Vertebral remodeling in eosinophilic granuloma of the spine. A long-term follow-up

Presentation, treatment, and outcomes of unifocal and multifocal osseous vertebral Langerhans cell histiocytosis lesions in patients under 18 years old

This study aims to (1) clinically and radiographically characterize a series of unifocal (single-system single-site) and multifocal (single-system multiple-site) langerhans cell histiocytosis (LCH) lesions in the vertebra and (2) determine the success and recurrence rates with different treatment modalities in a pediatric population at a tertiary children's hospital. Patients younger than 18 years old with a diagnosis of LCH before 1 June 2021 at our institution were reviewed. The inclusion criteria were a unifocal or multifocal vertebral lesion without systemic disease. Clinical presentations, lesion sites, radiographic findings, treatments, complications, recurrence rates, and length of follow-up were reviewed and recorded. Thirty-nine patients had unifocal (36%) or multifocal (64%) vertebral lesions. 44% of patients had vertebral lesions only. The most common clinical presentation was neck or back pain (51%) and difficulty or inability to ambulate (15%). 70 vertebrae were involved in total; 59% cervical, 62% thoracic, 49% lumbar, and 10% sacral. 88% of multifocal patients underwent chemotherapy compared to 60% of unifocal patients. The recurrence rate in the entire cohort was 10%. The median length of follow-up was 5.2 years (0.6-16.8). Chemotherapy is often utilized as a treatment for vertebral LCH lesions regardless of unifocal or multifocal osseous presentation, with good outcomes and low recurrence rates. However other treatments such as observation only and steroid injections may be a better option with smaller and less widespread lesions due to side effects and length of treatment with chemotherapy. Determination of more invasive treatments including surgical excision or fixation will need to be considered on a case-by-case basis. Level of evidence: IV.

Multiple Langerhans cell histiocytosis with spinal involvement

Aims

The aim of this study was to report the long-term prognosis of patients with multiple Langerhans cell histiocytosis (LCH) involving the spine, and to analyze the risk factors for progression-free survival (PFS).

Methods

We included 28 patients with multiple LCH involving the spine treated between January 2009 and August 2021. Kaplan-Meier methods were applied to estimate overall survival (OS) and PFS. Univariate Cox regression analysis was used to identify variables associated with PFS.

Results

Patients with multiple LCH involving the spine accounted for 15.4% (28/182 cases) of all cases of spinal LCH: their lesions primarily involved the thoracic and lumbar spines. The most common symptom was pain, followed by neurological dysfunction. All patients presented with osteolytic bone destruction, and 23 cases were accompanied by a paravertebral soft-tissue mass. The incidence of vertebra plana was low, whereas the oversleeve-like sign was a more common finding. The alkaline phosphatase was significantly higher in patients with single-system multifocal bone LCH than in patients with multisystem LCH. At final follow-up, one patient had been lost to follow-up, two patients had died, three patients had local recurrence, six patients had distant involvement, and 17 patients were alive with disease. The median PFS and OS were 50.5 months (interquartile range (IQR) 23.5 to 63.1) and 60.5 months (IQR 38.0 to 73.3), respectively. Stage (hazard ratio (HR) 4.324; p < 0.001) and chemotherapy (HR 0.203; p < 0.001) were prognostic factors for PFS.

Conclusion

Pain is primarily due to segmental instability of the spine from its destruction by LCH. Chemotherapy can significantly improve PFS, and radiotherapy has achieved good results in local control. The LCH lesions in some patients will continue to progress. It may initially appear as an isolated or single-system LCH, but will gradually involve multiple sites or systems. Therefore, long-term follow-up and timely intervention are important for patients with spinal LCH.

Vertebra Plana: A Narrative Clinical and Imaging Overview among Possible Differential Diagnoses

Vertebra plana is a rare radiologic condition characterized by a uniform loss of height of a vertebral body that represents a diagnostic challenge for surgeons. The purpose of this study was to review all possible differential diagnoses that may present with a vertebra plana (VP) described in the current literature. For that purpose, we performed a narrative literature review in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, analyzing 602 articles. Patient demographics, clinical presentation, imaging characteristics and diagnoses were investigated. VP is not a pathognomonic feature of Langerhans cell histiocytosis, but other oncologic and non-oncologic conditions should be considered. The list of differential diagnoses, based on our literature review, can be recalled with the mnemonic HEIGHT OF HOMO: H-Histiocytosis; E-Ewing's sarcoma; I-Infection; G-Giant cell tumor; H-Hematologic neoplasms; T-Tuberculosis; O-Osteogenesis imperfecta; F-Fracture; H-Hemangioma; O-Osteoblastoma; M-Metastasis; O-Osteomyelitis, chronic.

Posterior Focal Curettage and Spine Stability Reconstruction by Temporary Pedicle Screw Fixation in Children With Collapsed Vertebrae due to Eosinophilic Granuloma

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To evaluate the efficacy of growth-preserving posterior spinal column reconstruction surgery in children with collapsed vertebral eosinophilic granuloma (EG).

METHODS

We retrospectively reviewed 15 confirmed cases of vertebral EG who met the inclusion and exclusion criteria from March 2015 to March 2018 in our hospital. The recovery of diseased vertebrae was assessed.

RESULTS

The cases were composed of 11 males and 4 females with a mean age of 74.3 ± 38.8 months. Nine cases presented with thoracic vertebral destruction, 6 cases with lumbar vertebral destruction. Under Garg's classification, 10, 3 and 2 cases were classified as Grade IIA, IB and IIB lesions, respectively. All patients had mild to moderate night-aggravated back pain and recovered at 1-week after surgery. Three patients had Frankel D neurologic symptoms and recovered at 1-week, 1-week and 4-weeks after surgery, respectively. Follow-up time after surgery ranged from 1.9 years to 4.5 years, with a mean of 2.9 years. The median vertebral height at 12 months after surgery was significantly higher than the preoperative height. Furthermore, the vertebral heights of all diseased vertebrae displayed significant recovery trends at 3, 6 and 12 months after surgical treatment. The percentages of vertebral height recovery to references at 12 months after surgery ranged from 34.7% to 92.5%, with an average of 71.2%.

CONCLUSIONS

In children with collapsed vertebral EGs, active surgical treatment is necessary to retain the ability to restore height and to reconstruct the spine stability.

First technical report of a pediatric case with thoracic Langerhans cell histiocytosis: Gross total tumor removal, corpectomy, and 360° stabilization via posterolateral approach at a single stage

Background:

Langerhans cell histiocytosis (LCH) is a rare nonmalignant disease characterized by a clonal proliferation of mononuclear cells called Langerhans histiocytes and infiltrates surrounding tissues, mostly self-limiting and usually occurring in the first two decades of life. Vertebral involvement is rare, mostly seen in the thoracic region, and involves the anterior elements of the corpus. In the literature, several treatment options and surgical approaches have been reported concerning the treatment of this disease and surgery.

Case Presentation:

We report an 18-month-old male with thoracic LCH who underwent surgery due to progressive neurological deficit. Gross total removal of the tumor with one level corpectomy in this patient was achieved via a posterolateral approach with postoperative functional improvement. The surgical cavity was supported by corpectomy cage and unilateral screw-rod fixation system at the same stage.

