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Ezeokoli EU, Smith T, Mitchell P, Schlehr E, Borici N, Montgomery N. Presentation, treatment, and outcomes of unifocal and multifocal osseous vertebral Langerhans cell histiocytosis lesions in patients under 18 years old. J Pediatr Orthop B 2024; 33:274-279. [PMID: 37278277 DOI: 10.1097/bpb.0000000000001099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Ekene U Ezeokoli
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
- Department of Orthopedic and Scoliosis Surgery, Texas Children's Hospital, Houston, Texas
| | - Tyler Smith
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | | | - Eva Schlehr
- University at Buffalo Jacobs School of Medicine, Buffalo, New York
| | - Neritan Borici
- Department of Orthopedic and Scoliosis Surgery, Texas Children's Hospital, Houston, Texas
| | - Nicole Montgomery
- Department of Orthopedic and Scoliosis Surgery, Texas Children's Hospital, Houston, Texas
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
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Angelini A, Mosele N, Gnassi A, Baracco R, Rodà MG, Cerchiaro M, Ruggieri P. Vertebra Plana: A Narrative Clinical and Imaging Overview among Possible Differential Diagnoses. Diagnostics (Basel) 2023; 13:diagnostics13081438. [PMID: 37189540 DOI: 10.3390/diagnostics13081438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 05/17/2023] Open
Abstract
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.
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Affiliation(s)
- Andrea Angelini
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Nicolò Mosele
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Andrea Gnassi
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Riccardo Baracco
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Maria Grazia Rodà
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Mariachiara Cerchiaro
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Pietro Ruggieri
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
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Moscinksi N, Sullivan PZ, Gokaslan ZL. Benign primary bone tumors, long-term management into adulthood. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2022.101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Zheng Y, Zhang Z, Wang D. Better vertebrae remodeling in pediatric spinal eosinophilic granuloma patients treated with kyphoplasty and short-term posterior instrumentation: A minimal two-year follow-up with historical controls. Front Pediatr 2022; 10:922844. [PMID: 36507140 PMCID: PMC9727175 DOI: 10.3389/fped.2022.922844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To assess the validity and safety of kyphoplasty combined with short-term posterior instrumentation to treat children with vertebrae plana due to eosinophilic granuloma (EG). PATIENTS AND METHODS Clinical data of EG patients, who received kyphoplasty and short-term instrumentation from March 2019 to March 2020, were retrospectively reviewed. The recovery of diseased vertebrae was assessed and compared with historical case data. RESULTS Nine patients with EG had received kyphoplasty and short-term posterior instrumentation. The mean age at initial treatment was 66.7 months old (range, 28-132 months). The average number of follow-up months was 26.7. (range, 24-30 months).Four and 5 cases presented with thoracic and lumbar vertebral destruction, respectively. Under Garg's classification, 7 and 2 cases were classified as Grade IIA and IIB, respectively. The average diseased vertebral heights at 1-year and 2-year after surgery were significantly higher than the preoperative heights. The average percentages of diseased vertebral heights to references at 1-year and 2-year after surgery were 72.0% and 86.0%, respectively. The average percentage of diseased vertebral heights to the references at 2-year after surgery was significantly higher than that of the historical cases at the same time. No minor or major adverse events were observed. CONCLUSIONS Transpedicular balloon kyphoplasty for the direct restoration of vertebrae plana seems feasible and safe in combination with short-term posterior instrumentation. Better short-time vertebrae remodeling was observed 2 years after surgery. Active surgical treatment is suggested for children who have vertebrae plana as a result of EG in order to maintain the ability to recover vertebral height.
