- Email: [email protected]
Thoracic spinal osteochondroma: A rare presentation of spinal cord compression
Accepted Manuscript Thoracic spinal osteochondroma: A rare presentation of spinal cord compression
David R. Hansberry, Raghav Gupta, Arpan V. Prabhu, Nitin Agarwal, Mougnyan Cox, Upasana Joneja, Mark T. Curtis, James S. Harrop, Adam E. Flanders PII: DOI: Reference:
S0899-7071(17)30093-1 doi: 10.1016/j.clinimag.2017.05.014 JCT 8252
To appear in: Received date: Revised date: Accepted date:
26 February 2017 12 May 2017 15 May 2017
Please cite this article as: David R. Hansberry, Raghav Gupta, Arpan V. Prabhu, Nitin Agarwal, Mougnyan Cox, Upasana Joneja, Mark T. Curtis, James S. Harrop, Adam E. Flanders , Thoracic spinal osteochondroma: A rare presentation of spinal cord compression, (2017), doi: 10.1016/j.clinimag.2017.05.014
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Thoracic Spinal Osteochondroma: A Rare Presentation of Spinal Cord Compression David R. Hansberry, M.D., Ph.D., 1 Raghav Gupta, B.S.,2 Arpan V. Prabhu, B.S.3, Nitin Agarwal, M.D. 4, Mougnyan Cox, M.D.1, Upasana Joneja, M.D.5, Mark T. Curtis, M.D., Ph.D. 5, James S. Harrop, M.D.6, Adam E. Flanders, M.D.1
Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania,
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1
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U.S.A.
New Jersey Medical School, Rutgers University, Newark, New Jersey, U.S.A.
3
Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh,
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2
4
US
Pennsylvania, U.S.A.
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh,
5
AN
Pennsylvania, U.S.A.
Department of Pathology, Anatomy, & Cell Biology, Thomas Jefferson University Hospital,
6
M
Philadelphia, U.S.A.
Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia,
Osteochondroma; spine; hereditary multiple exostoses; myelopathy
PT
KEY WORDS:
ED
Pennsylvania, U.S.A.
resonance imaging (MRI); computed tomography (CT)
CE
ABBREVIATIONS: Magnetic
AC
Corresponding Author
David R. Hansberry, M.D., Ph.D. Department of Radiology Thomas Jefferson University Hospitals 132 South 10th Street Philadelphia, Pennsylvania 19107 Phone: (856) 577-2088 Email: [email protected]
ACCEPTED MANUSCRIPT ABSTRACT
Osteochondromas are the most common benign bone tumor typically seen in the appendicular skeleton and are rarely found in the spine. We present a case of an osteochondroma of the spine
IP
T
presenting with spinal cord compression.
CR
27-year-old male presented with lower extremity weakness and paresthesia, decreased lower extremity sensation, and decreased proprioception. MRI showed a heterogeneous mass with
US
minimal peripheral enhancement and without restricted diffusion. CT demonstrated a calcified
AN
mass extending from the left facet joint of T11-T12 with medial extension, resulting in severe central canal stenosis and cord compression. The patient underwent surgical resection with
AC
CE
PT
ED
M
pathology demonstrating an osteochondroma.
ACCEPTED MANUSCRIPT INTRODUCTION
Osteochondromas comprise more than one-third of benign bone tumors. The condition is a result of progressive ossification of abnormal cartilaginous tissue during development, resulting in a bony outgrowth which is covered by cartilage.[1] The etiology of osteochondromas includes
IP
T
congenital, trauma, and post radiation therapy.[2] They have been attributed to significant radiation
CR
exposure in 12-15% of osteochondroma cases.[3] These lesions primarily develop in adolescents before they reach skeletal maturity, though the condition is usually diagnosed in adulthood as an
US
incidental finding on imaging.[4]
AN
Males are two and a half times more likely to develop osteochondromas than females.[5] Although
M
most of these lesions occur within the appendicular skeleton, 3% of cases can occur within the
ED
vertebral column, rarely resulting in neurological deficits. Half of spinal osteochondromas are found within the cervical spine although the thoracic spine is also commonly affected.[4-6] The
PT
lesions assume one of two forms: solitary or hereditary. Hereditary spinal osteochondromas are an autosomal dominant condition called ‘multiple exostoses’ that result in the formation of multiple
CE
lesions and are up to three times more likely to affect the spinal cord, resulting in compression.
