Schallmo Michael S, Drexelius Katherine D, Ahrens William A, Patt Joshua C
Orthopedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, USA.
Pathology, Atrium Health Levine Cancer Institute, Charlotte, USA.
Cureus. 2024 Oct 2;16(10):e70723. doi: 10.7759/cureus.70723. eCollection 2024 Oct.
In this report, we present a progressively enlarging, degenerative, intraspongious/intravertebral herniated nucleus pulposus, also referred to as a "Schmorl's node," in a 65-year-old patient with a history of prostate cancer. The patient initially presented to our orthopedic oncology clinic for the evaluation of lytic-appearing lesions involving the L4 and L5 vertebral bodies. He had been diagnosed with prostate cancer approximately four years prior and had been previously treated with prostatectomy. During evaluation for symptoms of neurogenic claudication, computed tomography (CT) demonstrated a hypodense lesion in the L5 vertebral body, which demonstrated mildly increased uptake in the left side of L5 on technetium pyrophosphate nuclear scintigraphy and 18 fluorine fluorodeoxyglucose positron emission tomography-CT scan. CT-guided fine-needle aspiration (FNA) of the lesion was performed and demonstrated no neoplastic findings. He underwent an L4-L5 microscopic unilateral laminotomy with bilateral decompression. However, his neurogenic claudication gradually returned, and he presented to his spine surgeon for further evaluation. Repeat CT of the lumbar spine demonstrated marked interval expansion of the erosive L5 lesion with poorly defined margins as well as a hypodense, erosive lesion in the left side of L4. The patient underwent a repeat FNA, along with a CT-guided core needle biopsy of the lesion at the outside facility which yielded a non-diagnostic specimen. After an extensive discussion with the patient, the decision was ultimately made to proceed with an open biopsy of the L5 lesion with partial L5 corpectomy via left-sided transpedicular approach and L4-S1 decompression and instrumented posterolateral spinal fusion. The primary purpose of the operation was to remove material from the lesion, directly visualize it, and have ample tissue for histopathological analysis. Based on these intraoperative findings and subsequent final histopathologic evaluation, the lesion was definitively diagnosed as a large, aggressive, intraspongious/intravertebral herniated nucleus pulposus. While the differentiation of non-neoplastic conditions, such as a Schmorl's node, from osseous metastatic spine disease can be elusive, it is essential for the appropriate management of patients with a history of malignancy.
在本报告中，我们介绍了一名65岁前列腺癌病史患者，其存在一个逐渐增大的、退行性的、海绵状/椎体内髓核突出，也称为“许莫氏结节”。该患者最初因涉及L4和L5椎体的溶骨性病变来我们的骨肿瘤门诊评估。他大约在四年前被诊断为前列腺癌，此前接受过前列腺切除术。在评估神经源性间歇性跛行症状期间，计算机断层扫描（CT）显示L5椎体有一个低密度病变，在焦磷酸锝核闪烁扫描和18氟氟脱氧葡萄糖正电子发射断层扫描-CT上，L5左侧摄取轻度增加。对该病变进行了CT引导下细针穿刺抽吸（FNA），未发现肿瘤性病变。他接受了L4-L5显微镜下单侧椎板切开术及双侧减压。然而，他的神经源性间歇性跛行逐渐复发，于是他找脊柱外科医生进行进一步评估。腰椎重复CT显示，侵蚀性L5病变明显扩大，边界不清，L4左侧还有一个低密度侵蚀性病变。患者再次接受FNA，并在外部机构进行了CT引导下病变的粗针活检，结果未得到诊断性标本。在与患者进行广泛讨论后，最终决定通过左侧经椎弓根入路对L5病变进行开放性活检并部分切除L5椎体，同时进行L4-S1减压和后路外侧脊柱内固定融合术。手术的主要目的是从病变中取出材料，直接观察病变，并获取足够的组织进行组织病理学分析。基于这些术中发现及随后的最终组织病理学评估，该病变最终被确诊为一个大的、侵袭性的、海绵状/椎体内髓核突出。虽然将非肿瘤性病变，如许莫氏结节，与骨转移性脊柱疾病区分开来可能很困难，但这对于有恶性肿瘤病史患者的恰当管理至关重要。
