MRI features of spinal chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis in children.

BACKGROUND: Spinal lesions in pediatric chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis (CRMO/CNO) can cause permanent sequelae; thus, early recognition of these is vital for management. OBJECTIVE: To characterize the MR imaging features and patterns of pediatric spinal CRMO/CNO. MATERIALS AND METHODS: This cross-section study received IRB approval. The first available MRI with documented spine involvement in children with CRMO/CNO was reviewed by a pediatric radiologist. Descriptive statistics were used to describe the characteristics of vertebral lesions, disc involvement, and soft tissue abnormality. RESULTS: Forty-two patients were included (F:M, 30:12); median age was 10 years (range 4-17). At diagnosis, 34/42 (81%) had spine involvement. Kyphosis in 9/42 (21%) and scoliosis in 4/42 (9.5%) patients were present at the time of spinal disease recognition. Vertebral involvement was multifocal in 25/42 (59.5%). Disc involvement was found in 11/42 (26%) patients, commonly in the thoracic spine and often with adjacent vertebrae height loss. Posterior element abnormalities were present in 18/42 patients (43%) and soft tissue involvement in 7/42 (17%). One hundred nineteen vertebrae were affected, commonly the thoracic vertebrae (69/119; 58%). Vertebral body edema was focal in 77/119 (65%) and frequently superior (42/77; 54%). Sclerosis and endplate abnormality were present in 15/119 (13%) and 31/119 (26%) vertebrae, respectively. Height loss was present in 41/119 (34%). CONCLUSION: Chronic non-bacterial osteomyelitis of spine is usually thoracic. Vertebral body edema is often focal at the superior vertebral body. Kyphosis and scoliosis occur in a quarter and vertebral height loss in a third of children at spinal disease recognition.

Cone-Beam CT-Guided Vertebroplasty in a Patient With Vertebra Plana.

OBJECTIVE: Vertebra plana has been considered a contraindication for vertebroplasty for various reasons including difficulty in needle placement. Recently, vertebroplasty under conventional fluoroscopic guidance has been shown to be feasible in patients with vertebra plana. CONCLUSION: Cone-beam CT with a navigation guidance system can be used during vertebroplasty in patients with severe vertebra plana to allow safe needle trajectory and placement.

Multimodality imaging workup of classical Hodgkin lymphoma in an 8-month-old child.

The incidence of Hodgkin lymphoma (HL) varies by age, most commonly affecting 15-19-year-olds. Cases in children less than 3 years old are exceedingly rare. We report a case of classical HL in an 8-month-old male; the youngest case reported thus far in the literature to our knowledge. Furthermore, while lymphadenopathy is a salient feature of HL, it was absent in our patient, who presented with immunodeficiency and delays in achieving neurologic milestones. A thorough radiologic workup demonstrated bilateral paravertebral masses, collapse of the T3 vertebrae, and severe spinal cord compression. Involvement of the lung, liver, and spleen was also noted. Histopathological evaluation of the paravertebral mass revealed a diagnosis of classical HL. Various non-neoplastic and malignant disorders, such as tuberculosis, Langerhans cell histiocytosis, leukemia, and neuroblastoma, amongst others, could be included in the differential diagnosis of our patient. Using an Illustrative case report, we review the multimodality imaging workup of Hodgkin lymphoma.

Time to revisit contraindications of vertebroplasty- A retrospective study of osteoporotic burst fracture operated with vertebroplasty and short segment fixation.