Conclusion:

Gross total tumor removal, corpectomy, and 360° stabilization via posterolateral approach at a single stage are safe, effective, and definite neurosurgical methods in terms of providing neurological recovery, long-term tumor-free survival, and spinal stability.

Langerhans Cell Histiocytosis With Vertebral Involvement Diagnosed and Treated Over the Last 15 Years in a Single Canadian Pediatric Academic Institution

We report 11 children with vertebral lesion of Langerhans cell histiocytosis (LCH) diagnosed and treated between 2000 and 2015. Vertebral lesions were usually present at LCH diagnosis. No child developed neurologic symptoms. Among 29 vertebral lesions, only 2 were unstable. Chemotherapy was used in all children but 3. A LCH recurrence was observed in 6 patients, involving vertebrae in 4 cases. All children were disease-free at their last follow-up. Sequelae were more often radiologic than clinical. Since potential recurrences and incomplete bone regeneration exist, discussion about optimal treatment and long-term follow-up of vertebral lesions are essential.

Characteristic Reconstitution of the Spinal Langerhans Cell Histiocytosis in Young Children

BACKGROUND

Pediatric Langerhans cell histiocytosis (LCH) often results in vertebral compression fracture. However, few reports have reported vertebral remodeling during the course of LCH. We aimed to investigate the longitudinal reconstitution and transformation of the affected vertebrae and the adjacent structures in young children with spinal LCH.

METHODS

We recruited 13 patients, including 16 affected vertebrae, diagnosed with LCH via biopsy. The average age at first visit was 3.6 years. The average follow-up period was 10.2 years. Vertebral lesions involved L2 in 3 cases; T12, L1, or L5 in 2 cases; and C4, C5, C7, T5, T8, T9, or L3 in 1 case. We measured the ratios of the height of the affected vertebra and 1 vertebra above the affected one to that of the second vertebra above the affected one, local kyphotic angles, and the ratio of the height of the center of the adjacent disk to that of one disk above it.

RESULTS

The collapse of the affected vertebra was most severe after 1 year of disease onset. The rate of reconstitution accelerated at 2 years or later of disease onset. The recovery speed of the anterior wall was faster than that of the center height. While the height of the affected vertebrae was restored, the thickness of the adjacent disk also increased. Further, the height of the adjacent vertebrae increased in a similar manner. The average local kyphosis angle shifted to lordosis within the first 3 years.

CONCLUSIONS

The heights of not only the disk but also the adjacent vertebra increased during the vertebral collapse phase in pediatric spinal LCH patients. These transformations may affect the realignment of the sagittal spinal balance at the earlier stage of the disease. During the collapse phase, the heights of the adjacent vertebrae and disks increase but after the affected vertebrae reconstituted, the augmentation of adjacent vertebrae and disks diminished.

LEVEL OF EVIDENCE

Level IV.

Spontaneous and complete regeneration of a vertebra plana after surgical curettage of an eosinophilic granuloma

PURPOSE

The eosinophilic granuloma is a unifocal or multifocal Langerhans cell histiocytosis characterized by an expanding proliferation of Langerhans cells in bones. Skeletal LCH is a rare condition, and vertebral regeneration in cases of vertebral body collapse is even rarer. We report the case of a girl with spontaneous complete healing.

METHODS AD RESULTS

A 3-year-old girl was referred for nighttime back pain, with no fever and no neurologic signs. Within a few days, she developed sudden painful restriction of all spine movements. X-ray and computed tomography (CT) of the spine showed reduced T7 vertebral body height (vertebra plana).The patient underwent T7 curettage and the histopathological exam was suggestive of LCH. Two additional skull lesions were found and therefore she underwent chemotherapy. After 7 years of follow-up, total vertebral reconstruction was observed.

CONCLUSIONS

Despite the rarity of the condition and despite the rarity of vertebral body lesion resolution, total vertebral body reconstruction was observed over a 7-year period. Long-term follow-up is necessary for a better understanding of the final outcome of patients with EG.

Current concepts for the diagnosis and management of eosinophilic granuloma of bone

This review summarizes current concepts in the diagnosis and management of the patients with eosinophilic granuloma. Given the benign biology, the clinical course, and the pediatric group of patients that this condition more commonly affects, a treatment approach that carries a lower risk of complications while ensuring a successful cure is desirable. Variable treatment options have been reported with satisfactory results and a recurrence rate of less than 20 %. In this setting, symptomatic lesions that are accessible in the spine or the extremities may be treated with intralesional methylprednisolone injection after tissue biopsy for histological diagnosis.

Primary osseous tumors of the pediatric spinal column: review of pathology and surgical decision making

Spinal column tumors are rare in children and young adults, accounting for only 1% of all spine and spinal cord tumors combined. They often present diagnostic and therapeutic challenges. In this article, the authors review the current management of primary osseous tumors of the pediatric spinal column and highlight diagnosis, management, and surgical decision making.

Surgical treatment of Langerhans cell histiocytosis of cervical spine: case report and review of literature

INTRODUCTION

Langerhans cell histiocytosis (LCH) is a rare condition, and even rare is cervical spine involvement.

CASE REPORT

A 9-year-old girl had neck pain, neck tilt and left upper limb weakness, occasional fever and positive family history of tuberculosis. Imaging showed C5 vertebral body collapse with epidural and prevertebral soft tissue collection causing cord and nerve root compression. The patient underwent C5 corpectomy and fusion. Histopathological was suggestive of LCH. She underwent radiotherapy and was asymptomatic at 1-year follow-up.

CONCLUSION

Despite the rarity of the condition, the possibility of LCH should be considered in such cases. When neurologic deficits are present, operative treatment should be considered.

Eosinophilic granuloma of the sacrum treated with radiation therapy: a case report

BACKGROUND CONTEXT

Eosinophilic granulomas (EGs) of the sacrum have been reported in fewer than 10 patients. Treatment algorithms for these tumors remain poorly defined; there are no reports of treating solitary sacral EG with radiation therapy (RT).

PURPOSE

This study aimed to describe the presentation, treatment, and outcome of sacral EG in an adult patient with intractable pain and radiculopathy, treated in a novel fashion with RT.

STUDY DESIGN/SETTING

The study design was a case report from a tertiary cancer referral center.

METHODS

Patient records, imaging, and pathology were reviewed.

RESULTS

A 35-year-old man received 20 Gy of radiation to his S1 EG lesion. He subsequently developed vertebra plana of S1 causing symptomatic L5-S1 stenosis, but 15 months after RT treatment was free of pain or tumor recurrence.

CONCLUSION

Radiation therapy is an effective treatment option for sacral EG causing severe axial pain and neural impingement.

Langerhans Cell Histiocytosis of the Temporal Bone with Otic Capsule Involvement

INTRODUCTION

This study is conducted to demonstrate that destructive lesions of the otic capsule by Langerhans cell histiocytosis (LCH) causing both radiographic and audiologic findings can be completely reversed with adequate treatment. Retrospective case review and analysis of clinical and imaging data were obtained as part of the diagnosis and treatment of patients with LCH of the temporal bone.

