Osteoblastoma of the cervical spine

S Aravind; Jim F Vellara; Arjun Krishnan; Amal Antony Paul

doi:10.4103/joasis.joasis_28_22

CASE REPORT

Year : 2022 | Volume : 19 | Issue : 2 | Page : 99-101

Osteoblastoma of the cervical spine

S Aravind¹, Jim F Vellara², Arjun Krishnan², Amal Antony Paul¹
¹ Department of Orthopedics, Amrita Institute of Medical Sciences and Research Institute, Kochi, Kerala, India
² Department of Orthopedics, Division of Spine, Amrita Institute of Medical Sciences and Research Institute, Kochi, Kerala, India

Date of Submission	08-Aug-2022
Date of Decision	11-Aug-2022
Date of Acceptance	13-Aug-2022
Date of Web Publication	09-Feb-2023

Correspondence Address:
Jim F Vellara
Department of Orthopedics, Division of Spine, Amrita Institute of Medical Sciences and Research Institute, Kochi, Kerala
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joasis.joasis_28_22

Abstract

A 15-year-old female presented with left-sided neck and shoulder pain for the past 1 year. Computed tomography scan and contrast magnetic resonance imaging revealed a mass lesion at the C7 level suggestive of osteoblastoma. Tumor resection was performed along with posterior stabilization. At 1-year follow-up, the patient had no restrictions on daily activities, and to date, there has been no evidence of recurrence. In case of neck pain, which is persistent and accompanied by stiffness, deformity, or neurological deficit, especially in young adults, osteoblastoma of the cervical spine may be considered one of the differential diagnoses.

Keywords: Cervical spine, osteoblastoma, painful scoliosis, resection with stabilization

How to cite this article:
Aravind S, Vellara JF, Krishnan A, Paul AA. Osteoblastoma of the cervical spine. J Orthop Assoc South Indian States 2022;19:99-101

How to cite this URL:
Aravind S, Vellara JF, Krishnan A, Paul AA. Osteoblastoma of the cervical spine. J Orthop Assoc South Indian States [serial online] 2022 [cited 2023 Mar 27];19:99-101. Available from: https://www.joasis.org/text.asp?2022/19/2/99/369403

Introduction

Osteoblastoma is a rare benign primary bone tumor that accounts for 3% of benign and 1% of all primary bone tumors.^[1] Approximately 32%–46% involve the spine.^[2] Predominantly occurs in the second and third decade of life with a male:female ratio of 2:1 and usually presents with pain.^[3] Osteoblastoma is histologically similar to osteoid osteoma, but is more common in older patients, has a greater propensity for the spine, and is more biologically aggressive.^[4]

Patients typically present with progressive axial or radicular pain exacerbated by movements. Often presents more than 12 months of history and many patients will go on to manifest neurological sequelae or painful scoliosis.^[5] Delayed diagnosis mainly occurs because of nonspecific initial symptoms and the rare nature of the tumor.^[6] The tumor is often radiolucent on radiographs, almost always involve the posterior elements, and the adjacent bone may or may not exhibit reactive sclerosis. Vertebral body involvement rarely occurs but may occur through tumor extension through the pedicle.^[7] With the utilization of computed tomography (CT), magnetic resonance imaging (MRI), and bone scan in the workup of low back pain and painful scoliosis, the sensitivity for detecting these tumors has risen substantially. The treatment goal is complete surgical resection, aimed at protecting the sensitive neurological structures which avoids the need for radiotherapy and decreases the risk of recurrence. In highly vascular tumors, complete surgical resection is often difficult, and recurrence postresection is described in almost 10% of the cases.^[8] Authors have also reported the possibility of malignant transformation.^[9]

Case Report

A 14-year-old female presenting with left-sided neck pain for the past 12 months, initially started over the left shoulder and progressed to the neck, dull aching pain with associated night pain that relieves on analgesics and lateral decubitus position, also gives a history of tingling and numbness of the left upper limb that relieves spontaneously. On evaluation noticed a head tilt toward the left side with restricted neck flexion and rotations, and X-rays showed a right proximal thoracic with a left dorsolumbar curve [Figure 1]. CT showed a well-circumscribed round lesion with osteoid matrix involving the left lamina of C7 [Figure 2], and in contrast, MRI a well-defined focal circumscribed T1, T2 hypo intense lesion showing postcontrast enhancement in the left pedicle, and lamina of C7 with marrow edema extending into the body of C7 and T1 [Figure 3], with no intraspinal or foraminal soft-tissue component and no cord or nerve root compression.