AC
Solitary spinal osteochondromas are associated with singular, sporadic lesion-formations. Approximately 3% of osteochondromas can undergo malignant transformations.[5] Affected patients typically present with sciatica, back pain, radiculopathy, or associated myelopathies, although a majority of patients are likely asymptomatic.[4] Here, we present a case in which a patient with a thoracic osteochondroma underwent surgical resection.
ACCEPTED MANUSCRIPT CASE REPORT
A 27-year-old male presented with progressive left greater than right, lower extremity numbness, mild lower extremity weakness, and decreased proprioception. Physical exam found decreased
T
lower extremity sensation of the feet and posterior legs extending from the heels to buttock as well
IP
as minimal decreased strength with left foot dorsiflexion and toe extension. Magnetic resonance
CR
imaging (MRI) of the lumbar spine with and without contrast found a mass measuring 3.1 x 1.5 x 2.7 cm at the T11-T12 level with extension into the T12 neural foramina (Figure 1). There was a
US
heterogeneous signal with areas of increased T1 and T2 signal. Post contrast enhanced images
AN
showed minimal peripheral enhancement. There was no abnormal diffusion signal. Subsequent computed tomography (CT) imaging of the thoracic spine without contrast demonstrated an
M
ossified mass from the left facet joint at T11-T12 projecting medially into the spinal canal with
ED
moderate to severe central canal stenosis (Figure 2).
PT
The patient underwent a partial vertebrectomy through a left sided costotransversectomy/
CE
extracavitary approach to remove the T11-T12 mass. Laminectomies from T10 to T12 with foraminotomies were performed. Additionally, there was fusion from T9 to L1 with pedicular
AC
fixation and local bone graft. Surgical pathology demonstrated a 3.3 cm lesion with attached bone. Histologically, the lesion comprised of fibrous perichondrium, linear columns of maturing cartilage and trabecular bone with bone marrow elements at the base (Figure 3). The histologic findings were consistent with an osteochondroma. Postoperatively he was discharged home with 5/5 strength in all muscle groups. At three-year follow-up, he had only minimal weakness in his
ACCEPTED MANUSCRIPT left anterior tibialis and extensor hallucis longus. An MRI at this time indicated no local recurrence
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ED
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or residual.
ACCEPTED MANUSCRIPT DISCUSSION
Solitary spinal osteochondromas are a rare occurrence and account for less than 1% of all tumors within the spine. Although benign, a small subset of these exostoses can become malignant, though this is far more frequent (10-25%) in patients harboring the congenital form of the condition.[5]
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Amongst solitary lesions, only 2.7% are believed to undergo a malignant conversion.[7] These
CR
tumors exclusively occur in bones that undergo endochondral ossification and are most commonly found on the posterior spine, including the transverse and spinous processes; these tumors are also
US
more frequently diagnosed in males.[4, 8, 9] They often occur in the second or third decades of life.[10] The condition may be symptomatic, depending on whether the in-growth encroaches on
M
AN
the spinal canal.
ED
They most commonly affect the cervical and thoracic regions of the spinal cord, though rare cases have reported finding the lesions in the sacral and lumbar regions.[4, 6, 7, 11-39] Two different
PT
hypotheses have been proposed to help explain the anatomical distribution of these lesions within the spine. Albrecht et al suggests that the predominance of cervical osteochondromas is a function
CE
of the increased mobility and flexibility of these vertebrae, resulting in micro trauma to the
AC
underlying cartilaginous tissue and enabling aberrant growth.[1] Fiumara and colleagues contend that mobility is likely not an issue, given the paucity of cases documented within the amply mobile lumbar spine. They propose that the rate of ossification processes within the secondary centers influences the distribution of the lesions.[17]
CT, MRI, and radiographs can each be used to characterize osteochondromas. Radiographs of the lesions typically depict sessile osseous projections emanating from the posterior elements of the
ACCEPTED MANUSCRIPT spine.[1, 6] The cortex and spongiosa of the tumors are continuous with the original bone, serving as imaging identification markers. CT is the preferred imaging modality given the complex anatomy of the vertebrae. It can detect intervertebral foramen intrusion as well as the lesion’s site of origin.[6, 29] Used in conjunction with MRI, which can detect the size of the cartilaginous cap
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and delineate the surrounding soft tissue, the two imaging modalities provide a robust picture of
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the tumor’s immediate microenvironment.