METHODS

With Institutional Review Board (IRB) approval, cases of LCH involving the temporal bone were searched for within the institutional databases. Criteria for inclusion was histologic diagnosis of LCH and pretreatment computed tomography (CT) demonstrating temporal bone and/or otic capsule involvement and posttreatment follow-up CT/magnetic resonance imaging (MRI) scans obtained at least 6 months after starting treatment.

RESULTS

We report eight cases of LCH of the temporal bone with three demonstrating otic capsule involvement radiographically and/or clinically. Review of posttreatment imaging revealed all three patients had complete restoration of the bony labyrinthine architecture and near or complete restoration of their hearing.

CONCLUSIONS

Though LCH of the temporal bone is a common site within the spectrum of the disease, involvement of the otic capsule remains rare. Here, we report the largest series of otic capsule involvement by LCH and investigate whether both architecture and hearing are recovered with appropriate treatment. Lastly, restoration of the bony architecture of the labyrinth suggests the mechanism of LCH is demineralization and not ablative.

Atlantoaxial instability secondary to eosinophilic granuloma of the axis in adults: long-term follow-up in six cases

BACKGROUND CONTEXT

Eosinophilic granuloma (EG) involving the spine is uncommon in adults. Atlantoaxial instability (AAI) secondary to EG of the axis in adults is an extremely rare clinical condition that can give rise to severe neurologic morbidity or mortality if not treated appropriately. There have been no previous reports on the condition in adults.

PURPOSE

To present the outcome and clinical experience for the management of AAI secondary to EG of the axis in adults.

STUDY DESIGN

A retrospective review study.

PATIENT SAMPLE

All adult patients with AAI secondary to EG of the axis who were admitted to the spine service at the study institution between January 1999 and April 2012.

OUTCOME MEASURES

Clinical symptoms, neurologic status, radiologic manifestations, treatment, outcome, and/or complications were recorded and analyzed.

METHODS

Six consecutive adults who presented clinical and radiographic manifestations of AAI secondary to EG of axis were treated and monitored. All patients were treated surgically with anterior tumor resection and posterior reconstruction of spinal stability. Oral steroid therapy was administered after surgery as adjuvant therapy.

RESULTS

The mean duration of follow-up was 77 months (range, 37-140 months). The most common radiographic feature was osteolytic destruction of the vertebral body of the axis. All patients had favorable recoveries, with osseous fusion. There were no surgery-related postoperative complications, and neither recurrence nor spinal deformity had occurred by the final follow-up examination.

CONCLUSIONS

Surgical intervention via anterior tumor resection and posterior reconstruction was found to be safe and effective for treating AAI secondary to EG in adults, in terms of recovering neurologic function, improving symptom relief, and reducing the risks resulting from osteolytic destruction. Surgical treatment plus oral steroid therapy can produce beneficial results and definitive local control during the follow-up period.

Surgical treatment based on pedicle screw instrumentation for thoracic or lumbar spinal Langerhans cell histiocytosis complicated with neurologic deficit in children

BACKGROUND CONTEXT

Surgical indications and procedures for spinal Langerhans cell histiocytosis (LCH) in children are still controversial. Reports containing large samples of surgically treated patients are few in the currently available literature, and the reported operative procedures were also somewhat obsolete. So, further investigation based on large-sample cases and using improved surgical techniques is beneficial and helpful to refine the treatment strategy.

PURPOSE

To recommend a reasonable treatment strategy for thoracic or lumbar spine LCH in children complicated with neurologic deficit.

STUDY DESIGN/SETTING

Retrospective/academic medical center.

PATIENT SAMPLE

Twelve children aged from 2 to 16 years old with the diagnosis of thoracic or lumbar spinal LCH accompanied by neurologic deficit received surgical treatment from January 2005 to January 2010.

OUTCOME MEASURES

Frankel scale for neurologic function, fusion of the mass, and recurrence of the lesion.

METHODS

All 12 patients presented initially with local pain and progressive neurologic detriment. Neurologic evaluation revealed two patients with Frankel Grade B, eight with Grade C, and two with Grade D. Radiographic features were positive for typical vertebra plana, a space-occupying mass in the spinal canal compressing neural elements, and a spinal canal encroachment rate more than 50%. Posterior instrumentation with pedicle screw combined with anterior corpectomy, decompression, and support bone graft was performed in the first seven patients as a one-stage procedure. In the remaining five patients, posterior pedicle screw fixation, laminectomy for decompression (via excision of the tumor-like mass), and repair of laminae with allograft bone block were performed. The collapsed vertebral body was left untouched. No chemotherapy or radiotherapy was administrated postoperatively in any of the cases.

RESULTS

The mean follow-up duration was 43.3 months. The mean operation time was 330 minutes with combined procedure and 142 minutes with single posterior approach (p=.000). The average blood loss was 933 mL with combined procedure and 497 mL with single posterior approach (p=.039). Three of seven patients who received combined surgery encountered approach-related complications, that is, one with intercostal neuralgia and two with pleural effusion. No severe neurologic deteriorate, instrumentation failure, or disease recurrence was detected at follow-up. Neurologic function completely recovered in all 12 patients from 2 to 12 weeks after surgery. The anterior bone graft fused and shaped well in all seven patients, and allograft bone block for lamina repair also achieved complete fusion in the remaining five patients. The internal fixator was removed at 3 to 5 years (average 4.1 years) after initial operation in six patients. No deformity, including scoliosis and kyphosis, has been identified during follow-up period in both procedures.

CONCLUSIONS

For spinal LCH patients, neurologic deficit is a main indication for operative treatment to prevent permanent and serious consequences. Surgery provides an opportunity for rapid recovery of neurologic function. Both combined and single-stage posterior approaches based on pedicle screw instrumentation techniques are similarly effective in relieving neurologic compression. However, single-stage posterior approach is more favorable with less complications, and preserving involved vertebral body is not a latent hazard of recurrence.

[Benign and semimalignant spinal tumors. Characteristics in children and adults]

Diagnostic radiology and magnetic resonance imaging (MRI) are the most important imaging tools in the evaluation of benign bone tumors. Computed tomography (CT) is an additional tool for bony lesions, such as in cases of confirmation of the diagnosis of osteoid osteomas. For benign bony lesions three-stage skeletal scintigraphy is an optional additional diagnostic tool. The identification of benign or semimalignant bone tumors is not always clear; therefore percutaneous biopsy is necessary in most cases. In benign spinal tumors an intralesional curettage with reconstruction and stabilization is sufficient. In cases of semimalignant tumors, e.g. giant cell tumors localized in the spine, an en bloc resection is necessary because of the high recurrence rate.

Primary atlantoaxial bone tumors in children: management strategies and long-term follow-up

OBJECT

Atlantoaxial tumors account for a substantial proportion of primary bone tumors in children. Before resection, surgeons must consider the complex regional anatomy, the potential for neurological compromise, craniocervical instability, and the question of tumor resectability in a growing spine. Using current technology, the authors analyzed surgical cases in this light and present outcomes and treatment recommendations after long-term patient follow-up.

