Anterior cervical corpectomy and fusion using miniplate and screws in a 7-year-old child with eosinophilic granuloma of the cervical spine

Langerhans Cell Histiocytosis in the Pediatric Spine Requiring Stabilization: A Literature Review and Report of 3 Cases

CASE

This report describes 3 cases of Langerhans cell histiocytosis (LCH) of the cervical and thoracic spine in patients aged 4 to 10 years. Each patient had painful lytic spinal lesions with vertebral body collapse and posterior involvement suggesting instability requiring corpectomy, grafting, and fusion. All 3 patients were doing well at their most recent follow-up without pain or recurrence.

CONCLUSION

Although LCH of the pediatric spine is usually successfully treated non-operatively, we recommend corpectomy and fusion when there is instability of the spinal column and/or severe stenosis. Posterior element involvement occurred in all 3 cases and may lead to instability.

Anterior cervical transvertebral approach for resection of an intraspinal ventral lesion: illustrative case

BACKGROUND

The anterior cervical corpectomy and fusion approach has been reported for the removal of ventral cervical tumors. However, the normal cervical vertebral body and the adjacent intervertebral discs have to be sacrificed. In this paper, the authors describe a novel anterior cervical transvertebral approach for the resection of cervical intraspinal ventral lesions.

OBSERVATIONS

A patient presented with an anteriorly placed extramedullary cyst. An anterior cervical transvertebral open-window and close-window approach was designed and applied to resect an intraspinal ventral enterogenous cyst. With this novel technique, a square was cut through the whole vertebral body at the four sides. After the cyst resection, the bone block was restored and fixed with a titanium miniplate. The lesion was totally resected, and the compression of the spinal cord was relieved. The physiological function of the cervical spine was kept intact after the operation. There was no postsurgical complication. The cervical alignment was normal at the 1-year postoperative follow-up.

LESSONS

The anterior cervical transvertebral open-window and close-window approach was developed and confirmed to be effective for the resection of cervical intraspinal lesions. The cervical physiological structure and function can be restored with this new technique.

Giant Granular Cell Tumor of the Cervical Spinal Cord Resected via Anterior Corpectomy with Reconstruction: Technical Note and Review of Literature

BACKGROUND

Granular cell tumors (GCT) are rare soft tissue neoplasms with a nerve sheath origin, most often found in female adult populations. When these tumors arise in the central nervous system, they most commonly appear intradurally in the thoracic or lumbar spine. GCT malignancy rates vary and recurrence rates can be relatively high, thereby necessitating complete resection.

CASE DESCRIPTION

We present an exceedingly rare case of an intradural, extramedullary GCT originating in the anterior cervical spine of a male pediatric patient who presented with progressive neck pain and gait instability.

CONCLUSIONS

The patient underwent an anterior C7 corpectomy for resection of the tumor, followed by stabilization and fusion, and recovered without neurologic deficit. A literature review of spinal GCTs is provided.

The surgical strategy for eosinophilic granuloma of the pediatric cervical spine complicated with neurologic deficit and/or spinal instability

Background

Various therapeutic approaches have been proposed for the treatment of pediatric patients with eosinophilic granuloma (EG) of the cervical spine. Our aim was to discuss and present our experience with the individualized surgical intervention of pediatric cervical EG complicated with neurologic deficits and/or spinal instability.

Methods

We retrospectively analyzed the clinical data of 19 children who were diagnosed with cervical EG comor spinal/or spinal instability (evaluated by the Spinal Instability Neoplastic Score, SINS ≥ 7) and treated surgically in our institution.

Results

Lesions involved C1–2 in 7 patients and C3–7 in 12 patients. Anterior tumor resection combined with posterior pedicle screw fixation, anterior approach of excision and instrumentation, and posterior tumor resection combined with pedicle screws instrumentation were selected according to the different locations of tumors. Frankel scale and Oucher scale improved significantly after surgery. There was no morphologic alteration of the neck at follow-up.

Conclusions

Surgery can significantly improve the neurologic status and symptoms. Surgical decision-making must be individually tailored to minimize the influence of surgery on spine growth.

