Eosinophilic granuloma of the spine: an unusual radiographic presentation

Primary intramedullary Langerhans cell histiocytosis of the thoracic spinal cord

A 28-year-old male presented with a rare case of primary intramedullary spinal Langerhans cell histiocytosis (LCH) manifesting as the chief complaint of a 6-month history of gait disturbance and back pain, and difficulty with sphincter control. Serial T2-weighted magnetic resonance imaging of the thoracic spine revealed enlargement and intramedullary hyperintensity of the spinal cord at T2 to T4. Biopsy of the lesion was performed. Histological examination of the biopsy specimens verified vascular proliferation and remarkable infiltration of histiocytes that were positive for CD1a, suggesting a diagnosis compatible with LCH. The patient was treated successfully by steroid pulse therapy. LCH is a rare disease that occurs mainly in children and may cause a broad range of manifestations, from a single osseous lesion to multiple lesions involving more than one organ or system. The present case illustrates the unexpected occurrence and important differential diagnosis of primary intramedullary spinal LCH of the thoracic spine in adult patients presenting with progressive paraparesis and back pain.

Solitary eosinophilic granuloma of the adult lumbar spine

INTRODUCTION

Eosinophilic granuloma (EG) is a benign bone tumor that rarely occurs in adults. It is usually found occurring in flat and long bones, but spine is often affected too. EG is of unknown aetiology, and the course of the disease is unpredictable.

MATERIALS AND METHODS

Two cases of EG of the adult lumbar spine are reported, representing a difficult challenge for diagnosis and treatment.

CONCLUSION

CT scan guided trocar biopsy allowed to achieve a definitive diagnosis, and CT scan guided intralesional infiltrations of corticosteroids were the successful treatment.

Eosinophilic granuloma of the atlas presenting as torticollis in a child

STUDY DESIGN

This report describes a case of successful surgical treatment of eosinophilic granuloma of the atlas in a 3.5-year-old boy who presented with torticollis.

OBJECTIVE

The purpose of this report was to illustrate the rare clinical presentation of eosinophilic granuloma in the atlas.

SUMMARY OF BACKGROUND DATA

Eosinophilic granuloma, a benign solitary lesion that commonly affects children, has a variable clinical course. Although eosinophilic granuloma has been reported to occur in the cervical spine, there have been only five reported cases of eosinophilic granuloma affecting the atlas. The management of eosinophilic granuloma ranges from observation and immobilization of the cervical spine to surgical excision.

METHODS

The tumor was located on the left lateral mass of the atlas. Biopsy and curettage were performed through an oblique incision through the posterior border of the sternocleidomastoid muscle. A histopathologic evaluation confirmed the diagnosis of eosinophilic granuloma.

RESULTS

The patient tolerated the procedure with no complications, and his torticollis has completely resolved.

CONCLUSION

Eosinophilic granuloma of the atlas initially presented in this patient as torticollis. Biopsy for confirmation of diagnosis and curettage for treatment provided a successful outcome in this patient. We suggest biopsy of the lesion and histopathologic evaluation to confirm the diagnosis in atypical cases.

Eosinophilic granuloma of the cervical spine

STUDY DESIGN

A meta-analysis was performed based on 53 cases of cervical eosinophilic granuloma reported in the literature and 1 in an adult treated by the authors.

OBJECTIVE

To stress the clinical and radiologic differences between cervical and thoracolumbar spinal eosinophilic granuloma and to point out differences between adults and children with cervical eosinophilic granuloma to avoid false diagnosis.

SUMMARY OF BACKGROUND DATA

Until now, cervical eosinophilic granuloma has been reported in 43 children and 9 adults. In 1 case the age is unknown. In previous studies, differences between adults and children with cervical eosinophilic granuloma have not been analyzed, nor has cervical eosinophilic granuloma been compared with thoracolumbar eosinophilic granuloma.

METHODS

All reported cases of cervical eosinophilic granuloma were analyzed concerning age and sex distribution, clinical and radiologic presentation, therapy, and outcome. The authors' case in a 46-year-old patient is discussed.

RESULTS

The presenting symptoms of cervical eosinophilic granuloma are usually pain and restricted range of motion. In contrast to eosinophilic granuloma of the thoracic spine and lumbar spine, the neurologic symptoms are less frequent, and the first radiographic sign is an osteolytic lesion. Vertebra plana is a rare sign in cervical eosinophilic granuloma. In children, the middle cervical spine is most often affected, whereas in adults it is the second vertebra. The outcome of the patients has been good in most cases, independently of treatment.