METHODS

The authors reviewed clinical records for 23 children whose primary atlantoaxial bone tumors were treated from 1996 through 2010.

RESULTS

Pathological lesions among the 23 patients were 4 aneurysmal bone cysts, 2 osteochondromas, 5 chordomas, 4 osteoblastomas, 3 fibrous dysplasias, 4 eosinophilic granulomas, and 1 Ewing's sarcoma. Clinical presentation consisted of neck pain (n = 23), headaches and occipital pain (n = 16), myelopathy (n = 8), and torticollis (n = 4). Selective angiography and coil embolization were undertaken for all patients with aneurysmal bone cysts and osteoblastomas, 2 patients with chordomas, 1 patient with fibrous dysplasia, and 1 patient with Ewing's sarcoma. Primary embolization treatment of radiation-induced aneurysmal bone cyst of the atlas showed complete reossification. Results of CT-guided needle biopsy were diagnostic for 1 patient with eosinophilic granuloma and 1 with Ewing's sarcoma. Needle biopsies performed before referral were associated with extreme blood loss for 1 patient and misdiagnosis for 2 patients. Surgery involved lateral extrapharyngeal, transoral, posterior, and posterolateral approaches with vertebral artery rerouting. Complete resection was possible for 9 patients (2 with osteochondroma, 3 with fibrous dysplasia, 2 with chordoma, and 2 with osteoblastoma). Decompression and internal fusion were performed for 3 patients with aneurysmal bone cysts. Of the 23 patients, 7 underwent dorsal fusion and 4 underwent ventral fusion of the axis body. Chemotherapy was necessary for the patients with eosinophilic granuloma with multifocal disease and for the patient with Ewing's sarcoma. There was no morbidity, and there were no deaths. All patients with benign lesions were free of disease at the time of the follow-up visit (mean ± SD follow-up 8.8 ± 1.1 years; range 2-18 years). Chordomas received proton or LINAC irradiation, and as of 4-15 years of follow-up, no recurrence has been noted.

CONCLUSIONS

Because most atlantoaxial tumors in children are benign, an intralesional procedure could suffice. Vascular control and staged resection are critical. Ventral transoral fusion or lateral extrapharyngeal fusion has been successful. Resection with ventral fusion and reconstruction are essential for vertebral body collapse. Management of eosinophilic granulomas must be individualized and might require diagnosis through needle biopsy.

Langerhans cell histiocytosis of spine: a comparative study of clinical, imaging features, and diagnosis in children, adolescents, and adults

BACKGROUND CONTEXT

Langerhans cell histiocytosis (LCH) of the spine has been well documented in the literature, but most studies concern management of the disease. No focused report on the differences in clinical and radiographic features of spinal LCH among children, adolescents, and adults exists.

PURPOSE

To review and stress the clinical and imaging differences of spinal LCH in children, adolescents, and adults to avoid false diagnosis.

STUDY DESIGN

A retrospective study of children and adults with LCH of the spine.

PATIENT SAMPLE

Consecutive patients treated at our institution.

OUTCOME MEASURES

Visual analog scale for pain, Frankel scale for neurologic status, and X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) for imaging.

METHODS

Seventy-six patients with pathology-proven LCH involving the spine were treated at our institution between 1996 and 2010. Only patients with spine involvement pathologically and/or radiographically were included. Two groups were identified based on the age. Group I comprised children and adolescents (age <18 years; n=40) and Group II comprised adults (age ≥18 years; n=36). Analysis included age and gender distribution, clinical presentation, and imaging features and diagnosis. Pathologic diagnosis was performed by needle or open biopsy of the lesions.

RESULTS

Of the 76 patients, 55 were male and 21 were female (ratio of 2.62:1). Neck or back pain was the most common symptom in all patients and was the only presenting symptom in some patients. Restricted motion of spine was the most frequent symptom secondary to pain. Thirty-seven patients presented with neurologic symptoms. Adult patients were more likely to suffer neurologic deficits (p<.005). The distribution of lesions revealed predominance in the cervical spine, followed by thoracic and lumbosacral spine. Plain radiology of children and adolescents with spinal LCH usually revealed a typical vertebral plana, but the adult patients represented different severity of vertebral collapse without typical features. The images of CT scans between the two groups were similar, and all revealed lytic lesions in vertebral bodies and/or posterior elements. In Group I, lesions showed hypointense on T1-weighted images in 15 cases and isointense in 25 cases. Nineteen patients presented as intermediate to slight high signal on T2-weighted images, and the remaining patients presented as hyperintense on T2-weighted images. In Group II, lesions showed hypointense on T1-weighted images in 29 cases, isointense on T1-weighted images in seven cases, and hyperintense on T2-weighted images in 36 cases. Paraspinal soft tissue mass was detected in 28 and 23 cases in Group I and Group II, respectively. Fifteen children and adolescent patients versus 23 adult patients had epidural spinal cord compression. Oversleeve-like or dumbbell sign was observed in 21 cases in Group I but only in four cases in Group II.

CONCLUSIONS

The most common clinical manifestations of LCH of the spine were neck or back pain, followed by restricted motion of spine, neurologic symptoms, and deformity. Neurologic deficits were more frequent in adult patients. Vertebral plana is the typical imaging feature in children and adolescent patients but seldom in adults. Computed tomography is best for characterizing anatomy of the involved vertebra, and MRI is best for delineating marrow and soft tissue. The oversleeve-like sign on MRI may be a feature of spinal LCH as well as vertebra plana in children and adolescents. Needle biopsy under CT guidance should be performed before a treatment strategy is determined.

Langerhans cell histiocytosis case with dense metaphyseal band sign

Eosinophilic granuloma, a type of Langerhans cell histiocytosis, exhibits a classic vertebral collapse, which is called vertebra plana (Calve's disease) and it manifests as a solitary bony lesion. Vertebra plana can cause severe pain in patients. Bisphosphonates (clodronate, pamidronate and zoledronic acid) have been recently used to treat osteolytic bone lesions of LCH. Zoledronic acid has 100 times relative potency that of pamidronate. We report a case of a 10-year-old girl who had zoledronic acid treatment for severe back pain due to vertebra plana. X-ray photographs of the patient's body showed dense metaphyseal band sign, which can be found in lead poisoning, treated leukemia, healing rickets, recovery from scurvy, vitamin D hypervitaminosis, congenital hypothyroidism and hypoparathyroidism. Increased biological potent zoledronic acid deprived her of severe back pain due to vertebra plana and might cause dense metaphyseal band sign of her skeleton. Conclusion; We have cured the severe back pain of a 10-year-old girl case of eosinophilic granuloma with zoledronic acid. After that treatment, X-ray photographs of the patient's body showed dense metaphyseal band sign. There have been few such cases reported until now.

