Turkish Neurosurgery 6: 88 - 92, 1996 Durmaz: Osteob/astoma of tlze Cervica/ Spiiie

Osteo blastoma

Histopathological

Ofand

The Cervical

RadiologicalSpine.

Correlation

Servikal Omurga Osteoblastomu.Bulgu

RadyolojikIliskisi

ve Histopatolojik

RAMAZAN DURMAZ, HAKAN BOZOGLU, SARE KABUKÇUOGLU,

ERKAN VARDARELI, ESREF TEL

Osmangazi University Faculty of Medicine, Oepartments of Neurosurgery (RO,HB,ED,Pathology (SK), and Nuclear Medicine (EV),Eskisehir, Turkey

Abstract: This is the case report of an eight-year old boywith a benign osteoblastoma of the C3 vertebra. Theclinical, radiologicaL, gross and histopathological findingsconcerning the tumor are sufficiently characteristic andexclusive to justify the diagnosis of "osteoblastoma".Key Words: Osteoblastoma, scintigraphy, spine, surgery.

INTRODUCTION

Osteoblastoma is arare, vaseular, andprogressively expansive, benign tumor of the bone,and has a 34.41 % predileetion for the spine (7,8,15).Sinee the lesion is histologieally indistinguishablefrom osteoid osteoma, a differential diagnosis wasma de on the basis of natural history, lesion size andradiological images (3,7,8,15,16). The majority of thecases is under the age of 30, with a peak in the seconddeeade of life (8,15). In this report, it is aimed to drawattention to the applieation of vertebral angiographyin primary eervieal spine neoplasni.s, for aseertainingthe existenee or absenee of any vaseulareomplieations

CASE REPORT

An eight-year old ehild with a history of neekpain over a six month period was admitted to theNeurosurgieal Department of Medical Faeu1ty ofOsmangazi University in Deeember 1994. He was

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Özet: Servikal üçüncü omurgada benigin osteoblastomuolan sekiz yasinda bir erkek hasta sunulmaktadir. Butümörün klinik, radyolojik, makroskopik ve mikroskopikpatolojik bulgulari 'osteoblastoma' tanisini kesinliklekoyduracak kadar kendine özgüdür.Anahtar sözcükler: Cerrahi, omurga, osteoblastoma, sintigrafi

suffering insidious pa in during the day whiehintensified at least twiee during the night. Salieylatesprovided some relief from the pain. The neurologiealexamination show ed no abnormality; however, aeervieal postero-anterior plain radiogram revealeda well- cireumseribed ovallesion on the pedides ofthe C2, C3, and C4 vertebrae on the right (Figure 1).Further, although the tumor itself was not visible inthe other projeetions, a narrowing secondintervertebral foramen appeared on the right obliquefilm, and the lateral radiogram revealed loss ofeervieal eurvature.

A whole-body seintigram performed threehours af ter an intravenous injection of 10 mCiTe-99 m methylene diphosphonate (MDP) revealeda well-demareated, hyperaetive round lesion on thethird eervical vertebral body (Figure 2).

A eomputerized tomography (CT) sean of theeervieal spine showed a patehy, ossified nidus,surounded by a bone shell, situated on all the

Turkish Neurosurgery 6: 88 - 92, 1996 Durmaz: Osteob/astoma of the Cervica/ Spine

transverse processes and one third of the lamina ofC3 vertebra with cannectian to C2 and C3 vertebrae.

A soft component of the mass was visible betweenthe posterior border of nidus and lamina. Areactivebone formatian at the lamina and the tip of thetransverse process of the C3 vertebra was alsaobserved (Figure 3).

b

Figure 3: CT scan showing a) the ossificated nidus ofthe lesion on the lateral part of C3 vertebra,and b) the new bone formatian at the laminaand the tip transverse process (arrows). Thesoft mass between lamina and nidus is alsaobserved.

Figure 1:Posterior- anterior radiogram of the cervical spineshows the radiolucent area surrounded by a slightsderotic rim on the right pedide of C2, C3 andC4 vertebrae.

Figure 2: Bone scintigraphy showing an intense focal uptakeof radionudide by lesion on the C3 vertebrae.

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Tiirkish Neiirosiirgery 6: 88 - 92, 1996

As the tumor destroyed the right foramentransversarium, a vertebral angiogram wasperformed. This showed that the mass had causedvertebral artery displacement, with a segmentalnarrowing at the tumor level (Figure 4).

Figure 4: Right vertebral angiogram shows that the tumorcauses vertebral artery displacement anteriorlywith a segmental narrowing at the tumor leveL.

To explore the vertebral artery in the uppercervical region, a far lateral approach with thepatient in sitting position, as defined by Spetzlerand Graham, was found to be the most appropriate(24). On removing laminae of Cl, C2, and C3vertebra on the affected side, a soft, yellow-grey­reddish pathological tissue of a friable, granularconsisteney was observed, most distinctivelyunder the lamina of the C3 vertebra. Curettage ofthis entire soft mass exposed a hard nidus,approximately 2 cm in diameter, which was thencompletely removed. During surgery vertebral arterywas seen to have been displaced anteriorly under thishard component of tumor and so was carefullyseparated from it.

