in association with occipito-vertebral dissociation (arrow) (<a class="elsevierStyleCrossRef" href="#f1-cln_64p1034">Figure 1</a>). MRI imaging revealed increased discontinuity/disruption of the ligaments effectively causing the observed occipito-vertebral dissociation (<a class="elsevierStyleCrossRef" href="#f2-cln_64p1034">Figure 2</a>).</p><elsevierMultimedia ident="f1-cln_64p1034"></elsevierMultimedia><elsevierMultimedia ident="f2-cln_64p1034"></elsevierMultimedia><p id="para80" class="elsevierStylePara elsevierViewall">Initial treatment of the patient involved immobilization for variable lengths of time, followed by re-evaluation by MRI imaging. Awareness and monitoring of the complications associated with Möbius syndrome <span class="elsevierStyleItalic">should be</span> instituted.</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para90" class="elsevierStylePara elsevierViewall">Möbius syndrome is characterized by non-progressive, congenital facial and abducens palsy and can be associated with other cranial nerve palsies, orofacial dysmorphisms, and limb or axial malformations.<a class="elsevierStyleCrossRef" href="#bib1">1</a></p><p id="para100" class="elsevierStylePara elsevierViewall">A number of reports have evaluated the extent of the malformations that occur in Möbius patients. Larrandaburu et al.<a class="elsevierStyleCrossRef" href="#bib11">11</a> reported a family in which a 14-year-old girl had a combination of Poland and Möbius syndromes and a maternal aunt had features only of Möbius syndrome. Hennekam<a class="elsevierStyleCrossRef" href="#bib12">12</a> reported a family in which one individual had a Poland-associated anomaly, another had a hemifacial microsomia, and yet another had a neural tube defect. An etiology of vascular origin was hypothesized. In support of this hypothesis, Lipson et al.<a class="elsevierStyleCrossRef" href="#bib13">13</a> reported the cases of two infants; one had “classical Möbius syndrome” but without any hand abnormalities, and the other had hypertonic cerebral palsy and was shown postmortem to have hypoxic/ ischemic lesions in the caudate nucleus, putamen, and striatum. In both of these cases the mothers had suffered trauma during pregnancy at 18 and 14 weeks of gestation, respectively, resulting in rupture of the spleen and severe hypotension. Pedraza et al.<a class="elsevierStyleCrossRef" href="#bib14">14</a> evaluated the MRI findings of three patients with Möbius syndrome. MRI scans revealed brainstem hypoplasia with straightening of the fourth ventricle floor indicating an absence of the facial colliculus. Verzijl et al.<a class="elsevierStyleCrossRef" href="#bib4">4</a> described Möbius syndrome as a condition of rhombencephalic maldevelopment that includes Duane retraction syndrome (34%), conjugated horizontal gaze palsy (48%), congenital fibrosis of the extraocular muscles (9%), and lingual involvement (77%). Dysfunction of the palate and pharynx occurred in 56% of cases, and respiratory problems, incoordination, and other features were thought to originate in the lower brain stem. None of the abovementioned case studies reported spinal malformations, as observed in our patient.</p><p id="para110" class="elsevierStylePara elsevierViewall">Facial weakness, Duane anomaly, and vertebral abnormalities are a well-known set of malformation complexes that occur in association with Goldenhar,<a class="elsevierStyleCrossRef" href="#bib15">15</a> Wildervanck,<a class="elsevierStyleCrossRef" href="#bib16">16</a> and Hanhart syndromes.<a class="elsevierStyleCrossRef" href="#bib17">17</a> The overall clinicoradiographic features of our patient did not fit any of these syndromic entities.</p><p id="para120" class="elsevierStylePara elsevierViewall">The craniocervical junction is a complex articulation consisting of multiple ligamentous structures. In normal individuals, the anterior third of the cervico-occipital canal is occupied by the dens axis and the middle third by the spinal cord, which, once infringed upon, can result in spinal cord injury. The combination of occipito-vertebral dissociation and hypermobility at the atlantoaxial junction, secondary to extensive malsegmentation of the upper cervical vertebras, uniquely predisposes patients with syndromic malformation complexes to various serious neurological deficits, as observed in our patient. The most common of these neurological deficits is myelopathy, which results in quadriplegia, paraplegia, weakness of the lower limbs, crossed paralysis, or hemiplegia. Other manifestations include nuchal pain and stiffness, foramen magnum syndrome, or sudden death due to compression of vital structures at the cervicomedullary junction.