Figure 1: X-ray showing right proximal thoracic curve with a left dorsolumbar curve

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Figure 2: CT scan showing lesion over the C7 laminae. CT: Computed tomography

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Figure 3: Contrast MRI. MRI: Magnetic resonance imaging

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In view of clinical and radiological findings, an osteoblastoma causing secondary scoliosis was considered, preoperative angiography was done to assess the vascularity and to identify the course of the vertebral artery, following which the patient underwent C7 laminectomy, mass was excised and sent for histopathological examination, and spine was stabilized with rods connected to lateral mass screws in C6 and pedicle screws in T2 [Figure 4].

Figure 4: Three month postoperative

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Histopathology revealed fragments showing inter anastomosing bony trabeculae of woven bone within a fibrovascular stroma, extravasated red blood cells, active osteoblasts and osteoblasts lined trabeculae, the presence of giant cells, and no atypical mitosis. The patient was managed with a Philadelphia collar and 4 weeks postsurgery, the plain film showed that the implants were in position and the hard collar was changed to soft collar which was discontinued at 3 months postoperative, she had complete resolution of the preoperative symptoms at 1-year follow-up with no features of recurrence.

Discussion

Osteoid osteoma and osteoblastoma are first discussed in 1956 by Jaffe.^[10],[11] Spine involvement is described in 20% of osteoid osteoma and 40% of osteoblastoma.^[12] Osteoblastoma is more frequently found in the posterior elements.^[13] The pain of osteoid osteoma is more at night and gets relieved with aspirin, whereas the pain due to osteoblastoma is not particularly severe at night and does not respond well to aspirin.^[14] Histologically, both appear similar, but pathologically, osteoblastoma demonstrates more aggressive behavior,^[15] because of its aggressive nature osteoblastoma may exhibit neurological deficits in 43%–70% of the cases due to intraspinal growth or cord compression.^[16] Patients with skeletal neoplasm usually presents with a progressive dull aching pain, similar to our reported case. Painful scoliosis is a well-recognized presentation for spinal osteoblastoma and is due to muscle spasms secondary due to pain on the side of the lesion. It has been noted that tumor is located typically over the concave aspect of the curve near its apex.^[17] In a review of literature, it was noted that 5% of the patients with cervical lesions have torticollis rather than scoliosis.^[18]

MRI and CT are the commonly used imaging modalities in the diagnosis of osteoid osteoma and osteoblastoma. CT scan will delineate the osseous involvement, and MRI will provide an appreciation of the effect on soft tissue and neural elements. If CT and MRI are nonconfirmatory, a technetium bone scan can be used which will show a double density sign.^[19]

The treatment of choice for osteoblastoma of the spine is complete surgical resection and neurological deficits usually recover after surgery. The main aim of surgery is complete resection, prevent recurrence, and protection of sensitive neuroanatomic structures. Angiography is to be done preoperatively to assess the vertebral artery and to plan for preoperative embolization since osteoblastoma can be highly vascular.^[20] Angiography of this patient showed no signs of compression of the vertebral arteries and relatively less vascular lesions. Reexcision is the mainstay of treatment in recurrent osteoblastoma.^[21] Radiation therapy has been used infrequently but has provided local control and long-term disease-free survival in some patients.^[22] Our patient had complete recovery of pain and neurological symptoms, and there are no features suggestive of recurrence at 1-year follow-up.

