Two-level thoracic pedicle subtraction osteotomy for progressive post-laminectomy kyphotic deformity following resection of an unusual thoracolumbar intradural extramedullary tumor

Case report

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The authors report a case in which multilevel thoracic pedicle subtraction osteotomy (PSO) was performed to correct post-laminectomy kyphotic deformity in a 9-year-old boy presenting with worsening lower-extremity neurological deficits. Five years prior to presentation, the patient underwent multilevel thoracolumbar laminectomies for resection of an atypical teratoid/rhabdoid tumor (AT/RT), a rare lesion that typically occurs intracranially and has a poor prognosis, making this particular presentation unusual and the patient's subsequent postoperative course remarkable. No fusion was undertaken at the time of resection, given the patient's age and presumptive poor prognosis. Over the next 5 years, the patient developed progressive thoracolumbar kyphotic deformity, with a Cobb angle greater than 110°, despite bracing, and bilateral lower-extremity weakness requiring ankle-foot orthotics for continued ambulation due to progressive foot drop. Worsening gait and the onset of respiratory issues prompted surgical intervention. Multilevel thoracic PSO and thoracolumbar fusion were performed, resulting in improved lower-extremity function and correction of the kyphotic deformity to approximately 65°. This report outlines an unusual AT/RT presentation and postoperative course and also discusses literature related to PSO within the context of pediatric kyphotic deformity. The authors' experience supports the use of multilevel PSO with fusion as a potential treatment option for significant pediatric thoracolumbar kyphotic deformity requiring surgical correction.

Abbreviations used in this paper:AT/RT = atypical teratoid/rhabdoid tumor; EMA = epithelial membrane antigen; PSO = pedicle subtraction osteotomy; SMA = smooth muscle actin.

Article Information

Address correspondence to: Brian J. Kelley M.D., Ph.D., Yale Spine Institute–Yale University School of Medicine, P.O. Box 208082, New Haven, Connecticut 06520-8082. email: brian.kelley@yale.edu.

Please include this information when citing this paper: published online August 3, 2012; DOI: 10.3171/2012.7.PEDS11526.

© AANS, except where prohibited by US copyright law.

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Figures

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    Sagittal STIR (left) and axial T1-weighted postcontrast, fat saturation (right) MR images showing a heterogeneously enhancing intradural extramedullary lesion encompassing most of the spinal canal and extending from approximately T-10 to L-1.

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    Representative midline sagittal T1-weighted postcontrast MR image demonstrating no evidence of intracranial disease to suggest potential drop metastasis etiology.

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    Preoperative sagittal plain radiograph of the spinal axis showing significant thoracolumbar kyphotic deformity with a Cobb angle of approximately 110°.

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    Postoperative sagittal plain radiograph of the spinal axis showing T-11 and T-12 PSO along with T7–10 and L2–4 screw-rod fusion. The Cobb angle approximates 65°, with significant improvement of thoracolumbar kyphotic deformity.

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    A PET scan obtained 18 months after spinal deformity correction (approximately 5 years after the initial surgery and diagnosis) showing no evidence of tracer uptake within the surgical site or systemically to suggest tumor recurrence.

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    Photomicrographs of sections of the patient's AT/RT. A: Staining with H & E revealed tumor cellularity with rhabdoid cells (arrow) and occasional cytoplasmic hyaline inclusions. B–D: Immunohistochemical staining demonstrated tumor cells positive for SMA (B) with scattered tumor cells also positive for cytokeratin AE1/AE3 (C) and EMA (D). Original magnification × 400.

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    Photomicrograph of a tumor section stained for INI-1 expression revealing lack of intranuclear staining within tumor cells consistent with an AT/RT. Nonspecific capillary immunoreactivity is observed, serving as an internal control. Original magnification × 400.

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