PICTURE OF THE MONTH

Hyperplasia of Cervical Spinous Process Presentingas Subcutaneous Mass

Kanwaljeet Garg & Guru Dutta Satyarthee &

Chinmaya Dash & Pankaj Kumar Singh &

Poodipedi Sarat Chandra & Bhawani Shankar Sharma

Received: 9 October 2013 /Accepted: 2 December 2013# Dr. K C Chaudhuri Foundation 2013

A 7-y-old male child presented with complaints of neck painfor last 2 y. There was no history of neck trauma or any othersignificant history. Physical examination revealed a tender,bony hard midline posterior cervical mass elevating the skin(Fig. 1). On direct questioning patient’s father came up withhistory of noticing the swelling for the first time 2 years back,

with no change in size since then. Neurological examinationwas unremarkable with no restriction of neck movements.

Radiographs revealed hypertrophy of the C3 spinous pro-cess. Computed tomography (CT) revealed hypertrophied leftlamina of C3 with enlarged and thickened spinous process(Fig. 2). In addition there was schisis of spinous process of C4

with thickened lamina (Fig. 2c, d). Magnetic resonance imag-ing revealed no abnormality of the cord (Fig. 3). Patientunderwent excision of the enlarged spinous process by poste-rior midline approach and made an uneventful recovery.Histopathological examination revealed it to be normal bonetissue.

Congenital abnormalities of spinous process are often in-cidental radiological findings and include double orhypertrophied spinous process [1]. Chitkara et al. described

Fig. 1 Clinical picture of the patient showing cervical swelling in the midline and towards left (a posterior view, b lateral view)

K. Garg :G. D. Satyarthee : C. Dash : P. K. Singh : P. S. Chandra :B. S. SharmaDepartment of Neurosurgery, All India Institute of Medical Sciences,New Delhi, India

G. D. Satyarthee (*)Department of Neurosurgery, Cardio-Neuro Centre, All IndiaInstitute of Medical Sciences, Room No 720, New Delhi 110029,Indiae-mail: duttaguru2002@yahoo.com

Indian J PediatrDOI 10.1007/s12098-013-1315-1

a patient with two ‘rib-like swellings’ at the back of the neck[2]. Unilateral hyperplasia of a spinous process is a rarefinding and has only been described thrice [3–5]. Spinousprocess abnormalities may be associated with other osseous

and/or non-osseous abnormalities, like in cases with Klippel–Feil syndrome or Down’s syndrome. Vertebral schisis is aform of neural tube defect and is caused by the failure ofclosure of spine.

Such abnormalities rarely cause clinical symptoms exceptfor aesthetic problems. However, few patients may presentwith localized pain, neurological impairment and limitationsof movement. The etiological factor behind this anomaly isnot clear and may involve abnormal extension ofchondrification and ossification of one vertebral arch withnormal development of the other arch [3].

CTwith three dimensional reconstruction andMRI providedetails of the pathology and help in making precise diagnosis.The significance of such abnormalities is that these should beincluded in the differential in patients with recurrent episodesof cervical neck pain.

Contribution Guru Dutta Satyarthee will act as guarantor for this paper.

Conflict of Interest None.

Role of Funding Source None.

References

1. Klimo P Jr, Rao G, Brockmeyer D. Congenital anomalies of thecervical spine. Neurosurg Clin N Am. 2007;18:463–78.

2. Chitkara N, Sharma NK, Dhall U, Bakshi N, Kamal H. Congenitalexostoses of the cervical vertebrae. Neurol India. 2003;51:130–1.

3. Esposito G, de Bonis P, Tamburrini G, Massimi L, ByvaltsevV, di Rocco C, et al. Unilateral hyperplasia of the left posteriorarch and associated vertebral schisis at C6 level. Skeletal Radiol.2009;38:1191–5.

Fig. 2 a Non contrast CT sagittalsections of cervical spine showingenlarged spinous process, b Noncontrast CT axial section showinghypertrophied left lamina andelongated spinous process of C3(star), c , d Non contrast CT axialsections showing schisis of C4spinous process with theenlargement of both halves

Fig. 3 a MRI T1WI sagittal images showing enlarged spinous processcausing skin elevation, b MRI T1WI axial section showing schisis of C4spinous process with the normal spinal cord

Indian J Pediatr

4. Heyer CM, Nicolas V, Peters SA. Unilateral hyperplasia of a cervicalspinous process as a rare congenital variant of the spine. Clin Imaging.2007;31:434–6.

5. Kazanci B, Tehli O, Adilay U, Guclu B. Unilateral hyperplasia oflamina and spinous process of C6 vertebra: Case report. Surg RadiolAnat. 2012;34:875–8.

Indian J Pediatr