Case of the Month       November, 1999

Case summaries taken from the monthly Orthopedic Oncology - Radiology - Pathology Multidisciplinary Conference at the University of Massachusetts Medical School

Case presentation:

An active thirty-one year old woman had focal back pain and a lesion in the second lumbar vertebra. Initial work-up including a CT revealed a solitary,lesion with a latent appearance. Primary treatment was non-operative, but after six months the pain was still present, and the patient complained of significant limitations of her lifestyle and was unable to perform many outdoor activities. A repeat CT scan did not show any progression of the lesion, and a CT guided needle biopsy revealed the histological appearance shown at right. What is your diagnosis? (Decide, then scroll down)

The lesion is fibrous dysplasia. The patient's symptoms seemed to make some sort of treatment necessary, but the lesion had not progressed, and the diagnosis was benign. Standard operative removal of the lesion by curettage and insertion of bone graft in L2 would require a retroperitoneal approach to the spine. A posterior approach would not allow adequate access to the anterior verebral body. Even though the lesion was painful, it did not seem a big enough risk to the patient to make it worth a major open spinal operation. What would you do?

The treatment chosen was currettage and bone grafting via a laparoscopically - assisted anterior approach to the spine, with application of technology and instruments developed for laparoscopically-assisted spinal fusion. The patient was in the supine position and the abdominal portals were created. Floro was used to assist in localization, and intraoperative xrays were used to verify the correct level. The lesion was curetted and partially filled with bone graft. The limitations of the transabdominal instruments prevented complete filling of the lesion with bone graft. A CT reconstruction shows two views of the graft in place.

The benign nature of the lesion was confirmed by pathological examination of the curetted fragments of the tumor. Postoperatively, the patient has had significant pain relief and has been able to return to activities she was previously unable to perform, such as riding horses and lifting full-sized bales of hay. She continues to experience mild intermittent back pain. The application of minimally invasive surgical techniques to carefully selected bone tumors is being pioneered at the University of Massachusetts Medical Center.

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