Neurological symptoms are uncommon given the infrequency with which these lesions present
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with cord compression.[33] These lesions typically affect the posterior portion of the spinal
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column away from the neural elements.[29] However, the incidence of spinal cord compression in patients with multiple hereditary exostosis is greater.[40] Good clinical outcomes following
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surgical removal of the lesions have been reported with low rates of morbidity.[1, 4, 6, 17]
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Removal of the entire cartilaginous sheath surrounding the lesion is necessary to prevent
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recurrence of the lesion.[33, 41]
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In our case report, this patient had a facet joint osteochondroma extending from the bottom of the thoracic spine (T11-T12) into the spinal canal. The occurrence of such lesions affecting the facet
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joint is exceedingly low, but has been reported upon in the literature.[5] A posterolateral approach was used to resect the lesion and decompress the neural foramen and spinal canal from a single vantage point in an attempt to minimize postoperative complications seen in posterior approaches.[42]
ACCEPTED MANUSCRIPT CONCLUSION
Osteochondromas are benign bone tumors that are primarily found within the appendicular skeleton. They comprise an acutely small subset of all tumors in the spine. We present a case in which a patient with a thoracic facet joint osteochondroma was treated via a costotransversectomy,
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laminectomy with foraminotomy and fusion, and pedicular fixation. Post-operative resolution of
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symptoms with no local recurrence of these lesions was noted at his three-year follow up. This
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ED
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case supports the efficacy of surgical resection for the treatment of spinal osteochondromas.
ACCEPTED MANUSCRIPT REFERENCES [1]
Albrecht S, Crutchfield JS, SeGall GK. On spinal osteochondromas. J Neurosurg 1992;77(2):247-52.
[2]
Kitsoulis P, Galani V, Stefanaki K, Paraskevas G, Karatzias G, Agnantis NJ, et al.
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Osteochondromas: review of the clinical, radiological and pathological features. In Vivo
Cree AK, Hadlow AT, Taylor TK, Chapman GK. Radiation-induced osteochondroma in
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Sciubba DM, Macki M, Bydon M, Germscheid NM, Wolinsky JP, Boriani S, et al. Long-
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Srikantha U, Bhagavatula ID, Satyanarayana S, Somanna S, Chandramouli BA. Spinal
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Childs Nerv Syst 2010;26(1):101-4. Gunay C, Atalar H, Yildiz Y, Saglik Y. Spinal osteochondroma: a report on six patients
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Cooke RS, Cumming WJ, Cowie RA. Osteochondroma of the cervical spine: case report and review of the literature. Br J Neurosurg 1994;8(3):359-63.
[10]
Sakai D, Mochida J, Toh E, Nomura T. Spinal osteochondromas in middle-aged to elderly patients. Spine (Phila Pa 1976) 2002;27(23):E503-6.
ACCEPTED MANUSCRIPT [11]
Arasil E, Erdem A, Yuceer N. Osteochondroma of the upper cervical spine. A case report. Spine (Phila Pa 1976) 1996;21(4):516-8.
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Bell MS. Benign cartilaginous tumours of the spine. A report of one case together with a review of the literature. Br J Surg 1971;58(9):707-11. Brastianos P, Pradilla G, McCarthy E, Gokaslan ZL. Solitary thoracic osteochondroma:
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Carrera JE, Castillo PA, Molina OM. [Lumbar osteochondroma and radicular compression.
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Faik A, Mahfoud Filali S, Lazrak N, El Hassani S, Hajjaj-Hassouni N. Spinal cord
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Fiumara E, Scarabino T, Guglielmi G, Bisceglia M, D'Angelo V. Osteochondroma of the
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L-5 vertebra: a rare cause of sciatic pain. Case report. J Neurosurg 1999;91(2 Suppl):219-
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Giudicissi-Filho M, de Holanda CV, Borba LA, Rassi-Neto A, Ribeiro CA, de Oliveira JG.
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Cervical spinal cord compression due to an osteochondroma in hereditary multiple exostosis: case report and review of the literature. Surg Neurol 2006;66 Suppl 3:S7-S11. [19]
Gorospe L, Madrid-Muniz C, Royo A, Garcia-Raya P, Alvarez-Ruiz F, Lopez-Barea F. Radiation-induced osteochondroma of the T4 vertebra causing spinal cord compression. Eur Radiol 2002;12(4):844-8.