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Affiliation(s)
- Yiming Zheng
- Department of Pediatric Orthopaedics, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Zhiqiang Zhang
- Department of Pediatric Orthopaedics, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Dahui Wang
- Department of Pediatric Orthopaedics, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
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Abstract
BACKGROUND Vertebra plana in children is a diagnostic dilemma for orthopaedic surgeons. This radiographic finding sometimes has been said to be pathognomonic for eosinophilic granuloma (Langerhans cell histiocytosis); however, vertebra plana may also be caused by a range of other conditions. We sought to determine whether vertebra plana can be associated with malignancies other than eosinophilic granuloma. QUESTIONS/PURPOSES (1) To report the underlying diagnoses for children with vertebra plana and determine how frequently these patients were found to have eosinophilic granuloma as opposed to an underlying malignant process, (2) to evaluate the occurrence of nondiagnostic results on biopsy, and (3) to determine whether the presenting characteristics of spinal lesions were associated with the ultimate clinical diagnosis. METHODS As part of a retrospective review, our institutional electronic medical record was searched for all patients younger than 18 years between 1976 and 2017 whose clinical record included the term vertebra plana. Patients with trauma were excluded. Twenty-seven patients met the inclusion criteria (mean [range] age 9 years [0 to 18]; 12 girls). To address our first research purpose about the underlying diagnoses of patients with vertebra plana, we reviewed the final clinical diagnosis. To address our second research purpose about the utility of biopsy, we reviewed which patients underwent a biopsy and whether it had been diagnostic. To address our third research purpose about the radiographic criteria, we classified the radiographs and compared this to the clinical diagnosis. Vertebral collapse was described as less than 50% collapse, 50% to 100% collapse, symmetrical, and asymmetrical. The location of each lesion was noted. RESULTS Twelve of 27 patients had a diagnosis of eosinophilic granuloma. Six of 27 had other neoplastic etiologies, including acute lymphoblastic leukemia, primary germ cell tumor, giant cell tumor, rhabdomyosarcoma and teratoma. Seventeen of 27 patients underwent biopsy to confirm the diagnosis; six biopsies were consistent with eosinophilic granuloma, six for other etiologies, and five were nondiagnostic. With the limited patient numbers available, there was no difference in the frequency of less than 50% loss of height or 50% to 100%, or symmetric and asymmetric loss of height, and location of the lesion among patients with eosinophilic granuloma and those with other diagnoses. CONCLUSIONS Eosinophilic granuloma or Langerhans cell histiocytosis is a common cause of vertebra plana, but other causes must be considered in children presenting with this radiographic finding. Six of 27 of patients presenting to our center with vertebra plana had an underlying neoplasm other than eosinophilic granuloma. With the limited patient numbers available, pain, spinal location, and the degree and symmetry of collapse were not associated with a diagnosis of eosinophilic granuloma in this series. Thus, patients presenting with vertebral plana and back pain need a comprehensive work-up and potentially tissue biopsy to determine diagnosis and appropriate treatment. LEVEL OF EVIDENCE Level IV, diagnostic study.
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Rustagi T, Schwab JH, Iwenofu H, Mendel E. Overview of the management of primary tumors of the spine. Int J Neurosci 2020; 132:543-557. [PMID: 32942943 DOI: 10.1080/00207454.2020.1825423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
STUDY DESIGN Narrative review. OBJECTIVE To provide a narrative review for diagnosis and management of Primary spine tumors. METHODS A detailed review of literature was done to identify relevant and well cited manuscripts to construct this narrative review. RESULTS Primary tumors of the spine are rare with some racial differences reported. There are numerous adjuvant technologies and developments that influence the way we currently manage these tumors. Collimated radiation allows for heavy dosage to be delivered and have been reported to give good local control both as an adjuvant and neoadjuvant setting. These have made surgical decision making even more intricate needing a multicentric approach. Dedicated care has been shown to significantly improve health quality of life measures and survival. CONCLUSION While, it is beyond the scope of this paper to discuss all primary tumors subtypes individually, this review highlights the developments and approach to primary spine tumors.
