Primary Ewing sarcoma of the axis-C2: A case report and the review of the literature

Imaging Assessment of Nontraumatic Pathologic Conditions at the Craniovertebral Junction: A Comprehensive Review

Nontraumatic pathologic conditions of the craniovertebral junction encompass a range of conditions affecting the complex anatomy of this region without direct physical injury. These conditions include congenital syndromes that predispose individuals to ligamentous laxity, potentially leading to instability. Additionally, rare but noteworthy cases such as Grisel syndrome, a cause of pediatric torticollis, may arise without a traumatic trigger. Inflammatory diseases, including rheumatoid arthritis, ankylosing spondylitis, and crystal deposition, can lead to cervical instability and spinal cord compression. Infections at the upper cervical spine are dominated by tuberculosis, typically transmitted through hematologic or lymphatic routes with characteristic imaging findings. On the other hand, purulent bacterial infections in this area are rare. Furthermore, although tumors involving the structures of the craniovertebral junction are infrequent, they can lead to significant complications, albeit less frequently through cord compression and more commonly via pathologic fractures or subluxation. The craniocervical junction is a complex anatomic region comprising ligaments, bones, joints, and muscles that support the head's weight and enable its wide range of motion. Accurate recognition and understanding of the complex anatomy and the various nontraumatic pathologic conditions at the craniovertebral junction are pivotal for initiating timely and appropriate treatment strategies. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Primary Ewing’s sarcoma of the C2 vertebra with progressive quadriparesis: Report of a rare case and review of the literature

Background:

Ewing’s sarcoma is a malignant primitive neuroectodermal tumor (PNET) of childhood and adolescence. Primary Ewing’s sarcoma of the spine is uncommon, and even more rarely involves the C2 vertebra.

Case Description:

A 14-year-old patient was admitted with a history of chronic neck pain, which exacerbated after playing contact sports 3 weeks before presentation. On initial examination, he had pain radiating into the left upper extremity plus spasticity in all the four limbs. The cervical X-rays revealed a mixed sclerotic-lytic lesion involving the C2 vertebral body. The CT bony and soft-tissue windows documented predominant left-sided tumor invasion of the posterior elements, pedicles, and body of C2 along with extension into the spinal canal resulting in severe cord compression with peritumoral soft-tissue edema. The angiogram revealed a patent left vertebral artery entirely surrounded/encased by tumor. The PET-CT scan demonstrated no other spinal or systemic lesions. Due to his rapid neurological deterioration, the patient underwent an emergent biopsy of the tumor with posterior decompression and occipitocervical stabilization. The biopsy demonstrated a PNET (e.g., positive CD 99 MIC2 marker for Ewing’s sarcoma). Following subsequent chemotherapy and radiation, the patient rapidly improved over a period of 3 months.

Conclusion:

Primary Ewing’s sarcoma involving the C2 vertebra is exceedingly rare and warrants surgical decompression with pathological confirmation to provide additional multi-modal/multi-disciplinary adjunctive radiation/chemotherapy.

Primary vertebral tumor of axis: A clinical and surgical challenge

We report the case of a 17-year-old male presented to the emergency department with a six weeks history of neck pain and no neurogical deficit. Computed tomography and magnetic resonance imaging revealed an expansile lesion in the axis, with soft tissue and spinal cavity invasion, without mielopathy signs. Tomography-guided mass biopsy was taken. Waiting for histopathologic results, the pacient developed acute tetraparesis and sphincter incompetence. Magnetic resonance revealed that the bone mass had grown with epidural compromise, mielopathy and new vertebral lesions. Medular decompression with laminectomy, excision of the posterior elements of axis with the involved soft tissue mass and occipito-cervical fixation was performed. Neurological recovery was complete. Inmunochemistry revealed an Ewing Sarcoma. Chemoteraphy treatment was given, with partial response. Primary Ewing sarcoma of atlas-axis is a rare entity with poor prognosis. Multidisciplinary approach treatment is needed, with a total surgical resection if it is possible, a real challenge for the surgeon.