- Department of Surgery, Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, Brazil.
Guilherme Brasileiro de Aguiar, Department of Surgery, Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, Brazil.
DOI:10.25259/SNI_588_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: Andrew Vinícius de Souza Batista, Guilherme Brasileiro de Aguiar, Priscilla Bennett, José Carlos Esteves Veiga. Periodontoid pseudotumoral lesions. 09-Aug-2021;12:403
How to cite this URL: Andrew Vinícius de Souza Batista, Guilherme Brasileiro de Aguiar, Priscilla Bennett, José Carlos Esteves Veiga. Periodontoid pseudotumoral lesions. 09-Aug-2021;12:403. Available from: https://surgicalneurologyint.com/surgicalint-articles/11025/
Background: Periodontoid pseudotumoral lesions (PPL) are an uncommon cause of cervical pain and myelopathy. In addition, they may be associated with atlantoaxial instability (AAI).
Case Description: Two patients over 60 years of age presented with neck pain alone. Their MR scans showed expansive lesions involving the odontoid process. One patient with AAI required an occipitocervical arthrodesis, while the other patient without instability was managed with an external orthosis (Philadelphia collar). Both of them experienced full resolution of pain and remained neurologically intact an average 36 months later (range 24–48).
Conclusion: Here, we discussed the clinical, MR, and non-surgical (without AAI) versus surgical management (with AAI) for different types of PPL.
Keywords: Atlanto-axial joint, Magnetic resonance imaging, Odontoid process, Skull base, Spinal cord diseases
In this study, we present the clinical, MR appearance, non-surgical, and surgical management for two cases of periodontoid pseudotumoral lesions (PPL), and selectively reviewed the appropriate literature.
Case 1: Non-surgical management of PPL
A 72-year-old male presented with neck pain alone, no neurological deficit, and a cervical MR that showed an expansive lesion posterior to the odontoid process [
Case 2: Surgical management of PPL
A 61-year-old female developed the rapid onset cervical pain exacerbated with cervical rotation but no neurological deficit.
Here, the cervical MRI revealed an intense inflammatory reaction involving the atlantoaxial joint (i.e. hyperintense T2 signal in anomalous tissue around the axis dens, with widening of the atlantodental interval) [
Sagittal sections from preoperative magnetic resonance imaging (a-c) indicating tissue formations that suggest an expansive process at the atlantodental joint, with low signal at T1 (a), intense enhancement after contrast injection (b) and heterogeneous signal at T2 (c). In (d), it is presented an axial section of a computed tomography image of the cervical spine obtained at the immediate postoperative period of occipitocervical arthrodesis; the arrow points to the calcification halo around the axon odontoid process. In (e) and (f), it is presented the final result of the occipitocervical arthrodesis.
Retro-odontoid pseudotumor (ROP)
ROP tumor is most often attributed to rheumatoid arthritis,[
The first patient we presented had a Tanaka’s type 2 ROP lesion without AAI.
Crowned dens syndrome (CDS)
In CDS, calcium pyrophosphate crystal deposition leads to expansion of the soft tissues and local inflammatory reaction (i.e. similar to pseudogout). CT is the most useful method for diagnosis.[
MR imaging of PPL and documentation of three types of lesions
Yonezawa et al. classified retro-odontoid lesions in three types based on MR signals: type I (inflammatory, typical of pannus) – hyposignal in T1 and hypersignal in T2; type II (fibrous) - hyposignal in T1 and T2; and type III (mixed) – heterogeneous signal in T2.[
Non-surgical and surgical management of PPL
The ideal approach to cases of PPL may be non-surgical or surgical [
Since those without instability do not typically warrant fusions,[
The best treatment for PPL requires MR evaluation and X-ray assessment of AAI; the latter may warrant fusion.
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