<a class="elsevierStyleCrossRefs" href="#bib8">8,9,18</a></p><p id="para130" class="elsevierStylePara elsevierViewall">Here, we describe a patient with Möbius syndrome in order to demonstrate the necessity, when appropriate, to detail the anatomy of the malformed occipito-vertebral junction and to signify the pathophysiology of the associated cervical spine malsegmentation.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "cesec10" "titulo" => "INTRODUCTION" ] 1 => array:2 [ "identificador" => "cesec20" "titulo" => "CLINICAL REPORT" ] 2 => array:2 [ "identificador" => "cesec30" "titulo" => "DISCUSSION" ] 3 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "f1-cln_64p1034" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1209 "Ancho" => 993 "Tamanyo" => 88022 ] ] "descripcion" => array:1 [ "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Lateral radiograph showing atlanto-occipital dissociation (more than 12 mm between the basion and dens with a space clearly visible between the cranium and C1). The radiograph demonstrates extensive fusion throughout the cervical spine of both the anterior and posterior elements. Note the extensive fusion of the vertebral bodies of C2/3-4 and the total fusion of the spinous processes of C2-6. Also, note the detached os terminale (arrow)</p>" ] ] 1 => array:7 [ "identificador" => "f2-cln_64p1034" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1064 "Ancho" => 993 "Tamanyo" => 81027 ] ] "descripcion" => array:1 [ "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Sagittal MRI imaging revealing <span class="elsevierStyleItalic">discontinuity of the cervical ligaments</span>. Note the disruption of the anterior atlanto-occipital ligament, which connects the lower anterior clivus with the anterior aspect of the body of C2, <span class="elsevierStyleItalic">as visualized by the superior continuation of the anterior longitudinal ligament.</span> In addition, disruption of the anterior longitudinal ligament is evident (arrow-b). Note the dislocated atlas (arrow-c) and compression of the <span class="elsevierStyleItalic">dura mater</span> space. Line (d) represents the Wachenheim-clivus line (a method to evaluate craniocervical abnormalities). The line is drawn along the posterior aspect of the clivus, toward the odontoid process (OP). In normal subjects, the line is tangential to the posterior aspect of the OP. In contrast, in our patient, this line intersects the anterior aspect of the OP</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ueber angeborene doppelseitige Abducens-Facialis-Lahmung" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ PJ Mobius \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Munch Med Wochenschr" "fecha" => "1888" "volumen" => "35" "paginaInicial" => "91" "paginaFinal" => "94" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Genetics of Moebius syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ M Baraitser \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/jmg.14.6.415" "Revista" => array:6 [ "tituloSerie" => "J Med Genet" "fecha" => "1977" "volumen" => "14" "paginaInicial" => "415" "paginaFinal" => "417" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/604491" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mobius sequence: further in vivo support for the subclavian artery supply disruption sequence" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ S St Charles \n \t\t\t\t\t\t\t\t """ 1 => """ FJ DiMario Jr \n \t\t\t\t\t\t\t\t """ 2 => """ ML Grunnet \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ajmg.1320470230" "Revista" => array:6 [ "tituloSerie" => "Am J Med Genet" "fecha" => "1993" "volumen" => "47" "paginaInicial" => "289" "paginaFinal" => "293" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8213922" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mobius syndrome redefined: a syndrome of rhombencephalic maldevelopment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ HT Verzijl \n \t\t\t\t\t\t\t\t """ 1 => """ B van der Zwaag \n \t\t\t\t\t\t\t\t """ 2 => """ JR Cruysberg \n \t\t\t\t\t\t\t\t """ 3 => """ GW Padberg \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1212/01.wnl.0000076484.91275.cd" "Revista" => array:6 [ "tituloSerie" => "Neurology" "fecha" => "2003" "volumen" => "61" "paginaInicial" => "327" "paginaFinal" => "333" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12913192" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Klippel M, Feil A. Un cas d’absence des vertebres cervicales. Avec cage thoracique remontant jusqu’a la base du crane (cage thoracique cervicale). Nouv Iconog Salpetriere 191225: 223-50" ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Congenital anomalies and normal skeletal variants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => """ GM Guebert \n \t\t\t\t\t\t\t\t """ 1 => """ LJ Rowe \n \t\t\t\t\t\t\t\t """ 2 => """ TR Yochum \n \t\t\t\t\t\t\t\t """ 3 => """ JR Thompson \n \t\t\t\t\t\t\t\t """ 4 => """ CJ Masia \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:6 [ "editores" => "TRYochum, LJRowe" "titulo" => "Essentials of Skeletal Radiology" "paginaInicial" => "257" "paginaFinal" => "403" "edicion" => "3rd ed" "serieFecha" => "2005" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiologic diagnosis of Traumatic Occipitovertebral Dissociation: Comparison of Three Methods of Detecting Occipitovertebral Relationships on Lateral Radiographs of Supine Subjects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ Harris Jr \n \t\t\t\t\t\t\t\t """ 1 => """ G Carson \n \t\t\t\t\t\t\t\t """ 2 => """ L Wagner \n \t\t\t\t\t\t\t\t """ 3 => """ N Kerr \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2214/ajr.162.4.8141013" "Revista" => array:6 [ "tituloSerie" => "AJR" "fecha" => "1994" "volumen" => "162" "paginaInicial" => "887" "paginaFinal" => "892" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8141013" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Craniovertebral junction: normal anatomy, craniometry, and congenital anomalies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ WR Smoker \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiographics.14.2.8190952" "Revista" => array:6 [ "tituloSerie" => "RadioGraphics" "fecha" => "1994" "volumen" => "14" "paginaInicial" => "255" "paginaFinal" => "277" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8190952" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atlantoaxial subluxation. Radiography and magnetic resonance imaging correlated to myelopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ Y Yamashita \n \t\t\t\t\t\t\t\t """ 1 => """ M Takahashi \n \t\t\t\t\t\t\t\t """ 2 => """ Y Sakamoto \n \t\t\t\t\t\t\t\t """ 3 => """ R Kojima \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Radiol" "fecha" => "1989" "volumen" => "30" "paginaInicial" => "135" "paginaFinal" => "140" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2923734" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiologic spectrum of craniocervical distraction injuries" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ AV Deliganis \n \t\t\t\t\t\t\t\t """ 1 => """ AB Baxter \n \t\t\t\t\t\t\t\t """ 2 => """ JA Hanson \n \t\t\t\t\t\t\t\t """ 3 => """ DJ Fisher \n \t\t\t\t\t\t\t\t """ 4 => """ WA Cohen \n \t\t\t\t\t\t\t\t """ 5 => """ AJ Wilson \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Radiographics" "fecha" => "2000" "volumen" => "20" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The occurrence of Poland and Poland-Moebius syndromes in the same family: further evidence of their genetic component" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ M Larrandaburu \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Dysmorphol" "fecha" => "1999" "volumen" => "8" "paginaInicial" => "93" "paginaFinal" => "99" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10319197" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Familial liability to intrauterine vascular impairments" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ RCM Hennekam \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "1990" "volumen" => "86" "paginaInicial" => "326" "paginaFinal" => "327" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2164658" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Two cases of maternal antenatal splenic rupture and hypotension associated with Moebius syndrome and cerebral palsy in