Management of benign tumors of the mobile spine

Minimally Invasive Resection of Benign Osseous Tumors of the Spinal Column: 10 Years' Experience and Long-Term Outcomes of a Specialized Center

Background and Objectives: Benign osseous tumors of the spinal column comprise about 10% of all spinal tumors and are rare cause for surgery. However, these tumors pose various management challenges and conventional surgery may be associated with significant morbidity. Previous reports on minimally invasive resection of these lesions are rare. We report a series of patients managed by total resection of benign osseous spine tumors using MIS techniques. Surgical decisions and technical considerations are discussed. Materials and Methods: A retrospective evaluation of prospectively collected data of patients who underwent minimally invasive surgery for removal of benign osseous vertebral tumors. Demographic, clinical and radiographic features, operative details and final pathological reports were summarized. Primary outcomes were completeness of tumor resection and pain relief assessed by VAS for back and leg pain. Secondary outcome measures were recurrence of tumor on repeat post-operative MRI and postoperative unstable deformity on standing scoliosis X-rays. Results: This series included 32 cases of primary osseous spine tumors resected by minimally invasive techniques. There were 17 males and 15 females aged 5-68 years (mean 23.3). The follow-up period was 8-90 months (mean 32 months) and the preoperative symptoms duration was 9-96 months. Axial spinal pain was the presenting symptom in all the patients. Five patients also complained about radicular pain and four patients had antalgic scoliosis. The tumor involved the thoracic spine in 12 cases, the lumbar segment in 11, the cervical in 5 and the sacral area in 4 cases. Complete tumor removal was performed in all patients. No procedure-related complications were encountered. Histopathology showed osteoid osteoma in 24 patients, osteoblastoma in 5 patients, and fibrous dysplasia, fibroadenoma and eosinophilic granuloma in one case each. All patients experienced significant pain relief after surgery, and had stopped pain medications by 12 months postoperatively. No patient suffered from tumor recurrence or spinal deformity. Conclusions: Minimally invasive surgery is feasible for total removal of selected benign vertebral tumors and may have some advantages over conventional surgical techniques.

Overview of the management of primary tumors of the spine

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.

Back Pain in Children- How Sinister?

Incidence of back pain among children and adolescents is gradually increasing. Children undergo extensive diagnostic workup that ultimately results in a nonconfirmative diagnosis. A good history and clinical examination can, to a large extent help differentiate non-specific from organic causes of backache. Diagnostic workup may be initiated if symptoms are severe and/or persistant. The authors review some of the common causes of back pain in pediatric population, clinical presentations, and the relevant investigations along with their management.

Targeting receptor-activator of nuclear kappaB ligand in aneurysmal bone cysts: verification of target and therapeutic response

Aneurysmal bone cyst (ABC) is a benign tumor of bone presenting as a cystic, expansile lesion in both the axial and appendicular skeleton. Axial lesions demand special consideration, because treatment-related morbidity can be devastating. In similar lesions, such as giant cell tumor of bone (GCTB), the receptor-activator of nuclear kappaB ligand (RANKL)-receptor-activator of nuclear kappaB (RANK) signaling axis is essential to tumor progression. Although ABC and GCTB are distinct entities, they both contain abundant multinucleated giant cells and are osteolytic characteristically. We hypothesize that ABCs express both RANKL and RANK similarly in a cell-type specific manner, and that targeted RANKL therapy will mitigate ABC tumor progression. Cellular expression of RANKL and RANK was determined in freshly harvested ABC samples using laser confocal microscopy. A consistent cell-type-specific pattern was observed: fibroblastlike stromal cells expressed RANKL strongly whereas monocyte/macrophage precursor and multinucleated giant cells expressed RANK. Relative RANKL expression was determined by quantitative real-time polymerase chain reaction in ABC and GCTB tissue samples; no difference in relative expression was observed (P > 0.05). In addition, we review the case of a 5-year-old boy with a large, aggressive sacral ABC. After 3 months of targeted RANKL inhibition with denosumab, magnetic resonance imaging demonstrated tumor shrinkage, bone reconstitution, and healing of a pathologic fracture. Ambulation, and bowel and bladder function were restored at 6 months. Denosumab treatment was well tolerated. Post hoc analysis demonstrated strong RANKL expression in the pretreatment tumor sample. These findings demonstrate that RANKL-RANK signal activation is essential to ABC tumor progression. RANKL-targeted therapy may be an effective alternative to surgery in select ABC presentations.

