Indian J Pediatr DOI 10.1007/s12098-013-1315-1
PICTURE OF THE MONTH
Hyperplasia of Cervical Spinous Process Presenting as 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 pain for last 2 y. There was no history of neck trauma or any other significant 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 with history of noticing the swelling for the first time 2 years back,
with no change in size since then. Neurological examination was unremarkable with no restriction of neck movements. Radiographs revealed hypertrophy of the C3 spinous process. Computed tomography (CT) revealed hypertrophied left lamina of C3 with enlarged and thickened spinous process (Fig. 2). In addition there was schisis of spinous process of C4
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. Sharma Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India G. D. Satyarthee (*) Department of Neurosurgery, Cardio-Neuro Centre, All India Institute of Medical Sciences, Room No 720, New Delhi 110029, India e-mail: [email protected]
with thickened lamina (Fig. 2c, d). Magnetic resonance imaging revealed no abnormality of the cord (Fig. 3). Patient underwent excision of the enlarged spinous process by posterior midline approach and made an uneventful recovery. Histopathological examination revealed it to be normal bone tissue. Congenital abnormalities of spinous process are often incidental radiological findings and include double or hypertrophied spinous process [1]. Chitkara et al. described
Indian J Pediatr Fig. 2 a Non contrast CT sagittal sections of cervical spine showing enlarged spinous process, b Non contrast CT axial section showing hypertrophied left lamina and elongated spinous process of C3 (star), c, d Non contrast CT axial sections showing schisis of C4 spinous process with the enlargement of both halves
a patient with two ‘rib-like swellings’ at the back of the neck [2]. Unilateral hyperplasia of a spinous process is a rare finding and has only been described thrice [3–5]. Spinous process 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 a form of neural tube defect and is caused by the failure of closure of spine. Such abnormalities rarely cause clinical symptoms except for aesthetic problems. However, few patients may present with localized pain, neurological impairment and limitations of movement. The etiological factor behind this anomaly is not clear and may involve abnormal extension of chondrification and ossification of one vertebral arch with normal development of the other arch [3]. CT with three dimensional reconstruction and MRI provide details of the pathology and help in making precise diagnosis. The significance of such abnormalities is that these should be included in the differential in patients with recurrent episodes of cervical neck pain. Contribution Guru Dutta Satyarthee will act as guarantor for this paper. Conflict of Interest None. Role of Funding Source None.
References
Fig. 3 a MRI T1WI sagittal images showing enlarged spinous process causing skin elevation, b MRI T1WI axial section showing schisis of C4 spinous process with the normal spinal cord
1. Klimo P Jr, Rao G, Brockmeyer D. Congenital anomalies of the cervical spine. Neurosurg Clin N Am. 2007;18:463–78. 2. Chitkara N, Sharma NK, Dhall U, Bakshi N, Kamal H. Congenital exostoses of the cervical vertebrae. Neurol India. 2003;51:130–1. 3. Esposito G, de Bonis P, Tamburrini G, Massimi L, Byvaltsev V, di Rocco C, et al. Unilateral hyperplasia of the left posterior arch and associated vertebral schisis at C6 level. Skeletal Radiol. 2009;38:1191–5.
Indian J Pediatr 4. Heyer CM, Nicolas V, Peters SA. Unilateral hyperplasia of a cervical spinous 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 of lamina and spinous process of C6 vertebra: Case report. Surg Radiol Anat. 2012;34:875–8.
PICTURE OF THE MONTH
Hyperplasia of Cervical Spinous Process Presenting as 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 pain for last 2 y. There was no history of neck trauma or any other significant 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 with history of noticing the swelling for the first time 2 years back,
with no change in size since then. Neurological examination was unremarkable with no restriction of neck movements. Radiographs revealed hypertrophy of the C3 spinous process. Computed tomography (CT) revealed hypertrophied left lamina of C3 with enlarged and thickened spinous process (Fig. 2). In addition there was schisis of spinous process of C4
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. Sharma Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India G. D. Satyarthee (*) Department of Neurosurgery, Cardio-Neuro Centre, All India Institute of Medical Sciences, Room No 720, New Delhi 110029, India e-mail: [email protected]
with thickened lamina (Fig. 2c, d). Magnetic resonance imaging revealed no abnormality of the cord (Fig. 3). Patient underwent excision of the enlarged spinous process by posterior midline approach and made an uneventful recovery. Histopathological examination revealed it to be normal bone tissue. Congenital abnormalities of spinous process are often incidental radiological findings and include double or hypertrophied spinous process [1]. Chitkara et al. described
Indian J Pediatr Fig. 2 a Non contrast CT sagittal sections of cervical spine showing enlarged spinous process, b Non contrast CT axial section showing hypertrophied left lamina and elongated spinous process of C3 (star), c, d Non contrast CT axial sections showing schisis of C4 spinous process with the enlargement of both halves
a patient with two ‘rib-like swellings’ at the back of the neck [2]. Unilateral hyperplasia of a spinous process is a rare finding and has only been described thrice [3–5]. Spinous process 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 a form of neural tube defect and is caused by the failure of closure of spine. Such abnormalities rarely cause clinical symptoms except for aesthetic problems. However, few patients may present with localized pain, neurological impairment and limitations of movement. The etiological factor behind this anomaly is not clear and may involve abnormal extension of chondrification and ossification of one vertebral arch with normal development of the other arch [3]. CT with three dimensional reconstruction and MRI provide details of the pathology and help in making precise diagnosis. The significance of such abnormalities is that these should be included in the differential in patients with recurrent episodes of cervical neck pain. Contribution Guru Dutta Satyarthee will act as guarantor for this paper. Conflict of Interest None. Role of Funding Source None.
References
Fig. 3 a MRI T1WI sagittal images showing enlarged spinous process causing skin elevation, b MRI T1WI axial section showing schisis of C4 spinous process with the normal spinal cord
1. Klimo P Jr, Rao G, Brockmeyer D. Congenital anomalies of the cervical spine. Neurosurg Clin N Am. 2007;18:463–78. 2. Chitkara N, Sharma NK, Dhall U, Bakshi N, Kamal H. Congenital exostoses of the cervical vertebrae. Neurol India. 2003;51:130–1. 3. Esposito G, de Bonis P, Tamburrini G, Massimi L, Byvaltsev V, di Rocco C, et al. Unilateral hyperplasia of the left posterior arch and associated vertebral schisis at C6 level. Skeletal Radiol. 2009;38:1191–5.
Indian J Pediatr 4. Heyer CM, Nicolas V, Peters SA. Unilateral hyperplasia of a cervical spinous 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 of lamina and spinous process of C6 vertebra: Case report. Surg Radiol Anat. 2012;34:875–8.