Background: To evaluate the safety and efficacy of vertebroplasty with short segmented cement augmented pedicle screws fixation for severe osteoporotic vertebral compression fractures (OVCF) with posterior/anterior wall fracture patients. Methods: A retrospective study of 48 patients of DGOU type-4 (vertebra plana) OVCF with posterior/anterior wall fracture, were treated by vertebroplasty and short segment PMMA cement augmented pedicle screws fixation. Radiological parameters (kyphosis angle and compression ratio) and clinical parameters Visual analogue scale (VAS) and Oswestry disability index (ODI) were analysed. Results: A significant improvement was noted in VAS (preoperative, 7.90±0.60; final follow-up 2.90±0.54) and ODI (77.10±6.96 to 21.30±6.70), (P<0.05). Neurological improvement was noted in all patients. Kyphosis corrected significantly from preoperative 23.20±5.90 to 5.30±1.40 postoperative with 5% (3.30±2.95) loss of correction at final follow-up. Anterior vertebral height restored significantly from 55.80±11.9% to 87.6±13.1% postoperative with 4.5±4.0% loss at final follow-up. Two cases of cement leakage were found, but both patients were asymptomatic. One patient had implant backout, one had Screw breakage and two had proximal junction kyphosis at final follow-up. No iatrogenic dural or nerve injury. Conclusions: Treatment with vertebroplasty with cement augmented screw fixation and direct decompression is a great option in treating such a complex situation in fragile age with fragile bones because. Vertebroplasty is a viable option for restoring vertebral anterior columns in patients who are considered as contraindications for vertebroplasty, like DGOU-4. It provides anterior support avoiding corpectomy, minimise blood loss, and also the duration of surgery. The addition of short segment fixation gives adequate support with less stress risers at the junctional area.

Vertebral Augmentation Compared to Conservative Treatment of Vertebra Plana and High-Degree Osteoporotic Vertebral Fractures: A Review of 110 Fractures in 100 Patients.

This is a retrospective study that evaluated surgical versus non-surgical treatment of 100 patients followed for up to six years diagnosed with severe osteoporotic vertebral compression fractures (VCF). Fractures were classified by percent collapse of vertebral body height as "high-degree fractures" (HDF) (>50%) or vertebra plana (VP) (>70%). A total of 310 patients with VCF were reviewed, identifying 110 severe fractures in 100 patients. The HDF group was composed of 47 patients with a total of 50 fractures. The VP group was composed of 53 patients with a total of 60 fractures. Surgical intervention was performed in 59 patients, comprised entirely of percutaneous vertebral cement augmentation procedures, including vertebroplasty, balloon kyphoplasty, or cement with expandable titanium implants. The remaining 41 patients only underwent conservative treatment that is the basis of the comparison study. All procedures were performed as an outpatient under local anesthesia with minimal sedation and there were no procedural complications. The initial or pre-procedural visual analog scale (VAS) score averaged 8.4 in all patients, with surgical patients having the most marked drop in VAS, averaging four points. This efficacy was achieved to a greater degree in surgically treated VP fractures compared to HDF. Non-surgical patients persisted with the most pain in both short- and long-term follow-up. This large series, with follow-up up to six years, demonstrated that the more severe fractures respond well to different percutaneous cement augmentation procedures with reduction of pain without increased complications in a comparison to conservatively treated patients.

Re-expansion and Stabilization of Vertebra Plana Fractures Using Bilateral SpineJack® Implants.

The surgical treatment of osteoporotic vertebral fractures with greater than 70% collapse, known as "Vertebra Plana (VP)" has been controversial. Originally VP was a considered a contraindication to vertebroplasty or kyphoplasty because of presumed difficulty of entering the collapsed vertebra as well as obtaining significant re-expansion or correct associated sagittal kyphosis. In some cases, multilevel pedicle screw fixation with or without attempts to correct the collapse is still performed to correct the kyphosis or prevent progression. With experience it was clear that the pedicle could be accessed and VP could be treated without added risk of epidural leak of cement or epidural extravasation. Now, with the introduction of newer third-generation intraspinal expansion devices that are larger and need to be placed bilaterally, their use in cases of VP was again an issue since VP cases were excluded from the original multicenter studies used for worldwide approval. This report reviews six cases of VP treated with bilateral SpineJack® implants (Stryker Corp, Kalamazoo, Michigan, USA) demonstrating it is not only feasible to place these larger size implants but achieve significant reconstitution of vertebral height as well as correction of the kyphotic deformity.

Multifocal Osseous Tuberculosis Mimicking Langerhans' Cell Histiocytosis: A Case Series.

Langerhans cell histiocytosis (LCH) is a common cause of multifocal lytic skeletal lesions in children. However, multifocal osseous tuberculosis can affect children and mimics LCH on imaging, especially in endemic regions. We report cases with atypical manifestations of multifocal osseous tuberculosis which were presumptively diagnosed as LCH. The findings of our series of cases suggest that on computed tomography (CT) irregular sclerotic margins, abscess formation, sclerosis of involved bone, and button sequestrum point toward a diagnosis of multifocal osseous tuberculosis, especially in endemic regions.