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

INTRODUCTION

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

CASE REPORT

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

CONCLUSION

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

Cervical Spine Instrumentation in Children

Instrumentation of the cervical spine enhances stability and improves arthrodesis rates in children undergoing surgery for deformity or instability. Various morphologic and clinical studies have been conducted in children, confirming the feasibility of anterior or posterior instrumentation of the cervical spine with modern implants. Knowledge of the relevant spine anatomy and preoperative imaging studies can aid the clinician in understanding the pitfalls of instrumentation for each patient. Preoperative planning, intraoperative positioning, and adherence to strict surgical techniques are required given the small size of children. Instrumentation options include anterior plating, occipital plating, and a variety of posterior screw techniques. Complications related to screw malposition include injury to the vertebral artery, neurologic injury, and instrumentation failure.

Short Segment Stabilization by Protecting the Alar Ligaments in a Case of Eosinophilic Granuloma Involving the C2 Spine

BACKGROUND

The craniocervical junction is a complex anatomic location that contains the occipital bone, atlas, axis, and important complex ligamentous structures. The stability of this region is ensured only with the help of ligaments.

CASE DESCRIPTION

A 6-year-old boy was admitted to our clinic for neck pain. Computed tomography and magnetic resonance imaging revealed a lytic bone lesion involving the C2 vertebral body and pedicle without odontoid tip. The tumor was resected using an anterior retropharyngeal approach and a wide marginal resection method. The odontoid tip and alar ligaments were protected, and the costal autografts were located between the C1-odontoid tip and the C3 body. The costal graft was stabilized in the C3 body with a miniplate. Then, C1-C3 posterior fixation with fusion was performed. The craniocervical junction was not considered unstable because the occipital bone was not involved in the fusion. Histologic examination confirmed the diagnosis of eosinophilic granuloma. Fusion was detected on a 1-year postoperative cervical computed tomography scan.

CONCLUSIONS

The occiput should not be involved in the fusion area when the alar ligaments are preserved during surgery for a C2 lesion.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

A retrospective review study.

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

[Langerhans cell histiocytosis causing cervical myelopathy]

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

Absorbable anterior cervical plate for corpectomy and fusion in a 2-year-old child with neurofibromatosis. Technical note

Postlaminectomy cervical kyphosis is one of the most challenging entities in spine surgery. Correction of this deformity usually requires anterior fusion with plating and a strut graft or interbody cage and posterior fusion with screws and rods. The situation is more complicated in the young child because fusion may affect future growth of the cervical spine. There is also a paucity of adequate instrumentation for the small bony structures. Some authors have reported utilization of absorbable cervical plates for fusion in pediatric patients with favorable results. The authors present a modified surgical technique that was used for circumferential fusion in a 2-year-old girl with cervical kyphosis and recurrent neurofibroma. Anterior fusion was performed using an autologous rib graft and an absorbable cervical plate. This was followed by posterior fusion using rib bone and cables. Previous reports on the use of absorbable cervical plates are reviewed and the advantages of the current technique are discussed.

Langerhans cell histiocytosis causing cervical myelopathy in a child

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

Langerhans cell histiocytosis with multiple spinal involvement

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

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

STUDY DESIGN

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Circumferential fixation with craniofacial miniplates for a cervical spine injury in a child

Unstable pediatric cervical spine injuries present significant challenges in terms of fixation. Given the smaller cervical vertebral bodies in the preschool-aged population, commercially available pediatric cervical fixation instrumentation may be unsuitable because of the inappropriately large size of the screws and plates. The authors describe a 2-year-old girl who sustained an unstable C6-7 distraction injury during a motor vehicle accident. Because of the small size of her vertebral bodies, standard cervical spine instrumentation was not feasible, and posterior wiring alone was believed to be insufficient because of the complete distraction of all 3 spinal columns. The patient was taken to the operating room where craniofacial plates with an inherent locking mechanism were used to circumferentially stabilize the cervical spine. Follow-up examination 6 months postoperatively demonstrated stable cervical spine alignment and fusion with no evidence of the failure of either the anterior or posterior hardware. The use of craniofacial miniplates with an intrinsic locking mechanism represents a superior alternative for both anterior and posterior cervical fixations when spinal instrumentation is needed in the pediatric age group.

Eosinophilic granuloma of the pediatric cervical spine

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.