ACCEPTED MANUSCRIPT [20]
Govender S, Parbhoo AH. Osteochondroma with compression of the spinal cord. A report of two cases. J Bone Joint Surg Br 1999;81(4):667-9.
[21]
Jackson A, Hughes D, St Clair Forbes W, Stewart G, Cummings WJ, Reid H. A case of osteochondroma of the cervical spine. Skeletal Radiol 1995;24(3):235-7. Kak VK, Prabhakar S, Khosla VK, Banerjee AK. Solitary osteochondroma of spine
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[22]
Malat J, Virapongse C, Levine A. Solitary osteochondroma of the spine. Spine (Phila Pa
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causing spinal cord compression. Clin Neurol Neurosurg 1985;87(2):135-8.
1976) 1986;11(6):625-8.
Mardi K, Madan S. Pediatric solitary osteochondroma of T1 vertebra causing spinal cord
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[24]
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compression: A case report. South Asian J Cancer 2013;2(3):144. Morikawa M, Numaguchi Y, Soliman JA. Osteochondroma of the cervical spine. MR
Natale M, Rotondo M, D'Avanzo R, Scuotto A. Solitary lumbar osteochondroma
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findings. Clin Imaging 1995;19(4):275-8.
presenting with spinal cord compression. BMJ Case Rep 2013;2013. O'Connor GA, Roberts TS. Spinal cord compression by an osteochondroma in a patient
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[27]
[28]
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with multiple osteochondromatosis. Case report. J Neurosurg 1984;60(2):420-3. Ozturk C, Tezer M, Hamzaoglu A. Solitary osteochondroma of the cervical spine causing
[29]
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spinal cord compression. Acta Orthop Belg 2007;73(1):133-6. Palmer FJ, Blum PW. Osteochondroma with spinal cord compression: report of three cases. J Neurosurg 1980;52(6):842-5. [30]
Prasad A, Renjen PN, Prasad ML, Bhatty GB, Madan VS, Buxi TB, et al. Solitary spinal osteochondroma causing neural syndromes. Paraplegia 1992;30(9):678-80.
ACCEPTED MANUSCRIPT [31]
Quirini GE, Meyer JR, Herman M, Russell EJ. Osteochondroma of the thoracic spine: an unusual cause of spinal cord compression. AJNR Am J Neuroradiol 1996;17(5):961-4.
[32]
Rahman A, Bhandari PB, Hoque SU, Ansari A, Hossain AT. Solitary osteochondroma of the atlas causing spinal cord compression: a case report and literature review. BMJ Case
Samartzis D, Marco RA. Osteochondroma of the sacrum: a case report and review of the
[34]
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literature. Spine (Phila Pa 1976) 2006;31(13):E425-9.
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[33]
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Rep 2012;2012.
Sharma MC, Arora R, Deol PS, Mahapatra AK, Mehta VS, Sarkar C. Osteochondroma of
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the spine: an enigmatic tumor of the spinal cord. A series of 10 cases. J Neurosurg Sci
[35]
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2002;46(2):66-70; discussion
Shuangshoti S, Lerdlum S. Concurrent occurrence of solitary spinal epidural
Silber JS, Mathur S, Ecker M. A solitary osteochondroma of the pediatric thoracic spine: a
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[36]
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osteochondroma and angiolipoma. Clin Neuropathol 1997;16(2):107-10.
case report and review of the literature. Am J Orthop (Belle Mead NJ) 2000;29(9):711-4. Spallone A, di Lorenzo N, Nardi P, Nolletti A. Spinal osteochondroma diagnosed by
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[37]
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computed tomography. Report of two cases and review of literature. Acta Neurochir (Wien) 1981;58(1-2):105-14. Xu J, Xu CR, Wu H, Pan HL, Tian J. Osteochondroma in the lumbar intraspinal canal
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[38]
causing nerve root compression. Orthopedics 2009;32(2):133. [39]
Yukawa Y, Kato F, Sugiura H. Solitary osteochondroma of the lower cervical spine. Orthopedics 2001;24(3):292-3.
[40]
Ratliff J, Voorhies R. Osteochondroma of the C5 lamina with cord compression: case report and review of the literature. Spine (Phila Pa 1976) 2000;25(10):1293-5.