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Affiliation(s)
- Tarush Rustagi
- Department of Neurosurgery, The Ohio State University and Wexner Medical Center, The James Cancer Hospital and Solvo Research Institute, Columbus, OH, USA.,Department of Orthopedics and Spine Surgery, Indian Spinal Injuries Centre, New Delhi, India
| | - Joseph H Schwab
- Department of Orthopedic Oncology, Massachusetts General Hospital, Boston, MA, USA.,Department of Orthopedics, Harvard Medical School, Boston, MA, USA
| | - Hans Iwenofu
- Division of Soft Tissue & Bone Pathology, Department of Pathology & Laboratory Medicine, The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solvo Research Institute, Columbus, OH, USA
| | - Ehud Mendel
- Department of Neurosurgery, The Ohio State University and Wexner Medical Center, The James Cancer Hospital and Solvo Research Institute, Columbus, OH, USA
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Langerhans Cell Histiocytosis With Vertebral Involvement Diagnosed and Treated Over the Last 15 Years in a Single Canadian Pediatric Academic Institution. J Pediatr Hematol Oncol 2020; 42:222-227. [PMID: 30855315 DOI: 10.1097/mph.0000000000001439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Heinrich C, Gospodarev V, Kheradpour A, Zuppan C, Douglas CC, Minasian T. Benign Giant Cell Lesion of C1 Lateral Mass: A Case Report and Literature Review. Brain Sci 2019; 9:brainsci9050105. [PMID: 31071908 PMCID: PMC6562483 DOI: 10.3390/brainsci9050105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 02/02/2023] Open
Abstract
Primary osseous tumors of the spinal column account for approximately 1% of the total number of spinal tumors found in the pediatric patient population. The authors present a case of a C1 benign giant cell lesion that was incidentally found in a 15-year-old patient. A transoral biopsy was performed followed by treatment with denosumab, with definitive management in the form of transoral tumor resection with subsequent occiput-cervical three posterior instrumented fusion. The patient tolerated all of the procedures well, as there were no post-operative complications, discharged home neurologically intact and was eager to return to school when assessed during a follow-up visit in clinic. Osteolytic lesions affecting the cervical spine are rare in the pediatric population. It is of utmost importance to have sufficient background knowledge in order to formulate a differential diagnosis, as well as an understanding of principles underlying surgical techniques required to prevent occipital-cervical instability in this patient population. The information presented will guide surgical decision-making by identifying the patient population that would benefit from neurosurgical interventions to stabilize the atlantoaxial junction, in the context of rare osteolytic conditions affecting the cervical spine.
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Affiliation(s)
| | - Vadim Gospodarev
- Center for Perinatal Biology, Department of Basic Sciences, Loma Linda University, 11234 Anderson Street, Room 2567, Loma Linda, CA 92354, USA.
| | - Albert Kheradpour
- Department of Pediatric Hematology/Oncology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA 92354, USA.
| | - Craig Zuppan
- Department of Pathology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA 92354, USA.
| | - Clifford C Douglas
- Department of Neurosurgery, Loma Linda University Medical Center, 11234 Anderson Street, Room 2556, Loma Linda, CA 92354, USA.
| | - Tanya Minasian
- Department of Neurosurgery, Loma Linda University Medical Center, 11234 Anderson Street, Room 2556, Loma Linda, CA 92354, USA.
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Abstract
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.
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Lan ZG, Richard SA, Lei C, Ju Y. Thoracolumbar Langerhans cell histiocytosis in a toddler. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2017.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Sparacello VS, Roberts CA, Kerudin A, Müller R. A 6500-year-old Middle Neolithic child from Pollera Cave (Liguria, Italy) with probable multifocal osteoarticular tuberculosis. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2017; 17:67-74. [PMID: 28521913 DOI: 10.1016/j.ijpp.2017.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 01/11/2017] [Accepted: 01/14/2017] [Indexed: 06/07/2023]
Abstract
Clear skeletal evidence of prehistoric tuberculosis (TB) is rare, especially in children. We describe and differentially diagnose the pathological changes displayed by a five-year-old child, Pollera 21 (PO21) dated to the Middle Neolithic of Liguria (Italy), or 5740±30 BP (Beta-409341; 6635-6453cal BP, 2σ, OxCal 4.2). PO21 shows a number of osteoarticular lesions, mainly of a lytic nature with very little bone proliferation: the vertebral column, the shoulder and pelvic girdles, and the ribcage are involved. Given the nature and pattern of the lesions, we propose a diagnosis of multifocal (or multiple) bone TB. Attempts to detect TB aDNA through molecular analysis gave negative results, but this alone is not sufficient to prove that PO21 was not infected with TB. The lesions observed in PO21 share similarities with other published evidence, such as spinal and joint involvement, and disseminated cyst-like lesions. Conversely, PO21 does not show diffuse bone deposition, such as hypertrophic osteoarthropathy (HOA) or endocranial modifications such as serpens endocrania symmetrica (SES). PO21 adds to our knowledge of patterns of TB manifestation in archaeological skeletal remains, which is especially important considering the variability in types and patterns of osteoarticular lesions seen today in people with TB.