Low Volume Vertebral Augmentation with Cortoss® Cement for Treatment of High Degree Vertebral Compression Fractures and Vertebra Plana.

This is a retrospective analysis of a consecutive series of patients undergoing vertebroplasty and vertebral augmentation in an outpatient setting for high degree osteoporotic vertebral fractures or vertebra plana using consistently low volumes (less than 3 cc) of Cortoss® cement, rather than polymethylmethacrylate (PMMA). The results in these patients demonstrate that it is both technically feasible to do vertebroplasty on these patients and using a low volume hydrophilic silica-based cement is effective in providing diffuse vertebral body fill with minimal complications. There was no increased risk of complications, such as cement leakage, displacement of bone fragments, or progression of the angulation. Specifically, with over a 24-month follow-up, the preoperative collapse or angulation did not worsen and none of the patients developed adjacent level fractures or required further surgery at the involved vertebral level.

Corpectomy and expandable cage replacement versus third generation percutaneous augmentation system in case of vertebra plana: rationale and recommendations.

BACKGROUND: To evaluate the role of third generation percutaneous vertebral augmentation systems (Spine Jack®) as alternative to the corpectomies and expandable cages replacement (X-Core® Adjustable VBR System) in the treatment of vertebra plana (VP) as complication of the osteoporosis vertebral fracture (OVF). METHODS: Spine Jack® is a new device for mechanical kyphoplasty (MK). It is a titanium implant designed to restore the height of the vertebral body in OVF, primary or secondary bone tumors, or traumatic fractures. The X-Core® adjustable VBR System is a vertebral body replacement device indicated for use in the thoracolumbar spine (T1 to L5). The preoperative radiographic exams, computed tomography (CT), and magnetic resonance imaging (MRI) were performed in all cases. Clinical outcome measures included preoperative and postoperative Oswestry Disability Index (ODI), Visual Analog Scale pain score (VAS), neurologic examination, complications, estimated blood loss, and operating time. Postoperative radiographic evaluations were made at 1, 6, and 12 months. RESULTS: The anterior and middle column reconstruction by Spine Jack represents a valid alternative to the corpectomy in the patients affected by VP, especially in case elderly and/or high operative risk. In case of Spine Jack use, the correct indications must be respected: the hyperintense signal in STIR MRI sequences to the level of the fractures must be present. The eventual posterior spinal cord compression represents a relative contraindication. In case it would be superior to 1/3 and 2/3 respectively in case of fractures level above and below the spinal cord, a direct posterior spinal cord decompression must be performed. CONCLUSIONS: Avoiding the corpectomy, it is possible to reduce the operating time and the associated risks, as well as reducing blood loss.

[Langerhans cell histiocytosis with vertebral involvement and soft tissue extension: clinical case]. / Histiocitosis de células de Langerhans con compromiso vertebral y de partes blandas: caso clínico.

UNLABELLED: Langerhans cell histiocytosis is a heterogeneous disease of unknown etiology characterized by proliferation of Langerhans cells. It is a rare disease. Bone involvement is common but vertebral disease is rare. We present a 4 year old patient with abdominal pain and neurologic symptoms. Magnetic resonance showed vertebra plana in D9 with involvement of paravertebral soft tissues. The child underwent surgery for decompression and biopsy. Biopsy confirmed Langerhans cell histiocytosis. She was treated with vinblastine and prednisone during 6 months following LCH-III with complete recovery of neurologic symptoms. CONCLUSION: Langerhans cell histiocytosis is a differential diagnosis in a radiograph with vertebra plana or collapse of vertebral body.