Conclusion

Osteoblastoma should be ruled out in young patients with deformity of the spine, neurological symptoms, and pain over an extended period of time. Delay in diagnosis is common due to nonspecific symptoms, and effective treatment is important to prevent neurological complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Nemoto O, Moser RP Jr., Van Dam BE, Aoki J, Gilkey FW. Osteoblastoma of the spine. A review of 75 cases. Spine (Phila Pa 1976) 1990;15:1272-80.
2.	Healey JH, Ghelman B. Osteoid osteoma and osteoblastoma. Current concepts and recent advances. Clin Orthop Relat Res 1986;(204):76-85.
3.	Knoeller SM, Uhl M, Adler CP, Herget GW. Differential diagnosis of benign tumors and tumor-like lesions in the spine. Own cases and review of the literature. Neoplasma 2004;51:117-26.
4.	Boriani S, Capanna R, Donati D, Levine A, Picci P, Savini R. Osteoblastoma of the spine. Clin Orthop Relat Res 1992;(278):37-45.
5.	Ransford AO, Pozo JL, Hutton PA, Kirwan EO. The behaviour pattern of the scoliosis associated with osteoid osteoma or osteoblastoma of the spine. J Bone Joint Surg Br 1984;66:16-20.
6.	Lucas DR, Unni KK, McLeod RA, O'Connor MI, Sim FH. Osteoblastoma: Clinicopathologic study of 306 cases. Hum Pathol 1994;25:117-34.
7.	McLeod RA, Dahlin DC, Beabout JW. The spectrum of osteoblastoma. AJR Am J Roentgenol 1976;126:321-5.
8.	Di Lorenzo N, Delfini R, Ciappetta P, Cantore G, Fortuna A. Primary tumors of the cervical spine: Surgical experience with 38 cases. Surg Neurol 1992;38:12-8.
9.	Dahlin DC, Unni KK. Bone Tumors: General Aspects and Data on 8542 Cases. Springfield: Charles C. Thomas; 1986. p. 102-17.
10.	Jaffe HL. Benign osteoblastoma. Bull Hosp Joint Dis 1956;17:141-51.
11.	Lichtenstein L. Benign osteoblastoma; a category of osteoid-and bone-forming tumors other than classical osteoid osteoma, which may be mistaken for giant-cell tumor or osteogenic sarcoma. Cancer 1956;9:1044-52.
12.	Marsh BW, Bonfiglio M, Brady LP, Enneking WF. Benign osteoblastoma: Range of manifestations. J Bone Joint Surg Am 1975;57:1-9.
13.	Frassica FJ, Waltrip RL, Sponseller PD, Ma LD, McCarthy EF Jr. Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am 1996;27:559-74.
14.	Saccomanni B. Erratum to: Osteoid osteoma and osteoblastoma of the spine: A review of the literature. Curr Rev Musculoskelet Med 2012;5:263.
15.	Seki T, Fukuda H, Ishii Y, Hanaoka H, Yatabe S. Malignant transformation of benign osteoblastoma. A case report. J Bone Joint Surg Am 1975;57:424-6.
16.	Basdemir G, Ersahin Y. Osteoid osteomas and osteoblastomas of the spine. Neurosurg Focus 2003;15:E5.
17.	Saifuddin A, White J, Sherazi Z, Shaikh MI, Natali C, Ransford AO. Osteoid osteoma and osteoblastoma of the spine. Factors associated with the presence of scoliosis. Spine (Phila Pa 1976) 1998;23:47-53.
18.	Lian X, Zhao J, Hou T, Ma H, Chen Z. Benign intraspinal osteoblastoma stemming from C7 lamina in cervicothoracic junction: A case report. Spine (Phila Pa 1976). 2006;31:E895-9.
19.	Ozkal E, Erongun U, Cakir B, Acar O, Uygun A, Bitik M. CT and MR imaging of vertebral osteoblastoma. A report of two cases. Clin Imaging 1996;20:37-41.
20.	Schneider M, Sabo D, Gerner HJ, Bernd L. Destructive osteoblastoma of the cervical spine with complete neurologic recovery. Spinal Cord 2002;40:248-52.
21.	Ozaki T, Liljenqvist U, Hillmann A, Halm H, Lindner N, Gosheger G, et al. Osteoid osteoma and osteoblastoma of the spine: Experiences with 22 patients. Clin Orthop Relat Res 2002;(397):394-402.
22.	Berberoglu S, Oguz A, Aribal E, Ataoglu O. Osteoblastoma response to radiotherapy and chemotherapy. Med Pediatr Oncol 1997;28:305-9.