The following case is courtesy of Drs. G. Hiremath and E. Benzel of the Cleveland Clinic Department of Neurosurgery and the Cleveland Clinic Spine Institute.
History & Physical: The patient is a 21 year old white female with a two year history of low back pain, treated conservatively with non-steroidal anti-inflammatory drugs. She was involved in a low speed motor vehicle accident a few months prior to presentation. She suffered no apparent trauma either to her head or spine, but began to complain of worsening low back pain. In addition, she began having pain in bilateral buttocks down to her knees. On physical exam, she had 5/5 strength in bilateral lower extremities. Her sensation was intact to light touch and pinprick; she had no bowel or bladder difficulties. She underwent repeat evaluation, and imaging with CT and MRI of her lumbar spine, and was noted to have a sacral mass. (Figure 1 & 2 Below)
Given that this mass would likely enlarge without intervention, and compress surrounding gastrointestinal, and neurovascular structures, in addition to the need to diagnose the lesion, the patient was consented for surgery, and an en bloc resection of the mass was performed with the assistance of the colorectal service providing anterior exposure to the mass. Final pathology revealed osteoblastoma with secondary aneurismal bone cyst.
Figure 1. MRI T1
Figure 2. Sagittal reconstruction of CT with contrast
1. Is this lesion the cause of this patient’s symptoms?
2. Is a percutaneous biopsy indicated in this patient?
3. What treatment options would you offer this patient?
4. If surgery is offered, what approach would you use?
5. If surgery is offered would you plan an en bloc resection?
6. Please add any suggestions or comments regarding this case:
appears to be sequelae related to prior trauma -?myositis ossificans/calcified hematoma
A CT guided biopsy is indicated, as this tumor may be eminently responsive to radiation therapy or chemotherapy. However,it must be ensured that the biopsy tract lies within the potential surgical field. If this tumor proves to be a sacrococcygeal chordoma, seeding by a poorly placed biopsy tract will have an untoward impact on the patient's prognosis. In case of a chordoma, an aggressive en bloc resection is the best strategy. The prognosis following surgical resection is 4.8 years and in combination with radiotherapy is 5.2 years. No treatment following the onset of symptoms may result in a survival of upto a year.
This can be a case of condroma of the sacrus, although some lymphomas can develop as similar lesions. the definitive treatment will depend on the results of biopsy