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Affiliation(s)
- Vitale S Sparacello
- Department of Archaeology, Durham University, Durham DH1 3LE, United Kingdom; UMR5199 PACEA, Univ. Bordeaux, Batiment B8, Avenue Geoffroy Saint Hilaire, CS 50023, 33615, Pessac Cedex, France.
| | - Charlotte A Roberts
- Department of Archaeology, Durham University, Durham DH1 3LE, United Kingdom
| | - Ammielle Kerudin
- Manchester Institute of Biotechnology, Faculty of Life Sciences, The University of Manchester, 131 Princess Street, Manchester M1 7DN, United Kingdom
| | - Romy Müller
- Manchester Institute of Biotechnology, Faculty of Life Sciences, The University of Manchester, 131 Princess Street, Manchester M1 7DN, United Kingdom
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Management of eosinophilic granuloma in pediatric patients: surgical intervention and surgery combined with postoperative radiotherapy and/or chemotherapy. Childs Nerv Syst 2017; 33:583-593. [PMID: 28247113 DOI: 10.1007/s00381-017-3363-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Eosinophilic granuloma (EG) of spine in pediatric patients presents kinds of clinical manifestation and a difficult management scenario. The choice of treatment, issues of surgical intervention versus conservative treatment, combination therapy or single treatment, all these factors, including neurological deficits, spinal stability, long-term complications, and continued skeletal growth, must be considered. METHODS From 2008 to the 2015, 31 pediatric patients of spinal EG were retrospectively reviewed. They were 17 males and 14 females, with a mean age 8.89 ± 2.84 years old (range, 3.5-14 years old). All the cases were divided into two groups. Twenty-three cases (Group S) accepted surgical interventions and surgery combined with local low-dose radiotherapy and/or chemotherapy. Eight patients (Group C) accepted radiotherapy and/or chemotherapy. All the patients had imaging studies of the lesion including standard radiography, three-dimensional computed tomography (CT) scan, and magnetic resonance imaging (MRI) prior to and after treatment. Cases in group S underwent surgery-related treatment, which include six patients accepted surgery only, nine patients accepted postoperative low-dose radiotherapy, four patients accepted additional chemotherapy, and four patients accepted both. Cases in group C accepted radiotherapy and/or chemotherapy, which include five patients accepted radiotherapy, one patient accepted chemotherapy, and two patients accepted both radiotherapy and chemotherapy. Clinical symptoms, neurologic status, radiologic manifestations, treatment, outcome, and/or complications were recorded and analyzed. RESULTS All the 31 patients had pain relief (both in group S and group C) but the patients in group S obtained more prompt pain relief. All the patients in group S obtained local kyphosis correction, reconstruction of stability of spine, and recovery of neurological deficit after treatment. They have no surgery-related complications after treatment and in follow-up. Seventeen patients who received additional postoperative radiotherapy and/or chemotherapy also had good outcomes. There were no severe radiation and chemotherapy complications in procedure. The patients (group C) who accepted non-surgical treatment also have no severe complications, and a new femur lesion was found in one patient in follow-up. CONCLUSION Surgical intervention, including anterior and/or posterior approach with bone graft or surgery combined with postoperative low-dose radiotherapy and/or chemotherapy is a safe and effective way for treatment of the spinal EG. Compared with radiotherapy and/or chemotherapy, more prompt pain relief can be achieved via surgical intervention or surgery combined radiotherapy and/or chemotherapy.
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Abstract
We describe the case of a spontaneous improvement of the cervical kyphosis in eosinophilic granuloma with long-term follow-up. A collapse of the C5 vertebral body was confirmed by cervical spine radiography and computed tomography. The patient wore a sterno-occipitalmandibular immobilizer brace for 6 months, and remodeling of the vertebral body was confirmed 18 months after onset. Seven years have passed since the onset of symptoms, and the patient's cervical spine has maintained normal alignment. Management of eosinophilic granuloma of the pediatric cervical spine is still controversial. Conservative treatment suffices as adequate management of cervical eosinophilic granuloma, even with kyphotic deformity.
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Angelini A, Mavrogenis AF, Rimondi E, Rossi G, Ruggieri P. Current concepts for the diagnosis and management of eosinophilic granuloma of bone. J Orthop Traumatol 2016; 18:83-90. [PMID: 27770337 PMCID: PMC5429252 DOI: 10.1007/s10195-016-0434-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 10/11/2016] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Andrea Angelini
- Department of Orthopedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli, 40136, Bologna, Italy.
