Disorders of Tumoral Calcification of the Spine

Systemic sclerosis-associated compressive cervical calcinosis: intersection of degenerative spine instability, lesional spinal cord compression, and traumatic spinal cord injury. Illustrative case

BACKGROUND

Tumoral calcinosis, mass-like calcium deposition into the soft tissues, is an uncommon manifestation of the systemic sclerosis subtype of scleroderma. When this process affects the spinal epidural space, it can cause canal narrowing and place the spinal cord at significant risk of injury.

OBSERVATIONS

Here a 62-year-old female with systemic sclerosis and no previous evidence of spinal cord compromise who developed acute spinal cord injury and quadriparesis after a mechanical fall is described. She was found to have a large dorsal epidural calcified mass compressing her cervical spinal cord. She underwent medical management for acute spinal cord compression as well as surgical management for acute spinal cord injury and degenerative spine disease. Her case illustrates a rare etiology of simultaneous degenerative spine instability and lesional spinal cord compression with acute spinal cord injury.

LESSONS

Tumor calcinosis leading to acute spinal cord injury in the setting of systemic sclerosis is an uncommon but critical entity to recognize in patients with scleroderma and may require the physician to use a combination of medical and surgical management strategies from each of these categories of spine pathology.

Tumoral Calcinosis of the Cervical Spine Associated with a Pathologic Odontoid Fracture

Tumoral calcinosis involves focal calcium deposits in the soft tissues surrounding a joint and most commonly occurs in the hips and elbows, rarely in the cervical spine. Furthermore, it has not been known to be associated with pathologic fractures. To the best of our knowledge, our case report highlights the first case of a pathologic type II odontoid fracture associated with adjacent tumoral calcinosis, resulting in pain, dysphagia, and severe spinal stenosis. The patient underwent a posterior occipitocervical fusion and C1 laminectomy, along with planned tracheostomy and gastrostomy to avoid expected difficulty with postoperative extubation and dysphagia. Additionally, we present a review of existing literature on tumoral calcinosis in the upper cervical spine.

Monosomy X in Female Mice Influences the Regional Formation and Augments the Severity of Angiotensin II-Induced Aortopathies

OBJECTIVE

Turner syndrome women (monosomy X) have high risk of aortopathies consistent with a role for sex chromosomes in disease development. We demonstrated that sex chromosomes influence regional development of Ang II (angiotensin II)-induced aortopathies in mice. In this study, we determined if the number of X chromosomes regulates regional development of Ang II-induced aortopathies. Approach and Results: We used females with varying numbers of X chromosomes (XX female mice [XXF] or XO female mice [XOF]) on an C57BL/6J (ascending aortopathies) or low-density lipoprotein receptor deficient (Ldlr-/-) background (descending and abdominal aortopathies) compared with XY males (XYM). To induce aortopathies, mice were infused with Ang II. XOF (C57BL/6J) exhibited larger percent increases in ascending aortic lumen diameters than Ang II-infused XXF or XYM. Ang II-infused XOF (Ldlr-/-) exhibited similar incidences of thoracic (XOF, 50%; XYM, 71%) and abdominal aortopathies (XOF, 83%; XYM, 71%) as XYM, which were greater than XXF (XXF, 0%). Abdominal aortic lumen diameters and maximal external diameters were similar between XOF and XYM but greater than XXF, and these effects persisted with extended Ang II infusions. Larger aortic lumen diameters, abdominal aortopathy incidence (XXF, 20%; XOF, 75%), and maximal aneurysm diameters (XXF, 1.02±0.17; XOF, 1.96±0.32 mm; P=0.027) persisted in ovariectomized Ang II-infused XOF mice. Data from RNA-seq demonstrated that X chromosome genes that escape X-inactivation (histone lysine demethylases Kdm5c and Kdm6a) exhibited lower mRNA abundance in aortas of XOF than XXF (P=0.033 and 0.024, respectively). Conversely, DNA methylation was higher in aortas of XOF than XXF (P=0.038).

CONCLUSIONS

The absence of a second X chromosome promotes diffuse Ang II-induced aortopathies in females.