Back pain in children and adolescents

Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management.

Cite this article: Bone Joint J 2014;96-B:717–23.

Aneurysmal bone cyst in a 21-year-old woman presenting with chronic low back pain in a chiropractic office: a case report

OBJECTIVE

To emphasize the importance of early detection, recognition, appropriate investigation, accurate diagnosis, proper referral, and treatment of an aneurysmal bone cyst (ABC) presenting as chronic low back pain (LBP) in a chiropractic office.

CLINICAL FEATURES

A 21-year-old female student presented to the chiropractic office with a 2-year history of severe and progressive LBP. The patient described the LBP as an aching type of pain that was more pronounced during activity and exercises. She also reported weight loss and increased fatigue.

INTERVENTION AND OUTCOME

A detailed clinical, physical, and imaging evaluation was performed. A well-defined, expansile, and lytic bone lesion with the appearance of a possible ABC was detected; it involved the left inferior half and posterolateral aspect of the vertebral body of L3.

RESULTS

Treatment consisted of an L3 hemivertebrectomy resection en bloc and a vertebral fusion from L2 to L4 with tricortical iliac crest graft. After surgery and recovery, LBP was relieved and the bone lesion did not recur.

CONCLUSION

Although uncommon, ABC is an important lesion that can affect the spine. Healthcare providers must be aware that the cause of LBP may extend beyond musculoskeletal dysfunction. It is important to identify an ABC and refer the patient for appropriate evaluation and care.

Spinal tumors found in the athlete

Spine tumors in the athlete are rare but should be included in the differential diagnosis of any patient in the adolescent or young adult age group with persistent or severe pain. Presenting symptoms are often nonspecific, so a high index of suspicion is needed to diagnose these lesions in a timely fashion. Early recognition and referral to an appropriate multidisciplinary spine tumor center can greatly improve prognosis for these challenging cases.

Primary spinal natural killer/T-cell lymphoma successfully treated with concurrent chemoradiotherapy and autologous stem cell transplantation

STUDY DESIGN

This case report shows primary natural killer (NK)/T-cell lymphoma originating in the spine as the first case of successful treatment with autologous stem cell transplantation, along with case presentation and literature review.

OBJECTIVE

For the proper treatment of this spinal tumor, the pathologic confirmation includes immunophenotypic profiling, the understanding of tumor characteristics, and the consideration of spinal stability are necessary.

SUMMARY OF BACKGROUND DATA

NK/T-cell lymphomas are rare, aggressive neoplastic disorders with a distinctive clinical pathologic profile and an unfavorable clinical prognosis. The extranodal nasal-type NK/T-cell lymphomas, which are characterized by an extranodal presentation and an aggressive clinical course, are prevalent in Asia and Central and South America.

METHODS

A 49-year-old woman presented with thoracic back pain that developed 3 months before she was admitted to Chung-Ang University. The radiological image showed a 6 × 4 × 5-cm mass lesion within the T6-T7 vertebral body. The histopathology was consistent with the finding of NK/T-cell lymphoma. Treatment with chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) in combination with radiotherapy (total dose, 30 Gy) was done, and salvage therapy with autologous stem cell transplantation was performed.

RESULTS

Two-year follow-up magnetic resonance image showed shrinking remnant mass without spinal deformation and/or instability. Rebiopsy for remnant mass, nasal area study, and positron emission tomographic scan were performed to determine the tumor recurrence. There was no evidence of recurrence at the 2-year follow-up evaluations.

CONCLUSION

Some primary NK/T-cell lymphomas that originate at sites other than the nasal cavity/nasopharynx do not present with typical clinical features and symptoms. A primary NK/T-cell lymphoma of the spine should be considered in the differential diagnosis of primary bone tumors. We report the first case of successful treatment with chemoradiotherapy and autologous stem cell transplantation in a patient with a primary spinal NK/T-cell lymphoma.