ACCEPTED MANUSCRIPT [41]
Boriani S, Weinstein JN, Biagini R. Primary bone tumors of the spine. Terminology and surgical staging. Spine (Phila Pa 1976) 1997;22(9):1036-44. Mazur MD, Mumert ML, Schmidt MH. Treatment of Costal Osteochondroma Causing Spinal Cord Compression by Costotransversectomy: Case Report and Review of the
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Literature. Clin Pract 2015;5(2):734.
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[42]
ACCEPTED MANUSCRIPT ACKNOWLEDGMENTS AND FUNDING SOURCES
Funding Statement This research did not receive any specific grant from funding agencies in the public, commercial,
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or not-for-profit sectors.
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Conflict of Interest Statement
The authors have no personal, financial, or institutional interest with regards to the authorship
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and/or publication of this manuscript.
ACCEPTED MANUSCRIPT FIGURE LEGENDS
Figure 1: Sagittal STIR imaging (left) demonstrates a mass measuring 3.1 x 1.5 x 2.7 cm centered at the T11-T12 level. Post contrast sagittal T1 weighted imaging (right) demonstrates heterogeneous hyperintense signal with minimal peripheral enhancement.
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Figure 2: Sagittal CT (left) and axial CT demonstrates an ossified mass from the left facet joint at
Figure 3: (A) Fibrous perichondrium (
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T11-T12 projecting medially into the spinal canal with moderate to severe central canal stenosis.
) overlies the cartilaginous cap of an osteochondroma (
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), and it mimics the zone of hypertrophy of a growth plate. The base of the cap is being sealed by bone, indicating cessation of growth (
). (B) The chondrocytes in the cartilaginous cap are
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arranged in columns and as they approach the base, they mature and acquire more cytoplasm.
ACCEPTED MANUSCRIPT
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Figure 1
ACCEPTED MANUSCRIPT
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Figure 2
ACCEPTED MANUSCRIPT
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Figure 3
David R. Hansberry, Raghav Gupta, Arpan V. Prabhu, Nitin Agarwal, Mougnyan Cox, Upasana Joneja, Mark T. Curtis, James S. Harrop, Adam E. Flanders PII: DOI: Reference:
S0899-7071(17)30093-1 doi: 10.1016/j.clinimag.2017.05.014 JCT 8252
To appear in: Received date: Revised date: Accepted date:
26 February 2017 12 May 2017 15 May 2017
Please cite this article as: David R. Hansberry, Raghav Gupta, Arpan V. Prabhu, Nitin Agarwal, Mougnyan Cox, Upasana Joneja, Mark T. Curtis, James S. Harrop, Adam E. Flanders , Thoracic spinal osteochondroma: A rare presentation of spinal cord compression, (2017), doi: 10.1016/j.clinimag.2017.05.014
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Thoracic Spinal Osteochondroma: A Rare Presentation of Spinal Cord Compression David R. Hansberry, M.D., Ph.D., 1 Raghav Gupta, B.S.,2 Arpan V. Prabhu, B.S.3, Nitin Agarwal, M.D. 4, Mougnyan Cox, M.D.1, Upasana Joneja, M.D.5, Mark T. Curtis, M.D., Ph.D. 5, James S. Harrop, M.D.6, Adam E. Flanders, M.D.1
Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania,
T
1
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U.S.A.
New Jersey Medical School, Rutgers University, Newark, New Jersey, U.S.A.
3
Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh,
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2
4
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Pennsylvania, U.S.A.
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh,
5
AN
Pennsylvania, U.S.A.
Department of Pathology, Anatomy, & Cell Biology, Thomas Jefferson University Hospital,
6
M
Philadelphia, U.S.A.
Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia,
Osteochondroma; spine; hereditary multiple exostoses; myelopathy
PT
KEY WORDS:
ED
Pennsylvania, U.S.A.
resonance imaging (MRI); computed tomography (CT)
CE
ABBREVIATIONS: Magnetic
AC
Corresponding Author
David R. Hansberry, M.D., Ph.D. Department of Radiology Thomas Jefferson University Hospitals 132 South 10th Street Philadelphia, Pennsylvania 19107 Phone: (856) 577-2088 Email: [email protected]
ACCEPTED MANUSCRIPT ABSTRACT
Osteochondromas are the most common benign bone tumor typically seen in the appendicular skeleton and are rarely found in the spine. We present a case of an osteochondroma of the spine
IP
T
presenting with spinal cord compression.
