Eosinophilic granuloma of C5 causing cervical cord compression

Eur Spine J (1992) 1 : 53-54

European SpreeJournal 9 Springer-Verlag 1992

Eosinophilic granuloma of C5 causing cervical cord compression Nicola Maffulli 1, Giovanni Capasso 2, and Vittorino Testa 2 1Department of Orthopaedics, Newham General Hospital, Glen Road, Plaistow, London El3 8RU, UK 2First Institute of Orthopaedics, University of Naples, First Medical School, Via S. Andrea delle Dame 4, 1-80100 Napoli, Italy

Granulome 6osinophile de C5 responsable d'une compression m6dullaire R6sum6. U n e petite fille de deux arts atteinte d ' u n granul o m e 6osinophile du corps de C5 prdsentait une subluxation de C5 sur C6 avec une atteinte n e u r o l o g i q u e par c o m p r e s s i o n m6dullaire. A p r 6 s une biopsie percutande h visde diagnostique, l'enfant a pu b6n6ficier avec succ6s d ' u n traitement conservateur. L a mise en place d ' u n halo a permis d ' a p p l i q u e r une traction cervicale p e n d a n t n e u f semaines et d'obtenir ainsi la r6cup6ration neurologique. Mots-clds: Rachis cervical - T u m e u r - H a l o - t r a c t i o n Summary. A 2-year-old girl suffering f r o m eosinophilic g r a n u l o m a of the b o d y of C5 presented with subluxation of C5 on C6 and neurological i m p a i r m e n t due to cervical cord compression. Following a diagnostic p e r c u t a n e o u s biopsy, the child was m a n a g e d conservatively with halo traction for 9 weeks and r e c o v e r e d successfully. Key words: Cervical spine - T u m o u r - H a l o traction Correspondence to: N. Maffulli

T h e m o s t c o m m o n cause of a v e r t e b r a plana in a y o u n g patient is eosinophilic g r a n u l o m a [18]. O t h e r radiological and clinical pictures are possible, and vertebral instability with neurological i m p a i r m e n t has b e e n described [1, 2, 4 - 8 , 10-14, 17, 19, 20]. W e r e p o r t such a case in a 2-year-old girl.

Case report A 2-year-old Caucasian girl was admitted following a 10-day history of progressive difficulty in walking. Neurological examination showed bilateral ankle clonus and a positive Babinski reflex. Range of motion was within normal limits, and muscle power was unaffected. A full blood count revealed a mild anaemia (haemoglobin 10 g/ dl) with mild microcytosis and an erythrocyte sedimentation rate (ESR) of 37 mm/h. The Mantoux reaction was negative. A lateral cervical radiograph (Fig. 1) showed expansion of the vertebral body of C5, with lysis and anterior subluxation of C5 on C6. A technetium bone scan revealed an area of non-specific increased uptake. A T2-weighted magnetic resonance imaging (MRI) scan confirmed the radiographic findings and showed marked compression of the cervical theca and cervical cord with severe anterior angulation as well (Fig. 2). Skull traction was applied. A percutaneous needle biopsy was carried out under radiographic guidance. No growth was obtained

Fig. 1. Lateral view of the cervical spine. Expansion and fragmentation of the body of C5 are shown (arrow). C5 is subluxated anteriorly on C6 Fig. 2. Midline sagittal T2-weighted magnetic resonance imaging (MRI) scan. The forward subluxation is shown with gross angulation and compression of the spinal cord and the theca. C5 is an area of low signal containing three fragments of intermediate signal (arrow)

54 on culture of the biopsied tissue. The biopsy showed cellular tissue composed of pale mononuclear cells, darker polymorphonuclear leucocytes and some multi-nucleate giant cells, diagnostic of eosinophilic granuloma [18]. Halo traction was applied. After 6 weeks in traction, the neurological signs had fully resolved. Traction was maintained for a further 3 weeks, at which point the subluxation had resolved. At the last clinical review, which took place in another country 9 months after discharge, the child was clinically normal.

Discussion Eosinophilic granutoma of the spine generally results in a vertebra plana [3, 16], but cases without such a finding have been described [9]. Cervical instability due to an eosinophilic granuloma has b e e n reported following a C2 lesion, resulting in a fracture of the odontoid peg and anterior subluxation of the atlas [13, 17], and in a patient with multiple cervical lesions [12]. Minor degrees of subluxation have also been reported [4]. However, none was of the entity reported here without a concomitant vertebra plana. The expansion of the vertebral body m a y have played an adjuvant role in determining the subluxation, while a vertebra plana could have resulted in a m o r e stable position. Neurological impairment is generally due to protrusion of the granuloma or of bony fragments into the spinal canal. This would cause direct root compression at the level of the lesion, or extradural compression of the cord itself or of the cauda equina [1, 2, 4 - 8 , 10-14, 17, 19, 201 . Conservative m a n a g e m e n t is generally advocated [i5, 16], although, when the integrity of the spinal cord or of the roots is threatened, it is necessary to undertake m o r e aggressive treatment. Spinal cord decompression is rarely required, but it is m a n d a t o r y in cases of m a r k e d and/or progressive neurological deficit with accompanying radiographic signs. In the present case, percutaneous biopsy with stabilization by halo traction was sufficient to initiate the healing process.

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