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Osteochondroma of the axis : letter to editor.
A 4 year old boy presented with a palpable mass in the paraspinal region of the neck, which was noticed by his parents two months prior to presentation to us. He complained of occasional pain in the region not related to any specific activity or movement of the spine. There were no symptoms or signs referable to the limbs. There was no neurological deficit on examination. A firm rounded non tender mass was palable in the paraspinal region. The overlying skin was normal. The lesion was not mobile. X-ray of the spine showed a cauliflower like enlargment of the C2 spinous process [Figure:1]. CT scan of the cervical spine showed a bony lesion arising from the spinous process and lamina of C2 which had a superficial hypodense 'cap' [Figure:2]. The lesion was approached though a posterior mildline incision. It was attached to the posterior elements of C2 on the right side and was firm and multilobulated. The spinous process itself was bulbous and deformed. The lesion extended to the pedicle on the right side. The soft tissue and bony lesion were radically removed. Care was taken to preserve the C2,3 joint, in order or prevent later instability. Histopatholgical examination confirmed the lesion to be an osteochondroma. Osteochondromas are among the most frequent of benign tumours of bone. They occur either as solitary lesions or as multiple osteochondromatosis.[1],[2],[3] However, the spine is affected in only 5 to 7% of these tumours. Osteochondromas are commonly seen in the second or the third decade of life. They develop from progressive enchondral ossification and thus show rapid growth. Spinal osteochondromas most commonly affect the posterior elements of the spine, though occasionally, they may invlove the pedicle and other parts of the vertebral body. In 1977, Inglis et al1 reported the second case of osteochondroma affecting the posterior elements of the cervical spine, and suggested that it be considered in the differential diagnosis of bony lesions affecting the spinal column. The lesions present as asymptomatic palpable masses or more unusually, with neurological deficit.[2] Tumours of the axis may also present with nuchal pain, or, as a parapharyngeal mass.4 X-rays are often diagnostic as they clearly show the bony cum soft tissue lesion. CT scans clearly delineate the origin of the tumour and are useful in the diagnosis, and follow up of these lesions, especially in the detection of early recurrences. MRI demonstrates the relationship of the tumour, the spinal cord, and adjacent soft tissue to each other. However, diagnosis by MRI may be made difficult due to unusual gadolinium enhancement by the tumour.[5] Radical excision of the lesion is the treatment of choice. This can sometimes be difficult, due to the extent of the tumour and involvement of the articular surfaces. The bulbous enlargement of the bony structures distorts the normal anatomical relationship in the region, and this should be kept in mind during excision of these benign tumours. Our patient was a young child who presented with an enlarging palpable mass at the back of the neck. Unusual features about the case were the young age of presentation and the location of the solitary osteochondroma.
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