CR
27-year-old male presented with lower extremity weakness and paresthesia, decreased lower extremity sensation, and decreased proprioception. MRI showed a heterogeneous mass with
US
minimal peripheral enhancement and without restricted diffusion. CT demonstrated a calcified
AN
mass extending from the left facet joint of T11-T12 with medial extension, resulting in severe central canal stenosis and cord compression. The patient underwent surgical resection with
AC
CE
PT
ED
M
pathology demonstrating an osteochondroma.
ACCEPTED MANUSCRIPT INTRODUCTION
Osteochondromas comprise more than one-third of benign bone tumors. The condition is a result of progressive ossification of abnormal cartilaginous tissue during development, resulting in a bony outgrowth which is covered by cartilage.[1] The etiology of osteochondromas includes
IP
T
congenital, trauma, and post radiation therapy.[2] They have been attributed to significant radiation
CR
exposure in 12-15% of osteochondroma cases.[3] These lesions primarily develop in adolescents before they reach skeletal maturity, though the condition is usually diagnosed in adulthood as an
US
incidental finding on imaging.[4]
AN
Males are two and a half times more likely to develop osteochondromas than females.[5] Although
M
most of these lesions occur within the appendicular skeleton, 3% of cases can occur within the
ED
vertebral column, rarely resulting in neurological deficits. Half of spinal osteochondromas are found within the cervical spine although the thoracic spine is also commonly affected.[4-6] The
PT
lesions assume one of two forms: solitary or hereditary. Hereditary spinal osteochondromas are an autosomal dominant condition called ‘multiple exostoses’ that result in the formation of multiple
CE
lesions and are up to three times more likely to affect the spinal cord, resulting in compression.
AC
Solitary spinal osteochondromas are associated with singular, sporadic lesion-formations. Approximately 3% of osteochondromas can undergo malignant transformations.[5] Affected patients typically present with sciatica, back pain, radiculopathy, or associated myelopathies, although a majority of patients are likely asymptomatic.[4] Here, we present a case in which a patient with a thoracic osteochondroma underwent surgical resection.
ACCEPTED MANUSCRIPT CASE REPORT
A 27-year-old male presented with progressive left greater than right, lower extremity numbness, mild lower extremity weakness, and decreased proprioception. Physical exam found decreased
T
lower extremity sensation of the feet and posterior legs extending from the heels to buttock as well
IP
as minimal decreased strength with left foot dorsiflexion and toe extension. Magnetic resonance
CR
imaging (MRI) of the lumbar spine with and without contrast found a mass measuring 3.1 x 1.5 x 2.7 cm at the T11-T12 level with extension into the T12 neural foramina (Figure 1). There was a
US
heterogeneous signal with areas of increased T1 and T2 signal. Post contrast enhanced images
AN
showed minimal peripheral enhancement. There was no abnormal diffusion signal. Subsequent computed tomography (CT) imaging of the thoracic spine without contrast demonstrated an
M
ossified mass from the left facet joint at T11-T12 projecting medially into the spinal canal with
ED
moderate to severe central canal stenosis (Figure 2).
PT
The patient underwent a partial vertebrectomy through a left sided costotransversectomy/
CE
extracavitary approach to remove the T11-T12 mass. Laminectomies from T10 to T12 with foraminotomies were performed. Additionally, there was fusion from T9 to L1 with pedicular
AC
fixation and local bone graft. Surgical pathology demonstrated a 3.3 cm lesion with attached bone. Histologically, the lesion comprised of fibrous perichondrium, linear columns of maturing cartilage and trabecular bone with bone marrow elements at the base (Figure 3). The histologic findings were consistent with an osteochondroma. Postoperatively he was discharged home with 5/5 strength in all muscle groups. At three-year follow-up, he had only minimal weakness in his
ACCEPTED MANUSCRIPT left anterior tibialis and extensor hallucis longus. An MRI at this time indicated no local recurrence
AC
CE
PT
ED
M
AN
US
CR
IP
T
or residual.
ACCEPTED MANUSCRIPT DISCUSSION
Solitary spinal osteochondromas are a rare occurrence and account for less than 1% of all tumors within the spine. Although benign, a small subset of these exostoses can become malignant, though this is far more frequent (10-25%) in patients harboring the congenital form of the condition.[5]
IP
T
Amongst solitary lesions, only 2.7% are believed to undergo a malignant conversion.[7] These
CR
tumors exclusively occur in bones that undergo endochondral ossification and are most commonly found on the posterior spine, including the transverse and spinous processes; these tumors are also
US
more frequently diagnosed in males.[4, 8, 9] They often occur in the second or third decades of life.[10] The condition may be symptomatic, depending on whether the in-growth encroaches on
M
AN
the spinal canal.
