Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Destructive osteoblastoma of the cervical spine with complete neurologic recovery

Abstract

Study design: Case report.

Objective: To describe a patient with a large tumor lesion of the 6th vertebrae affecting surrounding soft tissue, and symptoms of cord compression. Histologic diagnosis indicated a destructive osteoblastoma following dorsal and anterior resection and internal fixation.

Setting: University Hospital, Germany.

Methods: A 23-year old male patient was admitted with a 2-month history of increasing upper extremity weakness and pain. X-ray and MRI indicated massive involvement of the anterior and posterior elements of the 6th vertebrae with a large soft tissue mass. Following emergency decompression and dorsal stabilization, the pathologic investigation revealed a destructive osteoblastoma. Subsequent dorsal and anterior resection with internal fixation were performed.

Results: The patient initially presented with symptoms of beginning paraplegia of C6/7. According to the neurologic classification of spinal cord injury, motor function score was 56 and sensory function score 83. After emergency dorsal decompression and internal fixation with Luque-Instrumentation® he showed increasing neurological recovery. Complete neurological recovery was achieved at 2 and 12-months postoperatively, following secondary dorsal and anterior resection of the tumor and internal fixation with bone cement (PalacosR®) and Harms-cage®. Radiologic signs of local recurrence were identified 1 year postoperatively.

Conclusion: Osteoblastoma of the cervical spine is rare. Patients often present with severe neurological symptoms due to significant tumor mass. Complete resection is necessary to regain full recovery, to prevent recurrence and, in some cases, malignant transformation.

Introduction

Benign osteoblastoma was independently described by Jaffe (1956)1 and Lichtenstein (1956).2 It is a vascular, osteoid and bone-forming tumor, cytologically characterized by osteoblasts. Radiological signs include osteolytic lesions larger than 2 cm, showing little or no evidence of perifocal sclerosis.3 Osteoblastomas account for approximately 1% of all primary bone tumors.3,4,5 About 30% to 40% of all cases involve the spine3,5,6,7 and of those about 20% to 40% the cervical spine.5,7,8,9 Most often the osteoblastoma is confined to the posterior elements.7,10,11,12 The main clinical feature is pain, following neurological symptoms and scoliosis.5,7,8 Frequently, there is an invasion of the epidural space, surrounding of nerve roots and cord compression.7,8,13,14 Recurrence rates after resection are described up to 10%.9,14,15,16,17 Some authors have reported the possibility of malignant transformation.18,19,20 Surgery is aimed at complete resection and protection of the sensitive neuroanatomic structures.

Case Report

A 23-year-old male patient presented with acute neurological symptoms, after complaining of muscle weakness in the upper extremity for 2 months. No ambulatory X-ray investigation had been performed up to this point.

The physical examination indicated a loss of superficial pain in the lower extremity, the trunk and the right digiti quintus. Superficial sensory function was decreased in the lower extremity and the trunk. Muscle stretch reflexes of the upper extremity were hyperactive, and normal for the lower extremity. Muscular status results indicated grade 0 for the lumbrical muscles, grade 3 for C7 and C8 innervated muscles on both sides and grade 4 for C4–6 innervated muscles. C1–3 innervated muscles showed normal power on the right side. The patient's motor function score was 56 and his sensory function score reached 83 according to the standard neurologic classification of spinal cord injury. The ASIA/IMSOP scale was classified grade B. Standard cervical X-ray (anteroposterior and lateral view) showed a sclerotic tumor lesion involving the vertebrae with no sign of instability (Figure 1).

Figure 1
figure1

Sclerotic osteoblastoma of the 6th cervical vertebrae

MRI of the spine indicated a local destructive tumorous lesion of the 6th cervical vertebrae with compression of the spinal cord and paravertebral involvement, both anteriorly and posteriorly (Figures 2 and 3).

Figure 2
figure2

Involvement of the anterior and posterior parts of the vertebra with signs of spinal cord compression

Figure 3
figure3

Tumorous destruction of the posterior lamina and the vertebra with involvement of the surrounding soft tissue

According to the Enneking score of benign musculoskeletal lesions the tumor was classified grade 3.21

Emergency dorsal decompression of C5–7 combined with Luque-Spondylodesis® C4–Th1 was performed initially. Thereafter the patient presented with normal power, decrease of pain and an increase of sensory function. Biopsy results indicated a local destructive osteoblastoma. Postoperative angiography of the vertebral arteries produced no sign of compression. Complete dorsal extirpation of the tumor was performed 3 weeks later. The patient continued to present with normal power and reduction of sensation of the upper extremity. Light touch, pin prick and vibration were decreased, especially on the right side, of C7 and C8 dermatomes, where temperature was normal. During a 3rd stage operation the tumor and the 6th vertebrae were resected anteriorly and segment stabilization was performed with bone cement (PalacosR®), Orion-plate® and Harms-cage® implantation (Figure 4).