CONCLUSION

In most cases of cervical eosinophilic granuloma, immobilization is an adequate therapy. If the process continuous to progress, radiotherapy is recommended. Surgical treatment should be reserved for cases with instability or neurologic defects.

Langerhans' cell histiocytosis of the spine. Analysis of twenty-three cases

STUDY DESIGN

Retrospective review of clinical and radiologic data in four major tertiary referral centers.

OBJECTIVES

To report clinical and roentgenographic findings, to evaluate the results of various treatment methods, and to propose a protocol for management.

SUMMARY OF BACKGROUND DATA

Langerhans' cell histiocytosis of the spine is a rare condition, and therefore, appropriate management is still controversial.

METHODS

Clinical and roentgenographic findings of 38 vertebral lesions of 23 children, with average follow-up of 5.4 years, were investigated. This is the most extensive report apparent in the literature to date. The results of treatment were assessed clinically and radiologically. Anterior vertebral body height was measured sequentially to evaluate reconstitution of the vertebral body.

RESULTS

The last follow-up examination demonstrated no clinical evidence of disease in all patients, regardless of treatment method. Neurologic deficits developed in four patients, but they completely disappeared. Satisfactory restoration of height was demonstrated in all except five vertebrae: one that had collapsed maximally when the patient was more than 15 years of age and four that had been fused anteriorly or posteriorly. Unsatisfactory results were also seen in a patient with progressive scoliosis and in one with an irregular endplate with disc space narrowing. Both of these complications developed after curettage.

CONCLUSIONS

For treatment of single or dual spinal lesions, observation with or without bracing seems to be sufficient. In patients with multifocal lesions, chemotherapy produces good results. For treatment of neurologic deficit, low-dose radiotherapy is favored. Patients who underwent surgery--especially curettage and anterior fusion--had the worst outcome.

Isolated intramedullary histiocytosis-X of the cervical spinal cord. Case report

Histiocytosis-X is known to involve the central nervous system, but rarely does this disease involve the spinal cord. To the authors' knowledge, this is the first case of isolated intramedullary histiocytosis-X of the spinal cord to be reported.

Eosinophilic granuloma of the cervicothoracic junction. Case report

A case is reported of eosinophilic granuloma at the cervicothoracic junction presenting with profound quadriparesis preoperatively. The patient underwent excision via an anterior approach, with splitting of the sternum to gain access to the T-1 vertebra. Postoperatively, he has had an excellent return of function.

Benign tumors and tumorlike conditions of the spine. Radiological features, treatment, and results

A series of 44 benign tumors and tumorlike conditions of the spine treated surgically between 1952 and 1982 is reported. We have focused on their radiodiagnosis, treatment, and long-term results. The radiologic features considered pathognomonic of skeletal tumors, and frequently found in tumors outside the spine, are less common in the spinal variety. In fact, the radiologic findings in spinal tumors are, as a rule, nonspecific. The long-term results in this series are considered satisfactory, despite two recurrences of a giant cell tumor and late malignant degeneration of an osteochondroma. The prognosis was good, and recurrence rare even after conservative excision of the lesion. More aggressive treatment is nonetheless recommended nowadays for giant cell tumors and osteoblastomas, even if vertebral stability has to be sacrificed and fusion performed, as this affords the best chance of permanent cure. Conservative excision without radiotherapy remains the treatment of choice for other benign tumors. Spinal instability is a serious risk especially in younger patients who have undergone radiotherapy and have residual neurological deficits. Provision should be made against this risk by planning a fixation procedure either in the same operation as ablative surgery or at a later stage.

Eosinophilic granuloma of bone

Eosinophilic granuloma of bone is an uncommon granulomatous process for which therapy recommendations vary considerably. Consequently, a survey of the world literature from 1940 to 1974 was undertaken in an attempt to develop more concrete guidelines. This survey revealed that the disease manifests itself primarily in males under 20 years of age of all races. The most common symptom is pain, with or without swelling. Multiple sites in a single case are frequent. The clinical course is generally benign, unlike Letterer-Siwe disease or Hand-Schuller-Christian disease. A remission rate of 95% was noted, with relapses usually occurring as distant disease within the first year. Simple excision or curettage was the most common surgical procedure utilized, and radiotherapy doses varied widely. Excellent local control of the disease can be provided using conservative surgery, low-dose irradiation, or both. Morbidity secondary to pathologic fracture or to overly aggressive treatment are the major concerns, not failure to control the disease.