ED
They most commonly affect the cervical and thoracic regions of the spinal cord, though rare cases have reported finding the lesions in the sacral and lumbar regions.[4, 6, 7, 11-39] Two different
PT
hypotheses have been proposed to help explain the anatomical distribution of these lesions within the spine. Albrecht et al suggests that the predominance of cervical osteochondromas is a function
CE
of the increased mobility and flexibility of these vertebrae, resulting in micro trauma to the
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underlying cartilaginous tissue and enabling aberrant growth.[1] Fiumara and colleagues contend that mobility is likely not an issue, given the paucity of cases documented within the amply mobile lumbar spine. They propose that the rate of ossification processes within the secondary centers influences the distribution of the lesions.[17]
CT, MRI, and radiographs can each be used to characterize osteochondromas. Radiographs of the lesions typically depict sessile osseous projections emanating from the posterior elements of the
ACCEPTED MANUSCRIPT spine.[1, 6] The cortex and spongiosa of the tumors are continuous with the original bone, serving as imaging identification markers. CT is the preferred imaging modality given the complex anatomy of the vertebrae. It can detect intervertebral foramen intrusion as well as the lesion’s site of origin.[6, 29] Used in conjunction with MRI, which can detect the size of the cartilaginous cap
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and delineate the surrounding soft tissue, the two imaging modalities provide a robust picture of
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the tumor’s immediate microenvironment.
Neurological symptoms are uncommon given the infrequency with which these lesions present
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with cord compression.[33] These lesions typically affect the posterior portion of the spinal
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column away from the neural elements.[29] However, the incidence of spinal cord compression in patients with multiple hereditary exostosis is greater.[40] Good clinical outcomes following
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surgical removal of the lesions have been reported with low rates of morbidity.[1, 4, 6, 17]
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Removal of the entire cartilaginous sheath surrounding the lesion is necessary to prevent
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recurrence of the lesion.[33, 41]
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In our case report, this patient had a facet joint osteochondroma extending from the bottom of the thoracic spine (T11-T12) into the spinal canal. The occurrence of such lesions affecting the facet
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joint is exceedingly low, but has been reported upon in the literature.[5] A posterolateral approach was used to resect the lesion and decompress the neural foramen and spinal canal from a single vantage point in an attempt to minimize postoperative complications seen in posterior approaches.[42]
ACCEPTED MANUSCRIPT CONCLUSION
Osteochondromas are benign bone tumors that are primarily found within the appendicular skeleton. They comprise an acutely small subset of all tumors in the spine. We present a case in which a patient with a thoracic facet joint osteochondroma was treated via a costotransversectomy,
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laminectomy with foraminotomy and fusion, and pedicular fixation. Post-operative resolution of
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symptoms with no local recurrence of these lesions was noted at his three-year follow up. This
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case supports the efficacy of surgical resection for the treatment of spinal osteochondromas.
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ACCEPTED MANUSCRIPT ACKNOWLEDGMENTS AND FUNDING SOURCES
Funding Statement This research did not receive any specific grant from funding agencies in the public, commercial,
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or not-for-profit sectors.
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Conflict of Interest Statement
The authors have no personal, financial, or institutional interest with regards to the authorship
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and/or publication of this manuscript.
ACCEPTED MANUSCRIPT FIGURE LEGENDS
Figure 1: Sagittal STIR imaging (left) demonstrates a mass measuring 3.1 x 1.5 x 2.7 cm centered at the T11-T12 level. Post contrast sagittal T1 weighted imaging (right) demonstrates heterogeneous hyperintense signal with minimal peripheral enhancement.
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Figure 2: Sagittal CT (left) and axial CT demonstrates an ossified mass from the left facet joint at
Figure 3: (A) Fibrous perichondrium (
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T11-T12 projecting medially into the spinal canal with moderate to severe central canal stenosis.
) overlies the cartilaginous cap of an osteochondroma (
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), and it mimics the zone of hypertrophy of a growth plate. The base of the cap is being sealed by bone, indicating cessation of growth (
). (B) The chondrocytes in the cartilaginous cap are
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arranged in columns and as they approach the base, they mature and acquire more cytoplasm.
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Figure 1
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Figure 2
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Figure 3