Symptomatic Cervical Tumoral Calcinosis due to Cosmetic Body Contouring Mineral Oil Injections

Tumoral calcinosis (TC) is an uncommon disease that has been linked to familial genetic mutations but can often be due to secondary causes such as chronic renal failure and hyperparathyroidism. There are rare instances of tumoral calcinosis induced by foreign body injections, often for cosmetic purposes. Here we describe operative management of spinal cord compression due to mineral oil injection induced tumoral calcinosis. A 54-year-old transgender female presented with signs of myelopathy so severe that she had become wheelchair bound. Labs demonstrated hypercalcemia and imaging of the neuroaxis revealed significant calcification resulting in cervicothoracic and lumbar central canal stenosis. Given symptomatic cervical spinal cord compression, she was taken to the OR for urgent laminectomy and decompression. Postoperatively, she recovered well and was ambulating independently by postoperative day (POD) 9. This is the first reported case of localized mineral oil injections causing distant calcification with subsequent symptomatic cord compression requiring operative intervention.

Tumoral calcinosis in the cervical spine: a case report and review of the literature

Background

Tumoral calcinosis is rarely located in spine. A 55-year-old Japanese woman with cervical tumoral calcinosis is presented, along with a review of the literature relating to tumoral calcinosis in the spine. We discussed the etiology, diagnosis, and management of this condition.

Case presentation

We report a case of a patient with cervical tumoral calcinosis with end-stage renal disease. A computed tomography scan showed a lobulated, calcified mass around the right facet joint at the fourth-fifth cervical spine and calcifications were also observed in the right intervertebral foramens at fourth-fifth cervical spine and fifth-sixth cervical spine levels and the anterior wall of the spinal canal. By performing a cervical decompression and stabilization, the patient recovered from her neurological symptoms.

Conclusions

Although tumoral calcinosis is rarely located in the spine, it should be considered in the differential diagnosis of spinal lesions. If a calcified mass causes acute neurological symptoms, resection of the mass is still the most important treatment.

Tumoral calcinosis of the craniovertebral junction as a cause of dysphagia with treatment by transoral decompression: case report

Tumoral calcinosis is characterized by tumor-like deposition of calcium in periarticular soft tissue. Spinal involvement is rare, and perioperative diagnosis of tumoral calcinosis can be difficult because lesions may be confused with bony neoplasms. Symptoms of tumoral calcinosis result from bony involvement and/or direct compression of surrounding anatomical structures, for which treatment with surgical decompression can be highly successful. The craniovertebral junction is rarely affected by tumoral calcinosis, and patients with this condition may present with distinct symptoms. Herein, to their knowledge the authors present the first case of tumoral calcinosis affecting the craniovertebral junction in a patient who presented with severe dysphagia and required transoral decompression. Recognition of tumoral calcinosis by neurosurgeons is essential for facilitating diagnosis and treatment, and the transoral approach is an effective method for decompression in select patients.

Idiopathic tumoral calcinosis–like lesion in the lower cervical spine causing acute central cord syndrome: case report

A 57-year-old male presented with recurrent falls, bilateral lower-limb paresthesia, and severe neck pain. Imaging revealed a mass compressing his spinal cord. He was admitted for further workup for spinal cord compression. Within 24 hours of admission, he developed upper-extremity weakness while maintaining lower-extremity function. He underwent urgent decompression of his spinal cord. During exposure, a white, creamy odorless substance was noted. This same substance was found under pressure within the spinal canal. The mass was grossly removed, and the patient's weakness improved postoperatively. Based on the clinical picture, intraoperative presentation, and final histological examination, idiopathic tumoral calcinosis-like lesion was considered as the most appropriate diagnosis.

Tumoral calcinosis of the cervical spine in a dialysis patient. Case report and review of the literature

The authors present a case of tumoral calcinosis (TC) in a patient with chronic renal insufficiency. The clinical course, imaging features and microscopic findings are detailed. A 60-year-old woman with a 4-year history of hemodialysis presented with a painful mass in the right posterior cervical triangle. The neuroimaging revealed polycystic mass bulging from the C3-C5 facet joints and lamina on the right. The majority of cystic mass was excised and microscopic features of the specimen were consistent with TC. Tumoral calcinosis is a rare disease characterized by calcium salt deposits in periarticular soft tissue, which enlarge to form tumor-like cystic masses containing chalky calcareous material. TC is typically seen around large joints but rarely in the spine. Review of past publications provided six cases of TC involving the spine in dialyzed patients.