Paediatric spinal Langerhans cell histiocytosis requiring corpectomy and fusion at C7 and at Th8-Th9 levels

An 11-year-old girl was treated by corpectomy and anterior fusion because of the destruction of the C7 vertebral body. Pathological studies were not conclusive. The outcome was excellent, but 18 months later, she required thoracic corpectomy with anterior fusion owing to the impending kyphotic fracture of the Th8 vertebral body. Langerhans cell histiocytosis was now recognised and chemotherapy was given. 3 years later, the disease appears well controlled with normal shape of both the operated vertebral levels and maintenance of the movements of the adjacent vertebrae.

Langerhans cell histiocytosis of bone in children: a long-term retrospective study

Langerhans cell histiocytosis is rare and frequently involves the bone. We retrospectively reviewed the orthopaedic aspects (symptoms, localizations, treatments) and the long-term outcome [disease status, overall survival (OS), event-free survival (EFS)] of 121 patients (June 1968-December 2009). The main symptom was local pain. The orthopaedic treatment was mainly conservative. The most frequent localization was osseous monofocal (62% of monosystemic diseases). Monosystemic and osseous monofocal localizations, treatment after 1991 (OS, P=0.007; EFS, P=0.03) and age older than 2 years (OS, P=0.003; EFS, P=0.001) were prognostic factors that were positively associated with survival. Oncologic treatment has improved over time, translating into better survival. A biopsy is often mandatory.

[Langerhans cell histiocytosis causing cervical myelopathy]

Langerhans cell histiocytosis (LCH), a disorder of the phagocytic system, is a rare condition. Moreover, spinal involvement causing myelopathy is even rare and unusual. Here, we report a case of atypical LCH causing myelopathy, which was subsequently treated by corporectomy and fusion. An 8-year-old boy presented with 3 weeks of severe neck pain and limited neck movement accompanying upper and lower limbs motor weakness. CT scans revealed destruction of C5 body and magnetic resonance imaging showed a tumoral process at C5 with cord compression. Interbody fusion using anterior cervical plate packed by autologus iliac bone was performed. Pathological examination confirmed the diagnosis of LCH. After the surgery, the boy recovered from radiating pain and motor weakness of limbs. Despite the rarity of the LCH in the cervical spine, it is necessary to maintain our awareness of this condition. When neurologic deficits are present, operative treatment should be considered.

Does adjunctive chemotherapy reduce remission rates compared to cortisone alone in unifocal or multifocal histiocytosis of bone?

BACKGROUND

Langerhans cell histiocytosis (LCH) is a rare disorder that can affect almost any organ, including bone. Treatment options include local corticosteroid infiltration in isolated bone lesions and oral corticosteroids and chemotherapy in multifocal bone lesions. Several studies show local corticosteroid injection in unifocal bone lesions heal in more than 75% of patients with minimal side effects. Therefore, it is unclear whether chemotherapy adds materially to the healing rate.

QUESTIONS/PURPOSES

We therefore compared overall survival, remission rate, and recurrence rate in patients with bone LCH treated with chemotherapy and corticosteroids or corticosteroids alone.

METHODS

We retrospectively reviewed the records of 198 patients with LCH since 1950. Median age at diagnosis was 5 years, male-to-female ratio was 1.33, and the most frequent symptom was local pain (95%). We recorded the disease presentation, demographics, treatment, and clinical evolution of each patient. Minimum followup was 4 months (median, 24 months; range, 4-360 months).

RESULTS

The survival rate of the systemic disease group was 76.5% (65 of 85) while the survival rate in the unifocal and multifocal bone involvement groups was 100% at a median 5-year followup. All patients with unifocal bone involvement and 40 of 43 (93%) with multifocal bone involvement had complete remission. One of 30 patients with multifocal bone involvement treated with chemotherapy and oral corticosteroids did not achieve remission whereas two of six receiving only corticosteroids did not achieve remission.

CONCLUSIONS

Our observations suggest intralesional corticosteroid injection without adjunctive chemotherapy achieves remission in unifocal bone LCH but may not do so in multifocal single-system bone involvement. Larger series would be required to confirm this observation.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Eosinophilic granuloma presenting as post-traumatic scalp hematoma with epidural hemorrhage. A case report

Langerhans cell histiocytosis (LCH) encompasses a range of clinical presentations. Pure osseous involvement is referred to as eosinophilic granuloma (EG), whereas systemic involvement can either be classified as Hand-Schuller-Christian disease or Letterer-Siwe syndrome. It is estimated that of the total incidence of LCH (0.5 per 100,000 children per year in the United States), nearly 70% are categorized as EG (1). We describe a case of clinically occult calvarial eosinophilic granuloma brought to medical attention only after a traumatic event led to scalp and epidural hemorrhage at the site of the lesion. Osseous EG initially presents as a painful or tender mass, at times even mimicking osteomyelitis. Computed tomography (CT) reveals a lytic lesion with beveled edges. Magnetic resonance (MR) imaging is often non-specific, but usually demonstrates a marrow-replacing process that is T1 hypointense, T2 hyperintense, with homogenous enhancement. The complex MR imaging findings in our case provided a unique perspective regarding the presentation of EG. Once pathology established eosinophilic granuloma, skeletal survey confirmed the lesion was solitary, despite a compelling history of present illness.

CT-guided corticosteroid injection for solitary eosinophilic granuloma of the spine

OBJECTIVE

To evaluate the clinical and imaging outcome of patients with symptomatic eosinophilic granuloma of the spine treated with CT-guided intralesional methylprednisolone injection after biopsy.

MATERIALS AND METHODS

Patients (n =19) with symptomatic solitary eosinophilic granuloma of the spine treated by CT-guided intralesional methylprednisolone injection were retrospectively studied. There were 12 males and seven females with a mean age of 17 years (range, 3-43 years). The mean follow-up was 6 years (median, 4 years; range, 0.5-19 years). Spinal location included the cervical (two patients), thoracic (seven patients), lumbar spine (eight patients), and the sacrum (two patients). Vertebra plana was observed in two patients. All patients had biopsies before treatment.

RESULTS

Complete resolution of pain and healing of the lesion was observed in 17 patients (89.5%); none of these patients had recurrence at the latest examination. Reconstitution of the T1 and L1 vertebra plana was observed in both patients. Two patients initially diagnosed and treated for a solitary eosinophilic granuloma had constant pain after the procedure; in these patients, 6 and 12 months after the procedure, respectively, imaging showed multifocal disease and systemic therapy was administered. Complications related to the procedure were not observed. General anesthesia was administered in two patients because of intolerable pain during the procedure.

CONCLUSIONS

In view of the benign clinical course of eosinophilic granuloma, in patients with symptomatic lesions, CT-guided intralesional corticosteroid injection is a safe and effective outpatient treatment with a low complication rate.

Eosinophilic granuloma of spine in adults: a report of 30 cases and outcome

BACKGROUND

Eosinophilic granuloma (EG) of the spine is rare, especially in adults. There had been few large and long-term studies reported in the literature. The management goals of this disease in adults are preservation of neurologic function, relief of pain and reconstruction of spinal stability. However, there are still controversies over appropriate management modality of eosinophilic granuloma.

METHODS

Clinical manifestations, radiographic presentations, therapeutic outcomes and follow-up findings of 30 adults who were histiologically diagnosed with spinal eosinophilic granuloma, including 28 patients who received surgical treatment at our institutions from 1985 to 2008 were reviewed retrospectively.