offspring" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ AH Lipson \n \t\t\t\t\t\t\t\t """ 1 => """ Y Gillerot \n \t\t\t\t\t\t\t\t """ 2 => """ AEG Tannenberg \n \t\t\t\t\t\t\t\t """ 3 => """ S Giurgea \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/BF02002911" "Revista" => array:6 [ "tituloSerie" => "Eur J Pediatr" "fecha" => "1996" "volumen" => "155" "paginaInicial" => "800" "paginaFinal" => "804" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8874116" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "MRI findings in Mobius syndrome: correlation with clinical features" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ S Pedraza \n \t\t\t\t\t\t\t\t """ 1 => """ J Gámez \n \t\t\t\t\t\t\t\t """ 2 => """ A Rovira \n \t\t\t\t\t\t\t\t """ 3 => """ A Zamora \n \t\t\t\t\t\t\t\t """ 4 => """ E Grive \n \t\t\t\t\t\t\t\t """ 5 => """ N Raguer \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1212/wnl.55.7.1058" "Revista" => array:6 [ "tituloSerie" => "Neurology" "fecha" => "2000" "volumen" => "55" "paginaInicial" => "1058" "paginaFinal" => "1060" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11061273" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oculoauriculovertebral spectrum: an updated critique" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ MM Cohen Jr \n \t\t\t\t\t\t\t\t """ 1 => """ BR Rollnick \n \t\t\t\t\t\t\t\t """ 2 => """ CI Kaye \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cleft Palate J" "fecha" => "1989" "volumen" => "26" "paginaInicial" => "276" "paginaFinal" => "286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2680167" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cervical diastematomyelia in cervico-oculo-acoustic (Wildervanck) syndrome: MRI findings" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ S Balci \n \t\t\t\t\t\t\t\t """ 1 => """ KK Oguz \n \t\t\t\t\t\t\t\t """ 2 => """ MM Firat \n \t\t\t\t\t\t\t\t """ 3 => """ K Boduroglu \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00019605-200204000-00010" "Revista" => array:6 [ "tituloSerie" => "Clin Dysmorphol" "fecha" => "2002" "volumen" => "11" "paginaInicial" => "125" "paginaFinal" => "128" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12002143" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Craniocervical junction malformation in a child with Oromandibularlimb hypogenesis-Möbius syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:5 [ 0 => """ A Al Kaissi \n \t\t\t\t\t\t\t\t """ 1 => """ F Grill \n \t\t\t\t\t\t\t\t """ 2 => """ H Safi \n \t\t\t\t\t\t\t\t """ 3 => """ M Ben Ghachem \n \t\t\t\t\t\t\t\t """ 4 => """ F Ben Chehida \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1750-1172-2-2" "Revista" => array:5 [ "tituloSerie" => "Orphanet J Rare Dis" "fecha" => "2007" "volumen" => "2" "paginaInicial" => "2" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17210070" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric spinal trauma: vertebral column and spinal cord injuries in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ CA Dickman \n \t\t\t\t\t\t\t\t """ 1 => """ H Rekate \n \t\t\t\t\t\t\t\t """ 2 => """ VK Sonntag \n \t\t\t\t\t\t\t\t """ 3 => """ JM Zabramski \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Pediatric Neuri" "fecha" => "1989" "paginaInicial" => "237" "paginaFinal" => "256" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/18075932/0000006400000010/v1_202212060817/S1807593222025480/v1_202212060817/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/18075932/0000006400000010/v1_202212060817/S1807593222025480/v1_202212060817/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222025480?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 21 | 21 | 42 |
| 2024 September | 24 | 19 | 43 |
| 2024 August | 28 | 17 | 45 |
| 2024 July | 29 | 12 | 41 |
| 2024 June | 28 | 12 | 40 |
| 2024 May | 24 | 16 | 40 |
| 2024 April | 14 | 8 | 22 |
| 2024 March | 17 | 10 | 27 |
| 2024 February | 19 | 13 | 32 |
| 2024 January | 37 | 7 | 44 |
| 2023 December | 32 | 19 | 51 |
| 2023 November | 28 | 15 | 43 |
| 2023 October | 33 | 27 | 60 |
| 2023 September | 29 | 15 | 44 |
| 2023 August | 25 | 1 | 26 |
| 2023 July | 13 | 11 | 24 |
| 2023 June | 13 | 1 | 14 |
| 2023 May | 50 | 0 | 50 |
| 2023 April | 31 | 5 | 36 |
| 2023 March | 32 | 3 | 35 |
| 2023 February | 19 | 2 | 21 |
| 2023 January | 12 | 2 | 14 |
| 2022 December | 15 | 0 | 15 |
Show all