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, Athens University Medical School, ATTIKON University Hospital, Athens, Greece
| | - Eugenio Rimondi
- Department of Radiology and Interventional Angiographic Radiology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Rossi
- Department of Radiology and Interventional Angiographic Radiology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Pietro Ruggieri
- Department of Orthopedics and Orthopedic Oncology, University of Padova, Padova, Italy
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Ravindra VM, Eli IM, Schmidt MH, Brockmeyer DL. Primary osseous tumors of the pediatric spinal column: review of pathology and surgical decision making. Neurosurg Focus 2016; 41:E3. [DOI: 10.3171/2016.5.focus16155] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Vijay M. Ravindra
- 1Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah; and
| | - Ilyas M. Eli
- 1Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah; and
| | - Meic H. Schmidt
- 1Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah; and
| | - Douglas L. Brockmeyer
- 1Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah; and
- 2Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
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Lam S, Reddy GD, Mayer R, Lin Y, Jea A. Eosinophilic granuloma/Langerhans cell histiocytosis: Pediatric neurosurgery update. Surg Neurol Int 2015; 6:S435-9. [PMID: 26539317 PMCID: PMC4604648 DOI: 10.4103/2152-7806.166761] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 06/16/2015] [Indexed: 01/21/2023] Open
Affiliation(s)
- Sandi Lam
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Gaddum D Reddy
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Rory Mayer
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Yimo Lin
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Andrew Jea
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
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Zheng W, Wu J, Wu Z, Xiao J. Atlantoaxial instability secondary to eosinophilic granuloma of the axis in adults: long-term follow-up in six cases. Spine J 2014; 14:2701-9. [PMID: 24647385 DOI: 10.1016/j.spinee.2014.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 02/11/2014] [Accepted: 03/04/2014] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Wei Zheng
- Department of Orthopedics, ChengDu Military General Hospital, 270 Tianhui Rd, Rongdu Ave., ChengDu 610083, People's Republic of China
| | - Juan Wu
- Pharmacy Department, Research Center, ChengDu Military General Hospital, 270 Tianhui Rd, Rongdu Ave., ChengDu 610083, People's Republic of China
| | - ZhiPeng Wu
- Department of Orthopedics, Spine Tumor Center, ChangZheng Hospital, Second Military Medical University, 415 Fengyang Rd, Shanghai 200003, People's Republic of China
| | - JianRu Xiao
- Department of Orthopedics, Spine Tumor Center, ChangZheng Hospital, Second Military Medical University, 415 Fengyang Rd, Shanghai 200003, People's Republic of China.
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Lü GH, Li J, Wang XB, Wang B, Phan K. Surgical treatment based on pedicle screw instrumentation for thoracic or lumbar spinal Langerhans cell histiocytosis complicated with neurologic deficit in children. Spine J 2014; 14:768-76. [PMID: 24035731 DOI: 10.1016/j.spinee.2013.06.104] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 03/19/2013] [Accepted: 06/29/2013] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Guo-Hua Lü
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011, People's Republic of China
| | - Jing Li
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011, People's Republic of China.
| | - Xiao-Bin Wang
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011, People's Republic of China
| | - Bing Wang
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011, People's Republic of China
| | - Kevin Phan
- Department of Orthopaedic Surgery, University of California at Los Angeles, 1250 16th St, Suit 3145, Santa Monica, CA 90404, USA
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Menezes AH, Ahmed R. Primary atlantoaxial bone tumors in children: management strategies and long-term follow-up. J Neurosurg Pediatr 2014; 13:260-72. [PMID: 24437986 DOI: 10.3171/2013.11.peds13245] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Arnold H Menezes
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Huang WD, Yang XH, Wu ZP, Huang Q, Xiao JR, Yang MS, Zhou ZH, Yan WJ, Song DW, Liu TL, Jia NY. Langerhans cell histiocytosis of spine: a comparative study of clinical, imaging features, and diagnosis in children, adolescents, and adults. Spine J 2013; 13:1108-17. [PMID: 23602327 DOI: 10.1016/j.spinee.2013.03.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 05/21/2012] [Accepted: 03/07/2013] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Wending D Huang