Figure 4
figure4

Internal fixation with Orion-plate®, Harms-cage® and PalacosR® anterior and Luque-Spondylodesis® C4-Th1 posterior

Macroscopic and histologic results indicated disappearance of the tumor. However, postoperative X-ray showed a sclerotic area at the dorsal side of the preserved part of the body.

Philadelphia-Orthesis® was applied for postoperative mobilization during the following 6 weeks. Before discharge the patient still showed reduced sense of light touch, pin prick and vibration of C7 and C8 on both sides. ASIA/IMSOP scale was classified grade D. The motor function score increased to 89 points and the sensory function score to 216 points. Two months post surgery the patient presented with full neurologic recovery and functional scoliosis due to muscular weakness of the cervical spine. The X-ray still indicated a small sclerotic lesion on the dorsal side of the vertebral body and with stable internal fixation. At 4-months post surgery, CT-scans showed no evidence of recurrence and normal neurologic function. Changes in the sclerotic area were visible in the 1-year postoperative X-ray (Figure 5).

Figure 5
figure5

One year postoperative with changes of the dorsal sclerotic area

A subsequent MRI and CT-scan found high rates of metal artefacts, indicating signs of local recurrence paravertebrally at the right transverse process of the 6th vertebrae (Figure 6).

Figure 6
figure6

Signs of local recurrence at the right transverse process of the 6th vertebra

The patient maintains normal sensory and motor functions (100 points motory function score and 224 points sensory function score).

Therefore, current surgical treatment is not necessary, and the next follow-up is scheduled 4 months later for clinical, X-ray and MRI investigation.

Discussion

Osteoblastoma is rare. It accounts for approximately 0.5% to 1% of all primary bone tumors.3,4,5 Spinal involvement is described in 30% to 40% of all cases.3,5,6,7 In 20% to 40% of those, the cervical spine is affected.5,7,8,9 Osteoblastoma is most frequently found in the posterior elements.7,10,11,12 Involvement of the cervical spine when compared to other spinal regions is related to a higher rate of anterior destruction, probably due to reduced volume of the posterior elements.11 Pain is usually the main clinical symptom, followed by neurologic symptoms, scoliosis and torticollis.5,7,8 Compared to osteoid osteoma there is a higher rate of severe neurological deficit.7,8,13,14 The large tumor mass can be associated with compression of the vertebral arteries.

Angiography in the current case showed no sign of compression. Zambelli et al. recommended that the vertebral arteries should be preserved in all cases.22 Classical X-ray investigation shows radiolucent destructions with a perifocal sclerosis.3 In the current case the X-ray showed a sclerotic lesion of the vertebra and the pedicles, indicating a departure from the classic radiographic picture.

Delay of diagnosis is very common, and seems to occur on average 6–12 months or later following the initial presentation.5,8,23 In the current case, the patient was correctly diagnosed after 2 months due to his significant neurological symptoms. Symptoms of increasing muscle weakness and pain were evident even though no prior X-ray examination had been performed.

The treatment of choice for osteoblastoma is complete surgical resection. Preoperative interdisciplinary cooperation is necessary between radiologist, neurosurgeons, vascular surgeons and orthopaedic surgeons. In our case macroscopic and histologic results did not point to a residual tumor mass, but the postoperative X-ray still showed a sclerotic area at the dorsal column of the left vertebral part. Recurrence rates are described up into 10%, especially in Enneking Grade 3 lesions.9,14,15,16,17 One year post surgery, this case showed radiologic signs of paravertebral local recurrence without any neurological symptoms. In some cases there is a possibility of malignant transformation.18,19,20 If complete resection is not possible, radiotherapy and in some cases chemotherapy seem to be alternative treatment options.24,25,26,27

Osteoblastoma should be ruled out if patients present with neurological symptoms and pain over extended periods of time, especially at night. Delay in diagnosis is common and effective treatment is important to prevent neurologic complications, recurrence and malignant transformation. In cases with large tumor masses it is difficult to perform complete resection.

References

  1. 1

    Jaffe HL . Benign osteoblastoma Bull Hosp J Orthop Inst 1956 17: 141

    CAS  Google Scholar 

  2. 2

    Lichtenstein L . Benign osteoblastoma Cancer 1956 9: 1044

    CAS  Article  Google Scholar 

  3. 3

    Nemoto O et al. Osteoblastoma of the spine: A review of 75 cases Spine 1990 12: 1272–1280

    Article  Google Scholar 

  4. 4

    Huvos AG . Bone tumors: Diagnosis, treatment and prognosis Philadelphia: W.B. Saunders Co 1979 pp 33–46

    Google Scholar 

  5. 5

    Healey JH, Ghelman B . Osteoid osteoma and osteoblastoma: Current concepts and recent advances Clin Orthop 1986 204: 76–85