La histiocitosis de células de Langerhans es una enfermedad heterogénea de etiología desconocida, que se caracteriza por la proliferación no controlada de histiocitos. Es poco frecuente y, si bien el compromiso óseo es común, la afectación vertebral es rara. Se presenta una niña de 4 años que consultó por dolor abdominal difuso de un mes de evolución, al que se agregó constipación y, posteriormente, debilidad en los miembros inferiores. El examen físico mostraba clonus e hiperreflexia en los miembros inferiores y la marcha era inestable. Se realizó una resonancia magnética, que mostró la vértebra dorsal 9 (D9) plana con tejido blando patológico en el espacio epidural y laterovertebral. Se realizó una cirugía descompresiva, artrodesis para fijar la columna y toma de biopsia, que confirmó el diagnóstico de histiocitosis de células de Langerhans. Recibió 6 meses de tratamiento con metilprednisona y vinblastina, de acuerdo con el protocolo LCH III, con excelente evolución y remisión completa. Conclusión: frente a una imagen radiológica de vértebra plana o colapso vertebral, debe pensarse en histiocitosis de células de Langerhans como diagnóstico diferencial.

Vertebra plana: reappraisal of a contraindication to percutaneous vertebroplasty.

PURPOSE: We evaluated the efficacy of percutaneous vertebroplasty (PVP) in treating symptomatic vertebra plana, which is considered a relative contraindication to the procedure. METHODS: Out of 540 levels treated in 260 patients, we treated 40 patients (mean age: 74 years) with vertebra plana between T6 and L3 (37 osteoporotic and 3 metastatic levels). In most cases, the vertebra was accessed with fluoroscopic guidance from a single, transpedicular approach. All patients underwent a preliminary MRI examination, an immediate, post-procedure radiological examination, and a follow-up examination (mean duration, 6 months). RESULTS: Both immediate and follow-up examinations showed that the mean pain and physical disability scores were significantly reduced compared to the scores before treatment (p ≤ 0.001). No complications occurred during the procedures. In 23/40 cases, asymptomatic intradiscal cement leakage occurred. Posterior or perivertebral leakage never occurred. In most cases, an intravertebral cleft was present, and we filled it with polymethylmethacrylate, which healed the pseudarthrosis. Partial vertebral height was restored in 7 cases. In 6 cases, a new fracture occurred between 1 and 3 months at a different level from the treated level. CONCLUSION: Our preliminary results showed that PVP was a safe, effective treatment for symptomatic vertebra plana; thus, it should not be discounted for this group of patients. In most cases, the procedure was favored by the presence of an intravertebral cleft that appeared to contribute to minimizing the risk of posterior cement leakage. Filling the cleft with polymethylmethacrylate allowed intravertebral stabilization.

Histiocitosis de células de Langerhans con compromiso vertebral y de partes blandas: Caso clínico / Langerhans cell histiocytosis with vertebral involvement and soft tissue extension: Clinical case

La histiocitosis de células de Langerhans es una enfermedad heterogénea de etiología desconocida, que se caracteriza por la proliferación no controlada de histiocitos. Es poco frecuente y, si bien el compromiso óseo es común, la afectación vertebral es rara. Se presenta una niña de 4 años que consultó por dolor abdominal difuso de un mes de evolución, al que se agregó constipación y, posteriormente, debilidad en los miembros inferiores. El examen físico mostraba clonus e hiperreflexia en los miembros inferiores y la marcha era inestable. Se realizó una resonancia magnética, que mostró la vértebra dorsal 9 (D9) plana con tejido blando patológico en el espacio epidural y laterovertebral. Se realizó una cirugía descompresiva, artrodesis para fijar la columna y toma de biopsia, que confirmó el diagnóstico de histiocitosis de células de Langerhans. Recibió 6 meses de tratamiento con metilprednisona y vinblastina, de acuerdo con el protocolo LCH III, con excelente evolución y remisión completa. Conclusión. Frente a una imagen radiológica de vértebra plana o colapso vertebral, debe pensarse en histiocitosis de células de Langerhans como diagnóstico diferencial.

Langerhans cell histiocytosis is a heterogeneous disease of unknown etiology characterized by proliferation of Langerhans cells. It is a rare disease. Bone involvement is common but vertebral disease is rare. We present a 4 year old patient with abdominal pain and neurologic symptoms. Magnetic resonance showed vertebra plana in D9 with involvement of paravertebral soft tissues. The child underwent surgery for decompression and biopsy. Biopsy confirmed Langerhans cell histiocytosis. She was treated with vinblastine and prednisone during 6 months following LCH-III with complete recovery of neurologic symptoms. Conclusion. Langerhans cell histiocytosis is a differential diagnosis in a radiograph with vertebra plana or collapse of vertebral body.