A subsequent histopathological examinationof the tumor confirmed it to be osteoblastoma

(Figure 5). A CT sean and wholebody scintigramwere performed one month after operation, andno residual tumor was detected. During the oneyear of follow-up, the patient remained in goodhealth.

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Diirmaz: Osteob/astoma of the Ceruica/ Spiiie

Figure 5: Histopathological examination of the lesionshowing the following: 1. Well separated,irregularly serrated osteoid and woven bonetrabeculae. 2. One to three cell layers of plumposteoblasts in dos e apposition to woven bonetrabeculae. 3. Numerous osteodasts sprinkled onthe surface of the trabeculae. 4. Stroma composedof loose spindle cells and prominent capillaries(H&E, X 200).

DISCUSSION

Osteoblastoma of the spine arises mostcommonly from the posterior elements (15,16,19,22).In this case, however, the tumor involved the postero­lateral aspect of the vertebrae, and had causedvertebral artery displacement, with a segmentalnarrowing, without causing any clinical symptom.Vertebral artery involvement generally occurs inmalignant neoplasms, as well as in massiye benigntumors, such as osteoblastoma, aneurysmal bonecysts and giant cell tumors of the cervical spine(1,2,4,6,23). Bohlman et aL.noted a complication dueto vertebral artery distraction during removal of theneoplasm in the cervical spine , and suggested that incases where the tumor is located laterally, the extentof vertebral artery involvement should be defined byarteriogram (2).This is ofbenefit to surgical planning,as well as to preserving the artery during surgery. Incases with vertebral artery involvement the antero­lateral or postero-lateral routes are used (2,23);in thisease , a far lateral approach was found appropriate,not only to remove the laminae on the affected side,but also in order to gain a better view on the transverseprocess es and pedic1es.

Histologieally, osteogenie sareoma may bemisdiagnosed as an osteoblastoma (14). In some easesof recurrent osteoblastoma sarcomatous changes are

Turkish Neiirosurgery 6: 88 - 92, 1996

found that are probably due to initial misdiagnosisof a low-grade maIignant lesion (9).The features thatwere helpful in distinguishing this particular casefrom osteosarcoma were 1) absence of anaplasia, 2)focal osteoblastic rimming, 3) absence of cartilageproduction, and 4) sharply circumscribed edge ofthe lesion from the host lameller bone, and the lackof permeative pattem (7). On the other hand, severalcases of osteoblastoma with same features have

shown an aggressive behaviour to justify the clinicalterm "aggressive" as opposed to "maIignant" (10).Osteoblastoma must also be differentiated from

fibrous dysplasia; in the latter, new bone growth isnot usually rimmed by a prominent, single-rowosteoblast (17). In our case there was a rim ofosteoblasts 1-3 cells in thickness.

Although osteoblastoma in the thoracal andlumbar spine is frequently associated with painfulscoIiosis (1,11,19,22), neck pain may be the only signin a cervical lesion (5).Of patients with osteoblastomain the spine, including the subject of this report, 13% were reported to have noctumal pain (16).

On plain radiogram, osteoblastoma is generallyfound to be osteolytic, although some cases areosteosclerotic and some show a combination of two.A well-circumscribed radiolucent area surrounded

by a slight sclerotic rim is also generally observed(3,12,15,16,21). The fact that this image appearedclearly on posteroanterior film in this case, suggeststhat radiograms should be taken at four projections.

Bone scintigraphy is recommended where thereis a suspicion of osteoblastoma or osteoid osteoma,even if these are not visible on the plain radiograms(13,18,20). No false negatiye results have beenreported 0,19,22). Bone scintigraphy was appIiedintraoperatively and postoperatively, for detectionof any residual tumor tissue 03,25). In this case, theteehnique was used not only for supporting thediagnosis but also for evaluating the extent of thetumor removaL.

According to Mohan et aL.,it is possible to makea differential diagnosis between osteoblastoma andosteoid osteoma by CT sean; osteoblastoma isdistinguished by an expanding lesion, with evidenceof new bone formation and varying degrees ofealcification (18). Our case conforms with previousreports with respect to scanty ossifieation of matrix,surrounded by a shell of bone and a soft componentof lesion that are only visible by CT scan (12,18).

Durmaz: Osteob/astoma of the Cervica/ Spiiie

Osteoblastoma can be completely eured by en­bloc resection (8,9,15). In conclusion, early detectionof osteoblastoma in the spine is essential for theprevention of neural or vascular complications, andfor preserving the stability of the spinal eolumn.

Correspondence: Dr. Ramazan DurmazVisnelik Mh. Ali Fuat Güven Cd.Önçag Sitesi B-Blok 0:2026020, Eskisehir, TurkeyTelephone: (222) 239 29 79

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Durmaz: Osteoblastoma of the Cervical Spi/ie

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