- Department of Musculoskeletal Oncology Surgery, Changzheng Hospital, The Second Military Medical University, 415 Fengyang Rd, Shanghai 200003, China; Department of Orthopaedics, No. 411 Hospital of PLA, 15 Dongjiangwan Rd., Shanghai 200081, China
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Talamonti G, D'Aliberti GA, Debernardi A, Picano M. Paediatric spinal Langerhans cell histiocytosis requiring corpectomy and fusion at C7 and at Th8-Th9 levels. BMJ Case Rep 2012; 2012:bcr-2012-007660. [PMID: 23264157 DOI: 10.1136/bcr-2012-007660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Intralesional methylprednisolone for painful solitary eosinophilic granuloma of the appendicular skeleton in children. J Pediatr Orthop 2012; 32:416-22. [PMID: 22584845 DOI: 10.1097/bpo.0b013e3182561153] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous case reports and small series have reported on the treatment of eosinophilic granuloma of bone. We present our long experience in a large group of children and teenagers with symptomatic eosinophilic granuloma of the appendicular skeleton to evaluate clinical and imaging outcome after methylprednisolone injection. METHODS Sixty-six patients with symptomatic solitary eosinophilic granuloma of the appendicular skeleton treated by incisional or percutaneous biopsy and methylprednisolone injection were retrospectively studied. There were 38 boys and 28 girls (mean age, 7.2 y). The mean follow-up was 10.7 years (median, 11.2 y; range, 3 to 15 y). All patients presented with symptomatic lesions including pain or tenderness and fever and had 1 intralesional injection of methylprednisolone acetate after biopsy: 52 patients had incisional biopsy and 14 patients had percutaneous computed tomography-guided biopsy. RESULTS Complete resolution of symptoms was observed in 58 patients (92%) at 48 to 72 hours (50 patients) and in 7 days (8 patients) after the procedure. Complete imaging reconstitution of bone was observed in 60 patients (95.2%) at 1 to 2 years after the procedure. No patient had recurrence. Multifocal disease was diagnosed in 7 patients (11%) at 3 months to 6 years. Complications occurred in 2 patients: one patient with a clavicular lesion had a pathologic fracture after open direct methylprednisolone injection and the second patient developed trochanteric bursitis after computed tomography-guided methylprednisolone injection. CONCLUSIONS Biopsy and direct intralesional methylprednisolone injection is safe for symptomatic eosinophilic granulomas of the appendicular skeleton in children with effective clinical and imaging resolution of the lesions.
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Abstract
STUDY DESIGN A case report and literature review. OBJECTIVE To illustrate the spontaneous resolution of unstable pathological fracture of the odontoid process of the C2 caused by Langerhans cell histiocytosis (LCH) in early childhood. SUMMARY OF BACKGROUND DATA The involvement of atlantoaxial LCH is very rare and its treatment is unfamiliar to surgeons. Therefore, the management of pediatric LCH of the odontoid process and the C2 body is challenging and must be adapted according to the patient's needs; it could range from observation to surgical intervention. METHODS A case of pathological fracture of the odontoid process with torticollis diagnosed with LCH of the odontoid process and C2 body and involving right femur in early childhood is presented. A histopathological study showed LCH. The patient underwent brace immobilization and systemic chemotherapy. RESULTS The patient showed successful bony remodeling without LCH recurrence on CT. The neck pain was resolved, and there was no limitation in neck movement. CONCLUSION Immobilization and systemic chemotherapy with close observation are adequate for the management of patients despite the unstable pathological fracture of the odontoid process.
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CT-guided corticosteroid injection for solitary eosinophilic granuloma of the spine. Skeletal Radiol 2011; 40:757-64. [PMID: 20931189 DOI: 10.1007/s00256-010-1045-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 09/18/2010] [Accepted: 09/21/2010] [Indexed: 02/02/2023]
Abstract
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.
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Greenleaf RM, Ricciardella LF, Latona CR, Sangimino MJ. Vertebra plana in an adolescent caused by multiple myeloma: a case report and review of the literature. J Bone Joint Surg Am 2011; 93:e37. [PMID: 21508272 DOI: 10.2106/jbjs.j.00640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Robert M Greenleaf
- Allegheny General Hospital, 1307 Federal Street, 2nd floor, Pittsburgh, PA 15212, USA.