RESULTS

There were 25 males and five females with a mean age of 34.5 years (range, 18-71 years). The post-operative follow-up period ranged from 2 to 22.4 years (mean, 8.3 years). Neurologic deficits developed in 21 patients, apparent kyphosis developed in four cases. In contrast to the classic feature of vertebra plana in children, we found that more severe lesions often led to asymmetric collapse in adult patients and only three patients presented with vertebra plana. Thirty-three vertebral lesions distributed throughout the spine column. Twenty-one lesions were in cervical spine, seven in the thoracic spine and five in the lumbar spine. Twenty-eight adult patients underwent surgical resection with or without chemotherapy or radiotherapy, and four (13.3%) patients had recurrence after surgery. No patient in our series died.

CONCLUSIONS

The onset of spinal EG is insidious and mainly presents as osteolytic destruction. There is a particular high prevalence of lesions in the cervical spine and more severe lesions often led to asymmetric collapse. As the skeleton of adults is well-developed and the epiphysis has stopped growing, individualized management including surgical intervention should be considered in adult patients with spinal EG who present with neurological damage and spinal instability.

Langerhans cell histiocytosis causing cervical myelopathy in a child

Langerhans cell histiocytosis (LCH), a disorder of the phagocytic system, is a rare condition. Moreover, spinal involvement causing myelopathy is even rare and unusual. Here, we report a case of atypical LCH causing myelopathy, which was subsequently treated by corpectemy and fusion. A 5-year-old boy presented with 3 weeks of severe neck pain and limited neck movement accompanying right arm motor weakness. CT scans revealed destruction of C7 body and magnetic resonance imaging showed a tumoral process at C7 with cord compression. Interbody fusion using cervical mesh packed by autologus iliac bone was performed. Pathological examination confirmed the diagnosis of LCH. After the surgery, the boy recovered from radiating pain and motor weakness of right arm. Despite the rarity of the LCH in the cervical spine, it is necessary to maintain our awareness of this condition. When neurologic deficits are present, operative treatment should be considered.

Langerhans cell histiocytosis with multiple spinal involvement

To stress the clinical and radiologic presentation and treatment outcome of Langerhans cell histiocytosis (LCH) with multiple spinal involvements. A total of 42 cases with spinal LCH were reviewed in our hospital and 5 had multifocal spinal lesions. Multiple spinal LCH has been reported in 50 cases in the literature. All cases including ours were analyzed concerning age, sex, clinical and radiologic presentation, therapy and outcome. Of our five cases, three had neurological symptom, four soft tissue involvement and three had posterior arch extension. Compiling data from the eight largest case series of the spinal LCH reveals that 27.2% multiple vertebrae lesions. In these 55 cases, there were 26 female and 29 male with the mean age of 7.4 years (range 0.2-37). A total of 182 vertebrae were involved including 28.0% in the cervical spine, 47.8% in thoracic and 24.2% in the lumbar spine. Extraspinal LCH lesion was documented in 54.2% cases, visceral involvement in 31.1% and vertebra plana in 50% cases. Paravertebral and epidural extension were not documented in most cases. Pathological diagnosis was achieved in 47 cases including 8 open spine biopsy. The treatment strategy varied depending on different hospitals. One patient died, two had recurrence and the others had no evidence of the disease with an average of 7.2 years (range 1-21) of follow-up. Asymptomatic spinal lesions could be simply observed with or without bracing and chemotherapy is justified for multiple lesions. Surgical decompression should be reserved for the uncommon cases in which neurologic compromise does not respond to radiotherapy or progresses too rapidly for radiotherapy.

Multiple lytic lesions of the spine: a rare diagnosis of eosinophilic granuloma in an adult: a case report

Eosinophilic granuloma (EG) is a rare benign osteolytic lesion observed rarely in adults, with only some 18 cases of spinal location reported in the literature. We present an unusual variant of EG in a 23-year-old man with radiological features of multiple spinal lytic lesions which was evocated of metastatic processes. A surgically transpedicular biopsy of the thoracic collapsed vertebrae with posterior stabilization was made. Histological examination of the tissue showed features of eosinophilic granuloma. The clinical and radiological findings of EG present dilemmas of both diagnosis and treatment. The etiology is unclear and the therapeutic approach is still controversial.

Langerhans cell histiocytosis of the cervical spine: a single Chinese institution experience with thirty cases

STUDY DESIGN

A retrospective study of cervical Langerhans cell histiocytosis (LCH).

OBJECTIVE

To evaluate the safety and efficiency of the present diagnosis and treatment strategy.

SUMMARY OF BACKGROUND DATA

The diagnosis and treatment protocols are still controversial for the rarity of cervical LCH.

METHODS

Thirty patients with cervical LCH were diagnosed in the past 10 years. Biopsy was routinely performed to establish the final diagnosis before treatment. Immobilization was usually the first choice. Low-dose radiotherapy was suggested for cases with solitary marked bony erosion and/or soft tissue extension, and chemotherapy for cases with multiple lesions. Surgery was preserved for suspected malignancy, neurologic deficits, severe deformity, and/or instability.

RESULTS

The mean age at diagnosis was 14.2 (range: 1.5-41) years old. Neck pain (96.7%) was the most common symptom, followed by restricted motion (70%), neurologic symptoms (36.7%), and torticollis (30%). Four cases had multiple lesions. Fourteen cases had atlantoaxial lesion and 16 cases were subaxial. The lesion extended to paravertebral soft tissue in 40% cases, to epidural space in 30%, to pedicle and/or transverse process in 56.3%. One case had endplate destruction. The accuracy of percutaneous needle biopsy under CT guidance was 91.2%. Eighteen patients had conservative treatment and 12 underwent operation. Three cases involving C2 vertebral body had fixed atlantoaxial anterior dislocation. Another 3 cases with atlantoaxial lateral mass destruction had spontaneous fusion. Eighteen patients had conservative treatment (1 only by immobilization, 13 by radiotherapy, 2 by chemotherapy, and 2 by combined chemotherapy and radiotherapy) and 12 underwent operation. All the initial symptoms were resolved, and there was no recurrence. From retrospective view, the surgical procedure might be avoided in 60% cases. Twenty-five cases had an average 61.6-month follow-up. In cases with severe bony collapse, the vertebral height ratio increased from 20.0% to 44.9% and the lateral mass height ratio from 22.2% to 56.8%.

CONCLUSION

Cervical LCH lesions often extend to paravertebral soft tissue, epidural space, pedicles, and even to the endplate and lamina. Needle biopsy under CT guidance is safe and effective. The prognosis of cervical LCH is generally fair. Conservative treatment is usually enough and surgery should be reserved for major neurologic defects like myelopathy or monoparesis.

Management of eosinophilic granuloma occurring in the appendicular skeleton in children

Background

We compared indomethacin therapy with the more aggressive approaches of anti-cancer chemotherapy and surgery in the treatment of isolated Langerhans cell histiocytosis (LCH) of bone in children.

