A rare case of an expansile spinopelvic aneurysmal bone cyst managed with embolization, excision, and fusion
- Department of Orthopaedics, Seth G.S Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India.
- Department of Physiotherapy, MGM School of Physiotherapy, Mumbai, Maharashtra, India.
Rudra Mangesh Prabhu, Department of Orthopaedics, Seth G.S Medical College and K.E.M Hospital, Mumbai, Maharashtra, India.
DOI:10.25259/SNI_1045_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Rudra Mangesh Prabhu1, Tushar N. Rathod1, Akash Vasavda1, Shivaprasad S. Kolur1, Punit Tayade2. A rare case of an expansile spinopelvic aneurysmal bone cyst managed with embolization, excision, and fusion. 30-Nov-2021;12:580
How to cite this URL: Rudra Mangesh Prabhu1, Tushar N. Rathod1, Akash Vasavda1, Shivaprasad S. Kolur1, Punit Tayade2. A rare case of an expansile spinopelvic aneurysmal bone cyst managed with embolization, excision, and fusion. 30-Nov-2021;12:580. Available from: https://surgicalneurologyint.com/surgicalint-articles/11262/
Background: Aneurysmal bone cysts (ABC) are benign osteolytic lesions of the metaphyseal regions of long bones that typically contribute to rapid bony expansion. Here, we present an ABC involving the spinopelvic region in a 15-year-old male that required embolization, surgical excision, and fusion.
Case Description: A 15-year-old male, presented with gradually progressive painful lower back swelling of 4 months’ duration. Once the diagnosis of an ABC was established based on a combination of X-ray, MR, and CT studies, he underwent selective arterial embolization, extended surgical excision (i.e. curettage), with a posterior fusion. Two years postoperatively, the patient remained neurologically intact without radiographic evidence of lesion recurrence.
Conclusion: Large expansile ABC involving the vertebral bodies should be managed with preoperative selective arterial embolization, surgical decompression/curettage, and spinopelvic fixation.
Keywords: Aneurysmal bone cyst, Embolization, Expansile, Spino-pelvic
Aneurysmal bone cyst (ABC) primarily affects individuals between 10 and 20 years of age and is more common in females.[
Clinical presentation and radiographic findings
A 15-year-old male presented with gradually progressive painful low back swelling of 4 months’ duration without any neurological deficit. Plain lumbosacral X-rays showed an enlarged lytic lesion involving predominantly the left side of the sacrum and lower lumbar vertebrae L4-S2 [
(a) T2-weighted MRI scan (sagittal cut) of the whole spine demonstrates 85 × 75 × 140 mm sized, large multi-loculated expansible mass with soap-bubble-like appearance occupying the region of L4, L5, S1, and S2. (b) CT scan (axial cut) shows a large lytic lesion involving both the sacral alae.
Embolization of ABC lesion
An arterial angiogram confirmed the vascularity of the ABC mass. The patient underwent preoperative selective arterial embolization on the day of surgery, followed by an extended curettage [
The post-operative anteroposterior and lateral radiograph of the spine. (a) Antero-posterior radiograph demonstrates bilateral pedicle screw fixation at L4, right-sided L5, and S1 pedicle screw fixation with a left trans-iliac pedicle screw and an anterolateral inter-body fusion at L5-S1 level. (b) The lateral radiograph demonstrates the screw and rod construct with the cage at the above-described levels.
The histopathological examination confirmed the diagnosis of an ABC lesion: osteoid foci, spindle cells, multinucleated giant cells, and reactive changes.
Postoperative follow up
Two years later, the patient remained asymptomatic without evidence of ABC lesion recurrence. The only focal asymptomatic finding on radiography was the loosening of the set screw on the left side inferiorly [
Clinical presentation and etiology of ABC lesions
ABCs have an inherent high local recurrence rate (i.e. 12 to 31.5%) even after “definitive” primary treatment.[
Frequency of ABC lesions
ABCs comprise 8–20% of all spine tumors with 3–12% occurring in the sacrum and pelvis, respectively.[
Pathogenesis of ABCs
Several theories have been proposed regarding the pathogenesis of ABCs. Preexisting pathology with secondary vascular factors may initiate the formation of a periosteal and/or intra-osseous arterio-venous malformation. Increasing hemodynamic forces generated by high-pressure vascular channels inside the cavity likely contribute to the rapid erosion of osseous trabeculae.
MRI best documents the extent of soft tissue involvement and neural compression. T2 studies usually show heterogeneous lesions containing multiple fluid-filled interfaces.[
With ABC lesions, CT scans of the spinal pedicles and vertebral bodies typically demonstrate multiple communicating cavities containing fluid-filled levels.
The main goal of selective arterial embolization in the management of ABCs is to decrease vascularity and reduce the level of intraoperative blood loss. Surgery is performed within 24 to 48 hours of embolization.[
Radiation is not recommended as a primary treatment for the management of spinal ABC. Capanna et al. suggested that adjuvant radiotherapy alone had no significant advantages over surgical treatment alone; further, it might lead to an increased risk of malignant transformation, post-irradiation myelopathy, sarcoma, and growth disturbances in children.[
Incomplete resection of ABC at the time of the index surgery resulted in a 50 to 60% rate of recurrence within 6–12 months; recurrence after 2 years is unusual, and extremely rare after 4 years.[
Brastianos et al.[
Although ABCs are considered benign, they expand rapidly, have a high local recurrence rate, and can be mistaken as malignant tumors. Their management should include pre-operative selective arterial embolization, surgical excision/ curettage, and stabilization.
Patient’s consent not required as patients identity is not disclosed or compromised.
Publication of this article was made possible by the James I. and Carolyn R. Ausman Educational Foundation.
There are no conflicts of interest.
1. Brastianos P, Gokaslan Z, McCarthy EF. Aneurysmal bone cysts of the sacrum: A report of ten cases and review of the literature. Iowa Orthop J. 2009. 29: 74-8
2. Brembilla C, Lanterna LA, Bosisio M, Gritti P, Risso A, Signorelli A. Spontaneous regression after extensive recurrence of a pediatric cervical spine aneurysmal bone cyst. Case Rep Oncol Med. 2014. 2014: 291674
3. Capanna R, Albisinni U, Picci P, Calderoni P, Campanacci M, Springfield DS. aneurysmal bone cyst of the spine. J Bone Joint Surg Am. 1985. 67: 527-31
4. Chiras J, Cognard C, Rose M, Dessauge C, Martin N, Pierot L. Percutaneous injection of an alcoholic embolizing emulsion as an alternative preoperative embolization for spine tumor. AJNR Am J Neuroradiol. 1993. 14: 1113-7
5. Gellad FE, Sadato N, Numaguchi Y, Levine AM. Vascular metastatic lesions of the spine: Preoperative embolization. Radiology. 1990. 176: 683-6
6. Han SR, Yee GT, Kim HS, Whang CJ. Aneurysmal bone cyst of a thoracic vertebra. J Korean Neurosurg Soc. 2005. 37: 459-61
7. Hong CK, Hyun DK, Park CO, Ha YS. A case of aneurysmal bone cyst on the thoracic spine. J Korean Neurosurg Soc. 2000. 29: 675-9
8. Liu JK, Brockmeyer DL, Dailey AT, Schmidt MH. Surgical management of aneurysmal bone cyst of the spine. Neurosurg Focus. 2003. 15: E4
9. Papagelopoulos PJ, Currier BL, Shaughnessy WJ, Sim FH, Ebsersold MJ, Bond JR. Aneurysmal bone cyst of the spine. Management and outcome. Spine (Phila Pa 1976). 1998. 23: 621-8