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Mavrogenis AF, Rimondi E, Ussia G, Rossi G, Ruggieri P. Successful treatment of a bifocal eosinophilic granuloma of the spine with CT-guided corticosteroid injection. Orthopedics 2011; 34:230. [PMID: 21410115 DOI: 10.3928/01477447-20110124-29] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Observation and immobilization is adequate for most patients with spinal eosinophilic granuloma; however, in patients with symptomatic lesions, treatment other than simple observation or biopsy alone is recommended. In view of the benign clinical course of eosinophilic granuloma, a simple, minimally invasive, outpatient treatment with a low complication rate such as computed tomography (CT)-guided intralesional corticosteroid injection may be considered the treatment of choice. This article presents a case of a 21-year-old man with a symptomatic bifocal eosinophilic granuloma at the vertebral body of the L3 vertebra and the left T5 costovertebral joint treated effectively by CT-guided intralesional methylprednisolone injection. To the best of our knowledge, this is the first case of successful treatment of a bifocal eosinophilic granuloma with CT-guided corticosteroid injection. Under general anesthesia and CT guidance, the lesion was located through the right transpedicular approach for the L3 lesion and the left posterolateral approach for the T5 lesion using a biopsy trocar. Tissue sample was retrieved and frozen section biopsy showed eosinophilic granuloma. One intralesional CT-guided injection of 80 mg (2 mL) of methylprednisolone acetate was performed in each lesion. Complications related to the procedure were not observed. The patient was admitted postprocedural for overnight medical evaluation and was discharged from the hospital the next day. Complete resolution of pain was observed 72 hours after the procedure. At 5 years after diagnosis and treatment, the patient is asymptomatic; imaging showed healing of both lesions.
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Eosinophilic granuloma of spine in adults: a report of 30 cases and outcome. Acta Neurochir (Wien) 2010; 152:1129-37. [PMID: 20396916 DOI: 10.1007/s00701-010-0644-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Accepted: 03/17/2010] [Indexed: 12/28/2022]
Abstract
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.
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Langerhans cell histiocytosis of the cervical spine: a single Chinese institution experience with thirty cases. Spine (Phila Pa 1976) 2010; 35:E8-15. [PMID: 20042947 DOI: 10.1097/brs.0b013e3181b8aa2d] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Thoracic rib solitary eosinophilic granuloma in a child. J Pediatr Orthop B 2009; 18:148-50. [PMID: 19391248 DOI: 10.1097/bpb.0b013e32832a18f7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Eosinophilic granuloma is characterized by single or multiple skeletal lesions occurring predominantly in children, adolescents, and young adults, it accounts for 70% of Langerhans cell histiocytosis. The common sites are the skull, mandible, ribs, spines, and long bones particularly the femur and the humerus. Thoracic rib involvement is rarely seen. It was often regarded as malignant soft tissue tumor. We report an unusual case of eosinophilic granuloma in a female child presented with a solitary lesion at the thoracic rib.
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Abstract
STUDY DESIGN Retrospective case review of children with eosinophilic granuloma of the cervical spine. OBJECTIVE To present the clinical features, radiographic findings, management, and results of 7 pediatric patients with eosinophilic granuloma of the cervical spine. SUMMARY OF BACKGROUND DATA Management of the eosinophilic granuloma of the pediatric cervical spine is challenging, and must be adapted according to the patient, as no level I evidences have been produced. The therapeutic goals in these children are spinal stability, preservation of neurologic function, and relief of pain, always keeping in mind that patients are still growing. The localization in the cervical spine of children is extremely rare, with less than 50 patients reported in literature between 1966 and 2008. METHODS We reviewed the 7 pediatric patients with a diagnosis of eosinophilic granuloma of the cervical spine who were managed between 1970 and 1990 by the senior author. All patients presented with isolated cervical spine involvement, and all of them had a histologic diagnosis of eosinophilic granuloma (EG). All had open physes. RESULTS There were 5 boys and 2 girls (mean age: 10 years; range 4-16). We followed-up patients for 19 years (range 8-29). The symptoms at presentation varied according to the localization of the tumor in the cervical spine. CONCLUSION Management of pediatric patients with EG of the cervical spine is challenging, especially when there is neurologic involvement. Observation alone, prolonged immobilization, systemic chemotherapy, curettage with or without bone grafting, corticosteroid injection, and low dose radiation therapy have been proposed for the management of patients with EG. Surgery is required when the child presents neurologic involvement. Children who received a vertebral interbody fusion can show, at long period follow-up, normal shape of the neck, with maintenance of the normal motion of the adjacent segments.
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Gebauer GP, Farjoodi P, Sciubba DM, Gokaslan ZL, Riley LH, Wasserman BA, Khanna AJ. Magnetic resonance imaging of spine tumors: classification, differential diagnosis, and spectrum of disease. J Bone Joint Surg Am 2008; 90 Suppl 4:146-62. [PMID: 18984727 DOI: 10.2106/jbjs.h.00825] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Gregory P Gebauer
- Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224-2780, USA
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