Methods

Comparisons were made with respect to healing of the lesion without recurrence, time to radiological healing of the lesion, time to functional recovery, and complications related to treatment.

Results

Complete radiologic healing of the lesion (mean, 15.3 months) and functional recovery (mean, 5.6 months) were observed in all patients treated with either approach. No significant differences were noted in the time to complete radiologic healing or the time to functional recovery between the two groups. There were no recurrences with either approach until the last follow-up (mean, 56 months). Complications were common with anti-cancer chemotherapy, but indomethacin was well-tolerated.

Conclusions

Indomethacin seems to be effective for treating isolated LCH of bone in children. Hence, morbidities associated with aggressive treatment approaches such as anti-cancer chemotherapy or surgery can be avoided.

Primary musculoskeletal Langerhans cell histiocytosis in children: an analysis for a 3-decade period

BACKGROUND

Langerhans cell histiocytosis (LCH) is a rare group of disorders of unknown etiology with a wide spectrum of clinical presentation. We sought to identify what, if any, has changed in the past 3 decades. This review outlines the current concepts in etiology and molecular biology, clinical manifestations, imaging features, treatment guidelines, and outcomes for skeletal LCH.

METHODS

A database of LCH cases diagnosed at a tertiary referral center during a 3-decade period was retrospectively reviewed to identify children with primary bone involvement. All patients' charts and available imaging examinations were reviewed, and the data collected included sex, age, number and location of the musculoskeletal lesions, presence of extraskeletal lesions and/or systemic disease, presence of clinical symptoms, treatment (medical and/or surgical), complications, and outcomes.

RESULTS

Seventy-nine children met the inclusion criteria. Forty-five (57%) of the 79 children had single-bone disease, with a mean age at presentation of 8.9 years, whereas 34 (43%) of the 79 children presented with multiple skeletal lesions (range, 2-7 lesions) at a mean age of 7.4 years. There were 165 skeletal lesions in the 79 patients (mean, 2 lesions per patient). The most common presenting symptom was pain at the lesion site (63 patients, 79%). On imaging, the lesion usually presented as a well-defined, radiolucent lesion located within the diaphysis or metaphysis. Among children with single-bone involvement, 11 underwent observation and symptomatic treatment, 17 had biopsy followed by observation and symptomatic treatment, and 17 had biopsy followed by excision. Eight children also received chemotherapy, and 2 had radiation (early in the series). Among children with multiple-bone disease, 10 underwent biopsy followed by symptomatic treatment, 24 underwent biopsy, followed by chemotherapy, and 3 also received radiation (early in the series).

CONCLUSION

There is variability of presentation in musculoskeletal LCH. Biopsy is usually indicated for diagnostic confirmation. Although the natural history for most lesions is of gradual healing, curettage and grafting are sometimes indicated to accelerate the healing process. Internal fixation for stability is occasionally necessary. Chemotherapy is used for multisystemic disease, and radiotherapy is no longer used.

Primary bone tumors of the spine in children

OBJECT

Tumors originating in the vertebrae in children are difficult to treat. In this paper the authors sought to evaluate the decision-making process and outcome of surgical intervention in this population given the complex issues of spinal stability, continued skeletal growth, intraoperative blood loss, and long-term outcome.

METHODS

To select patients for this study, the authors retrospectively reviewed medical records and images at the University of Iowa Hospitals and Clinics between 1996 and 2005. Their inclusion criteria were age younger than 18 years at the time of diagnosis and histopathological findings confirming that the tumor originated from vertebral bone. Sixteen patients met these requirements. In addition, the authors conducted a comparison with 45 patients in whom similar diagnoses were made prior to 1996. Gross-total resection of all nonmetastatic primary bone tumors is desired, as exemplified in 11 patients in this series; biopsy sampling only was performed in two others. Gross-total resection was also not performed in three patients with eosinophilic granuloma (EG). These three patients underwent nonsurgical treatment, which is different from how patients with EG were treated in the earlier study. Nine histopathological diagnoses were included; with a mean follow-up period of 3.7 years, the survival rate is 94%. The tumor recurred in one patient with a giant cell tumor of the sacrum. The authors performed preoperative tumor embolization and found that it was a useful adjunct to resection. Provocative testing prior to embolization was part of the protocol to reduce ischemic complications. Motion-sparing surgical procedures were performed in which a few segments were fused, preserving axial mobility.

CONCLUSIONS

Overall, early intervention offers the best symptomatic relief, which can only be rendered if sufficient clinical suspicion provokes early diagnostic imaging.

Eosinophilic granuloma in the pediatric spine

BACKGROUND/AIMS

Eosinophilic granuloma (EG) involving the vertebrae in the pediatric population presents a difficult management scenario. Issues of surgical versus nonsurgical intervention, spinal stability and continued skeletal growth must all be considered.

METHODS

A retrospective review of medical records and radiographs from 1964 to the present yielded 12 patients with age less than 18 at the time of diagnosis of primary spinal EG.

RESULTS

Eleven of these 12 patients presented with pain; 2 patients had neurological deficits. Nine patients were managed nonsurgically, including those undergoing tissue diagnosis by needle (2) or extraspinal (3) biopsy; 3 patients underwent gross total resections. Radiographic diagnosis alone was made in 4. With an average follow-up of 8.1 years, survival is 100%.

CONCLUSIONS

EG in the spine infrequently produces neurological deficits in the pediatric age group, although it may result in spinal instability. As such, nonsurgical management is the preferred strategy to effect symptomatic relief.

Multifocal Langerhans cell histiocytosis of the pediatric spine: a case report and literature review

CASE REPORT

An 11-month-old boy presented with a 3-month history of lower extremity weakness. CT and MRI of the spine revealed an enhancing epidural mass, extending from T1 through T5 and exiting through multiple foramina. The largest extraspinal extent was located at the T3 vertebral level and was accompanied by complete T3 vertebral collapse. A second lytic lesion at the L2 vertebral body without an obvious enhancing mass was also noted. Open biopsy and decompression of the spinal cord were performed, and histopathological analysis revealed a mixed inflammatory lesion with abundant S-100 and CD1a immunoreactive Langerhans cells consistent with the diagnosis of Langerhans cell histiocytosis (LCH).

DISCUSSION

The authors present a very rare pediatric case of spinal LCH causing spinal cord compression. Possible clues to early detection, consideration of differential diagnoses, and a brief literature review are presented.

Bone tumors at the cranio-cervical junction. Surgical management and results from a series of 41 cases

BACKGROUND

Bone tumors located at the cranio-cervical junction (CCJ)are rare. Tumoral involvement of the neighbouring structures including bone, nerves and vertebral artery and the dynamic aspects of the bone structures raise technical difficulties in the surgical approach. The surgical management includes tumoral resection and stabilization of the CCJ.

