May 2017

A 15 Year Old Female with Progressive Quadriparesis

History 
A 15 y/o female presents with a serveral month history of progressive quadriparesis and spasticity. Past medical history is unremarkable.
 
Examination
Imaging including MRI and CT scan were obtained.
 

T2 Axial and Sagittal

T1 Post-contrast Axial and Sagittal - Note: image distorted from patient's braces

Figure 3

 
1. Which of the following is the most likely diagnosis?
2. What other imaging is indicated at this time?
3. What is the next step in treatment for this type of lesion?
After cervical laminectomy, mass removal & fusion w/ lateral mass screws & rods, the patient develops left-sided dysmetria w/ loss of pain & temperature sensation on L side of face and R side of body. What's the most likely explanation?
5. Which of the following describes you?
6. I practice in one of the following locations.
7. Comments
  • this girl I hope we can find the proper help for her
  • I don't think spinal instrumentation is necessarily after total removal of osteoma.

 

Case Explanation: Explanation of Answers

Answers

1.D
2.B
3.D
4.C

This lesion has imaging characteristics of osteochondroma. These benign lesions appear as calcified masses on CT, often attached to a bony surface via a bony pedicle. There is typically no bony destruction unless malignant transformation has occurred (a rare finding). MRI can show post-contrast enhancement that usually spares the cartilaginous cap of the mass. Lesions typically do not increase in size after skeletal maturity occurs. Growth after skeletal maturity, especially when accompanied by pain and bony destruction on imaging should prompt concern for malignant transformation. Imaging of the remainder of the neuraxis is indicated in this age group. Complete surgical resection without radiation is generally curative. The left PICA infarct presented is, in this case, likely from malpositioned cervical instrumentation in the lateral mass. CT angiogram will demonstrate the vertebral artery injury that caused the likely PICA infarct. MRI of the brain should confirm the infarct. 

References:

1. Raswan US1, Bhat AR2, Tanki H2, Samoon N3, Kirmani AR2. A solitary osteochondroma of the cervical spine: a case report and review of literature.Childs Nerv Syst. 2017 Mar 27. [Epub ahead of print]

2. Tian Y1, Yuan W, Chen H, Shen X. Spinal cord compression secondary to a thoracic vertebral osteochondroma.J Neurosurg Spine. 2011 Sep;15(3):252-7. Epub 2011 May 20.

3. Faik A1, Mahfoud Filali S, Lazrak N, El Hassani S, Hajjaj-Hassouni N. Spinal cord compression due to vertebral osteochondroma: report of two cases. Joint Bone Spine. 2005 Mar;72(2):177-9.

4. Gallard, F. Osteochondroma. https://radiopaedia.org/articles/osteochondroma

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