Uremic tumoral calcinosis in the cervical spine: case report

Tumoral calcinosis is an uncommon condition characterized by the calcification of periarticular soft tissue. In uremic patients the disease is secondary to metabolic disturbances in predisposed patients. The authors report the case of a 73-year-old woman who presented with a new painful cervical mass while undergoing continuous ambulatory peritoneal dialysis for long-standing end-stage renal disease (ESRD). A CT scan of the neck showed a lobulated, calcified mass in the left paraspinal soft tissue at C2-3. This mass affected the facet joint and also extended into the neural foramen but did not cause any neurological compromise. Due to the patient's significant medical comorbidities, resection was deferred and the patient was followed in the clinic. Subsequent repeat imaging has shown a significant decrease in the size of the mass. In the context of ESRD, a diagnosis of uremic tumoral calcinosis (UTC) was made. The authors conducted a search of the PubMed and EMBASE databases and identified 7 previously reported cases of UTC of the cervical spine. They present a summary of these cases and discuss the etiology, diagnosis, and management of the condition. Although the metabolic disturbances seen in patients undergoing dialysis can lead to tumoral calcinosis, most reported cases involve large joints such as the shoulder or the hip; however, the spine can also be affected and should be considered in the differential diagnosis of patients with uremia as it can mimic aggressive bone-forming neoplasms.

Calcium orthophosphates (CaPO4): occurrence and properties

The present overview is intended to point the readers' attention to the important subject of calcium orthophosphates (CaPO4). This type of materials is of the special significance for the human beings because they represent the inorganic part of major normal (bones, teeth and antlers) and pathological (i.e., those appearing due to various diseases) calcified tissues of mammals. For example, atherosclerosis results in blood vessel blockage caused by a solid composite of cholesterol with CaPO4, while dental caries and osteoporosis mean a partial decalcification of teeth and bones, respectively, that results in replacement of a less soluble and harder biological apatite by more soluble and softer calcium hydrogenorthophosphates. Therefore, the processes of both normal and pathological calcifications are just an in vivo crystallization of CaPO4. Similarly, dental caries and osteoporosis might be considered as in vivo dissolution of CaPO4. In addition, natural CaPO4 are the major source of phosphorus, which is used to produce agricultural fertilizers, detergents and various phosphorus-containing chemicals. Thus, there is a great significance of CaPO4 for the humankind and, in this paper, an overview on the current knowledge on this subject is provided.

Infantile tumoral calcinosis of the cervical spine presenting as torticollis

The computed tomography (CT) and MRI findings of infantile tumoral calcinosis and the utility of image-guided biopsy are demonstrated. A 5-month old presented with torticollis and a calcified cervical spinal mass. The radiologic appearance suggested a malignant neoplasm, prompting CT-guided biopsy, which diagnosed tumoral calcinosis. We hope to increase awareness of this entity and describe image-guided biopsy as a way to avoid morbidity associated with open biopsy.

Differential diagnosis of tumoral lesions in the spinal canal in patients undergoing hemodialysis

Study Design

A retrospective study.

Purpose

To clarify the features useful for the differential diagnosis of spinal canal tumoral lesions in patients undergoing hemodialysis.

Overview of Literature

Tumoral lesions in the spinal canal are rarely found in hemodialysis patients. Therefore, the differential diagnosis of tumoral lesions in the spinal canal in hemodialysis patients has been very difficult.

Methods

Spinal canal tumors in 17 patients undergoing hemodialysis or continuous ambulatory peritoneal dialysis were investigated. Histopathological analysis was conducted for all specimens obtained during surgery. The tumoral lesions were categorized into 3 groups on the basis of histopathology: spinal cord tumor, amyloidoma, and other. Patient medical history and diagnostic images of each group were reviewed.

Results

Eight of 17 cases were histopathologically diagnosed as spinal cord tumors and were neurinomas, 6 were amyloidomas, and 3 were classified as other. The rate of spinal cord tumors was 47.1% (8 of 17 cases), which revealed the most frequent lesion type. The rate of amyloidomas and other types was 35.3% (6 of 17 cases) and 17.6% (3 of 17cases), respectively. In the amyloidoma group, the mean duration of hemodialysis (24.3 years) was longer than that of spinal cord tumors and other types (9.2 years and 8.6 years, respectively). All spinal cord tumors were intradural extramedullary, whereas all amyloidomas and other types were extradural.

Conclusions

The rate of each tumoral lesion, the duration of hemodialysis, and the tumoral localization are important features for the differential diagnosis of tumoral lesions in the spinal canal in hemodialysis patients.

Giant, completely calcified lumbar juxtafacet cyst: report of an unusual case

Study Design Case report. Objective To report the case of one patient who developed a giant, completely calcified, juxtafacet cyst. Methods A 57-year-old woman presented with a 2-year history of progressively worsening lower back pain, left leg pain, weakness, and paresthesias. Imaging showed a giant, completely calcified mass arising from the left L5-S1 facet joint, with coexisting grade I L5 on S1 anterolisthesis. The patient was treated with laminectomy, excision of the mass, and L5-S1 fixation and fusion. Results The patient had an uncomplicated postoperative course and had complete resolution of her symptoms as of 1-year follow-up. Conclusions When presented with a solid-appearing, calcified mass arising from the facet joint, a completely calcified juxtafacet cyst should be considered as part of the differential diagnosis.