METHODS

Forty-one patients presenting a bone tumor (26 benign and 15 malignant tumors), excluding chordomas, located at the CCJ (including lower third of the clivus, C1 and C2) were observed over 20 years from 1981 to 2001. Imaging work-up included CT scanner with bone windows sequences and reconstruction in the coronal and sagittal plane; since 1984 most of the patients (N=35) underwent a MRI and angioMR scanning. Vertebral angiography was rarely performed (N=9) and mostly when the diagnosis was doubtful. In some cases the diagnosis was clear but in others, imaging studies showed destructive lesions suggesting a malignancy, which sometimes required a biopsy (N=4). The surgical resection was only performed through a lateral approach.

FINDINGS

Complete resection was achieved in 38 cases while in 3 cases a small remnant was left behind. A complementary stabilization procedure was necessary in 18 cases using either bone grafting during the same procedure and through the same approach (N=5) or a craniocervical plating and bone grafting (N=13). No recurrence in the group of benign tumors was seen during an average follow-up of 6 years (from 2 to 11 years). The pre-operative symptoms of pain and neck stiffness, improved or disappeared in most patients. Three patients with lower cranial nerves (N=2) or sphincter disturbances (N=1) remained unchanged. One patient with tetraplegia eventually died.

CONCLUSIONS

Various types of bone tumors may be found at the CCJ. Confusion between benign and malignant tumor or pseudo tumors must be avoided, sometimes requiring a biopsy. Surgery using a lateral approach, usually permits the surgeon to achieve a complete resection either preserving the stability of the CCJ whenever intact or associated with a stabilization procedure.

Signal intensity changes on MRI during the healing process of spinal Langerhans cell granulomatosis: report of two cases

Two patients with spinal Langerhans cell granulomatosis were followed by magnetic resonance imaging, and the observed signal changes were detailed. Both patients had no neurologic abnormalities but back pain. They were treated by immobilization with a brace and bed rest. Their back pain disappeared after about a month. At the first visit, the tumorous lesions involving vertebrae showed mainly low signal intensity on T1-weighted imaging (T1WI) and high intensity on T2-weighted imaging (T2WI). They were clearly enhanced by gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA). Their original intensities changed to iso-intensities on both T1WI and T2WI without enhancement by Gd-DTPA after a year. These signal changes might indicate the healing stage of the involved vertebrae and recommend the removal of the spinal brace.

Langerhans cell histiocytosis of the spine in children. Long-term follow-up

BACKGROUND

Langerhans cell histiocytosis causes destructive lesions in a child's spine. Few large, long-term studies have evaluated the clinical and radiographic presentation, natural history, outcomes of modern treatment approaches, and maintenance of normal spinal growth and stability after the diagnosis of this disease in children.

METHODS

Twenty-six children with biopsy-proven Langerhans cell histiocytosis involving the spine were treated at our institution between 1970 and 2003. They had a total of forty-four involved vertebrae (twenty cervical, fourteen thoracic, and ten lumbar). Vertebral body collapse was measured on radiographs and classified as grade I (0% to 50% collapse) or grade II (51% to 100% collapse) and subclassified as A (symmetric collapse) or B (asymmetric collapse). Lesions of the posterior elements of the spine were classified as grade III. Twenty-three children were followed for two years or more (mean, 9.4 years), and the analyses of treatment and long-term outcomes were performed in that group of patients.

RESULTS

There was a predominance of lesions in the cervical spine (p </= 0.02). Sixteen (62%) of the twenty-six children were found to have multifocal skeletal disease. Cervical and lumbar lesions were more commonly associated with multilevel spinal disease. The extent of the initial collapse seen radiographically was grade IA for twenty vertebrae, IB for three, IIA for ten, IIB for nine, and III for two. Grade-I lesions were more likely to be associated with symmetric collapse than were grade-II lesions. Spinal deformity developed in four children, and two later required spinal fusion. No relationship was observed between the grade of the initial collapse and the subsequent development of spinal deformity. Despite heterogeneous treatment, all patients were alive and well with resolution of all presenting signs and symptoms and no evidence of active disease at the time of the most recent follow-up.

CONCLUSIONS

We found a particularly high prevalence of lesions in the cervical spine and a high prevalence of multiple skeletal lesions. In contrast to the classic finding of vertebra plana, we found that more severe lesions often led to asymmetric collapse; yet, asymmetric collapse was not found to be associated with the development of subsequent spinal deformity. The natural history of these lesions in the spine in the absence of systemic disease or spinal deformity is such that aggressive surgical management is usually not indicated; only follow-up is necessary to monitor recovery and spinal balance.

An atypical presentation of Langerhans cell histiocytosis of the cervical spine in a child

STUDY DESIGN

A case report of a child with Langerhans cell histiocytosis of the posterior elements of the cervical spine treated conservatively and with long-term follow-up is described.

OBJECTIVES

To describe the unique diagnostic and therapeutic challenges of treating Langerhans cell histiocytosis located atypically in the posterior elements of the spine.

SUMMARY OF BACKGROUND DATA

Langerhans cell histiocytosis involves the spine in approximately 20% of children with the disease. In nearly 95% of cases, spinal Langerhans cell histiocytosis results in destruction of the vertebral body, sparing the posterior elements. Confident diagnosis of vertebral body lesions is often made based on plain radiographs and MRI; however, the diagnosis of posterior element disease is not so straight forward. The natural history of isolated skeletal Langerhans cell histiocytosis is benign in most cases.

METHODS

The clinical and radiographic presentation of a child with Langerhans cell histiocytosis involving the posterior elements of C3 is described. A soft tissue mass was observed on magnetic resonance imaging; however, a biopsy confirmed the benign diagnosis of Langerhans cell histiocytosis. No further surgical treatment was needed, and conservative therapy incorporating a short course of cervical bracing and low-grade chemotherapy was begun.

RESULTS

Within a year, reconstitution of the posterior elements of C3 was apparent on radiographs. By 9 years after diagnosis, the child had near full reconstitution of the posterior elements of C3 and resolution of anterior pseudosubluxation of C3 on C4 that was present at diagnosis. Although diagnosis of Langerhans cell histiocytosis was made difficult by an atypical location in the posterior elements of the spine, after biopsy, conservative treatment led to excellent vertebral reconstitution.

CONCLUSIONS

Isolated involvement of the posterior spine in Langerhans cell histiocytosis has not been described in detail previously. The reported case illustrates the diagnostic challenges of isolated posterior spine Langerhans cell histiocytosis. Despite an unusual presentation, posterior spine Langerhans cell histiocytosis should be treated conservatively in a similar manner to anterior lesions.

[Eosinophilic granuloma of the cervical spine: case report]

Eosinophilic granuloma (EG) is a benign condition of histocytes proliferation localized or multifocal. It is presents in the cervical spine in 1.5%-20% of the cases of EG. We report the case of a seven-year-old girl that presented with a one month history of cervical pain, persistent wryneck and vicious posture of the neck. A computerized tomography was performed and confirmed the presence of spreading lesion, ostheodestructive to the level of the left laminae of C2, with invasion of the spine and the muscular tissue. A laminectomy was underwent for removal of the lesion. The patient had a good post-operative recovery with improvement of the symptoms. Chemotherapy with prednisone, vinblastine and ethoposide was administred. After six months, this protocol was repeated associaded to methotrexate. The patient improved and had no new symptoms in a follow-up of 36 months.