Cervical eosinophilic granuloma and torticollis: a case report and review of the literature

Eosinophilic granuloma (EG) is a benign and solitary bony lesion of unknown etiology, which typically affects children: 90% of patients are between the ages of 5 and 15 years. EG, a variant of histiocytosis X, is a rare disease causing destructive bony lesions of the cervical spine in children. This report describes the case of a 5-year-old boy with torticollis who presented to the Emergency Department and was found to have EG of C6. He was successfully treated with anterior cervical corpectomy and fusion by using anterior plate and screws, with resolution of his symptoms.

Percutaneous vertebroplasty for eosinophilic granuloma of the cervical spine in a child

We report a case of eosinophilic granuloma at the fourth cervical vertebra in a 10-year-old girl presenting with a 1-month history of cervical pain and stiffness. This lesion was histologically diagnosed by needle biopsy and then treated by percutaneous vertebroplasty. After the procedure, the cervical pain and stiffness resolved rapidly. The height of the vertebral body remained stable without further collapse over a 6-month follow-up period.

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

CASE REPORT

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

DISCUSSION

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

Torticollis secondary to posterior fossa and cervical spinal cord tumors: report of five cases and literature review

Torticollis is either congenital or acquired in childhood. Acquired torticollis is not a diagnosis but rather a sign of an underlying disorder. The causes of acquired torticollis include ligamentous, muscular, osseous, ocular, psychiatric, and neurologic disorders and may be a symptom of significant abnormalities of the spinal cord and brain, such as spinal syrinx or central nervous system neoplasia. Torticollis is rarely considered to be an initial clinical presentation of posterior fossa and cervical spinal cord tumors. We report five cases of pediatric tumors with torticollis at the onset: an astrocytoma originating from the medulla oblongata, another presumptive astrocytoma of the spinal cord located between C1 and C6 cervical vertebrae (not operated), an ependymoma located throughout the whole cervical spinal cord extending into the bulbomedullary junction, an astrocytoma originating from the bulbus and extending into the posterior fossa, and another case of a eosinophilic granuloma located extradurally through the anterior and posterior portions of the vertebral bodies from C3 to C7 producing the collapse of the sixth cervical vertebra. All five cases were seen in children, aged between 3 and 12 years. All these cases reflect the misinterpretation of this neurological sign and the lack of association with the possibility of spinal or posterior fossa tumor. This delay in the diagnosis of these diseases led to progressive neurological deterioration and to the increase in the tumor size, which made surgical intervention difficult and the prognosis unfavorable. Although torticollis secondary to tumors is rarely seen, it is necessary to be kept in mind in the differential diagnosis.

The Langerhans' cell histiocytosis (eosinophilic granuloma) of the cervical spine: a rare diagnosis of cervical pain

We present the case of a 44-year-old man who complained of cervical pain. He was treated with physiotherapy and analgetics. Because of persistent pain, computed tomography (CT) scan and MRI were performed. They revealed an osteolytic destruction of the fourth cervical vertebra. The patient was treated surgically for removal of the tumor and stabilization of his cervical spine. Histology of the osteolytic material led to the diagnosis of an eosinophilic granuloma of the cervical spine. This case report describes the incidence, clinical significance, background and therapy of an eosinophilic granuloma of the spine.

Anterior approach to the subaxial cervical spine in children: a brief review

Although it was originally developed to address degenerative problems, including disc herniations and cervical spondylotic myelopathy in the adult population, the anterior approach to the subaxial spine has proven to be useful for select indications in the pediatric population. The authors review indications for surgery, bone grafting, and instrumentation as they pertain to children.

Temporary anterior cervical plating in a child with traumatic cervical ligamentous instability

Application of anterior cervical plates in children is problematic because of the growing spine, and thus has been reported only rarely in the medical literature. In this case report, a 7-year-old with traumatic C(2-3) and C(3-4) ligamentous instability was treated surgically by limited-duration anterior cervical plating. The plate was removed in a second operation, as the osseous union occurred 1 year after the primary operation. Limited-duration anterior cervical plating is an alternative for stabilization operations of the growing cervical spine in children.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

STUDY DESIGN

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

OBJECTIVES

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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