Giant thoracic osteophyte: a distinct clinical entity

Calcified lesions described within the neural axis are classified as either an ossification of the posterior longitudinal ligament, diffuse idiopathic skeletal hyperostosis, or ossification of the ligamentum flavum. We aim to describe a unique pathologic entity: the giant thoracic osteophyte. We identified four patients who were surgically treated at the Massachusetts General Hospital from 2006 to 2012 with unusual calcified lesions in the ventral aspect of the spinal canal. In order to differentiate giant thoracic osteophytes from calcified extruded disc material, disc volumetrics were performed on actual and simulated disc spaces. All patients underwent operative resection of the calcific lesion as they had signs and/or symptoms of spinal cord compression. The lesions were found to be isolated, large calcific masses that originated from the posterior aspect of adjacent thoracic vertebral bodies. Pathological examination was negative for tumor. Adjacent disc volumes were not significantly different from the index disc (p=0.91). A simulated calculation hypothesizing that the calcific mass was extruded disc material demonstrated a significant difference (p=0.01), making this scenario unlikely. In conclusion, giant thoracic osteophyte is a unique and rare entity that can be found in the thoracic spine. The central tenant of surgical treatment is resection to relieve spinal cord compression.

Uremic tumoral calcinosis causing atlantoaxial subluxation and spinal cord compression in a patient on continuous ambulatory peritoneal dialysis

Uremic tumoral calcinosis (UTC) is a form of metastatic tissue calcification unique to dialysis patients, manifesting with amorphous and cystic masses containing calcium phosphate deposits in periarticular soft tissue. An involvement of the cervical spine with bone destruction is extremely rare in UTC. We describe a 44-year-old uremic female on long-term continuous ambulatory peritoneal dialysis who developed UTC in the peri-odontoid region with consequent atlantoaxial subluxation and spinal cord compression, featuring severe neck soreness, headache, and hypertension. Surgical removal of the destructive cervical spine lesion, showing typical tumoral calcinosis on histology, completely resolved the clinical symptoms. To date, the patient maintains uneventful postoperative course with tight control of serum phosphorus, calcium, and secondary hyperparathyroidism by medical treatment. We also review other reported unusual cases of UTC involving the cervical spine and discuss the differential diagnosis of destructive spinal lesions in uremic patients, such as UTC, dialysis-related amyloidosis, and brown tumors.

Tumoral calcinosis presenting as a deformity of the thoracic spine

The authors describe a rare case of tumoral calcinosis (TC) of the thoracic spine in a 13-year-old boy with thoracic scoliosis. The patient presented with a 2-year history of back pain. He had no personal or family history of bone disease, deformity, or malignancy. Magnetic resonance imaging revealed a heterogeneously enhancing mass involving the T-7 vertebral body and the left pedicle. Computed tomography findings suggested that the mass was calcified and that this had resulted in scalloping of the vertebral body. The lesion was resected completely by using a left T-7 costotransversectomy and corpectomy. The deformity was corrected with placement of a vertebral body cage and pedicle screw fixation from T-5 to T-9. Pathological analysis of the mass demonstrated dystrophic calcification with marked hypercellularity and immunostaining consistent with TC. This represents the third reported case of vertebral TC in the pediatric population. Pediatric neurosurgeons should be familiar with lesions such as TC, which may be encountered in the elderly and in hemodialysis-dependent populations, and may not always require aggressive resection.

Tophaceous pseudogout in the knee joint mimicking a soft-tissue tumour: a case report

Tophaceous pseudogout in the knee joint is rare. We report an 82-year-old man who presented with a one-year history of pain and swelling of the right knee joint. Treatment with non-steroidal anti-inflammatory drugs and aspiration of the joint effusion had not been effective. The mass continued to enlarge, and the patient had difficulty walking. Radiographs and computed tomography showed meniscal calcification with an abnormal soft-tissue mass surrounded by calcification. After excision, massive calcified deposits were seen both inside and on the surface of the tophaceous pseudogout. The deposits showed birefringence under polarised light, suggestive of calcium pyrophosphate dihydrate crystals. At the 2-year follow-up, the patient could walk independently without knee pain or swelling, although his range of knee motion was slightly limited due to joint contracture that developed before surgery.