    Google Scholar 

  6. 6

    Marsh BW, Bonfiglio M, Brady LP, Enneking WF . Benign osteoblastoma: Range of manifestations J Bone Joint Surg 1975 57A: 1–9

    Article  Google Scholar 

  7. 7

    Boriani S et al. Osteoblastoma of the spine Clin Orthop 1992 278: 37–45

    Google Scholar 

  8. 8

    Raskas DS et al. Osteoid osteoma and osteoblastoma of the spine J Spinal Disord 1992 5: 204–211

    CAS  Article  Google Scholar 

  9. 9

    Di Lorenzo N et al. Primary tumors of the cervical spine: surgical experience with 38 cases Surg Neurol 1992 38: 12–18

    CAS  Article  Google Scholar 

  10. 10

    McLeod RA, Dahlin DC, Beabout JW . The spectrum of osteoblastoma Am J Roentgenol 1976 126: 321

    CAS  Article  Google Scholar 

  11. 11

    Schwartz HS, Pinto M . Osteoblastomas of the cervical spine J Spinal Disord 1990 3: 179–182

    CAS  PubMed  Google Scholar 

  12. 12

    Frassica FJ et al. Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents Orthop Clin North Am 1996 27: 559–574

    CAS  PubMed  Google Scholar 

  13. 13

    Janin Y, Epstein JA, Carras R, Khan A . Osteoid osteomas and osteoblastoma of the spine Neurosurgery 1981 8: 31

    CAS  Article  Google Scholar 

  14. 14

    Pettine KA, Klassen RA . Osteoid osteoma and osteoblastoma of the spine J Bone Joint Surg 1986 68A: 354

    Article  Google Scholar 

  15. 15

    Eisenbrey AB, Huber PJ, Rachmaninoff N . Benign osteoblastoma of the spine with multiple recurrences J Neurosurg 1969 31: 468–473

    CAS  Article  Google Scholar 

  16. 16

    Gertzbein SD et al. Recurrent benign osteoblastoma of the second vertebra: a case report J Bone Joint Surg 1973 55B: 841–847

    Article  Google Scholar 

  17. 17

    Myles ST, MacRae ME . Benign osteoblastoma of the spine in childhood J Neurosurg 1988 68: 884–888

    CAS  Article  Google Scholar 

  18. 18

    Corbett JM, Wilde AH, McCormick LJ, Evarts CM . Intra-articular osteoid-oseoma: a diagnostic problem Clin Orthop 1974 98: 225–230

    Article  Google Scholar 

  19. 19

    Dahlin DC, Unni KK . Bone tumors: General Aspects and Data on 8542 cases Springfield: Charles C. Thomas 1986 pp 102–117

    Google Scholar 

  20. 20

    Mirra JM . Bone tumors. Diagnosis and Treatment Philadelphia: J.B. Lippincott 1980 pp 110–117

    Google Scholar 

  21. 21

    Enneking WF . Clinical Musculoskeletal Pathology Gainesville: Florida, Storter 1986 pp 464

    Google Scholar 

  22. 22

    Zambelli PY, Lechevallier J, Bracq H, Carlioz H . Osteoid osteoma or osteoblastoma of the cervical spine in relation to the vertebral artery J Pediatr Orthop 1994 14: 788–792

    CAS  Article  Google Scholar 

  23. 23

    Klöckner C . Operative Therapiekonzepte bei Tumoren der kindlichen Wirbelsäule Z Orthop Ihre Grenzgeb 1999 137: 9–10

    Google Scholar 

  24. 24

    Dorfman HD et al. Case records of the Massachusetts General Hospital: Case 40 N Engl J Med 1980 303: 866–873

    Article  Google Scholar 

  25. 25

    Shikata J, Yamamuro T, Hiokazu I, Kotoura Y . Benign osteoblastoma of the cervical spine. A review of 75 cases Surg Neurol 1987 27: 381–385

    CAS  Article  Google Scholar 

  26. 26

    Camitta B et al. Osteoblastoma response to chemotherapy Cancer 1991 68: 999–1003

    CAS  Article  Google Scholar 

  27. 27

    Berberoglu S, Oguz A, Aribal E, Ataoglu O . Osteoblastoma response to radiotherapy and chemotherapy Med Pediatr Oncol 1997 28: 305–309

    CAS  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to M Schneider.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Schneider, M., Sabo, D., Gerner, H. et al. Destructive osteoblastoma of the cervical spine with complete neurologic recovery. Spinal Cord 40, 248–252 (2002). https://doi.org/10.1038/sj.sc.3101288

Download citation

Keywords

  • osteoblastoma
  • cervical spine
  • spinal cord compression
  • operative treatment

Further reading

Search

Quick links