Tumors

Back pain and stiffness is a common symptom in patients with both benign and malignant spinal tumors, but malignant tumors are more likely to be associated with neurological symptoms (44,53). Other symptoms suspicious for malignancy include bone pain, night sweats, fever, anorexia, weight loss, and fatigue (67). Fortunately, in adolescence, most spinal tumors are benign. Primary benign tumor and tumor-like lesions of the vertebrae, except for those of the sacrum, are more common during childhood and adolescence than later in life (53). Sacral lesions in children and adolescents are more likely to be malignant than in adults (53). Children with either benign or malignant lesions can have symptoms for months to several years before diagnosis (11,53,68), and may develop a painful scoliosis and rigid spine secondary to bony destruction or muscle spasm; the lesion is usually located on the concave aspect of the curve, with the scoliosis convex to the side opposite the lesion (3,53).

Benign bone tumors and lesions include osteochondroma, osteoid osteoma, osteoblastoma, aneurysmal bone cysts, eosinophilic granulomas, and osteoclastomas (53). Osteoid osteoma and osteoblastoma are classically associated with nocturnal pain that is readily relieved by NSAIDs, but many patients do not have this pattern (53). Osteoblastomas are often located in the lumbar spine and associated with a radicular type of pain (53). Although larger than osteoid osteomas, osteoblastomas are usually less painful (1,3). Aneurysmal bone cysts are also often found in the lumbar spine, and can be associated with pathological fractures and neurological symptoms as these lesions tend to extend into the vertebral body and adjacent vertebrae (3,53). Osteoclastoma is more commonly seen after skeletal maturity is attained and in the spine, is most common in the sacrum (53). Although eosinophilic granuloma is a benign lesion, it is often associated with fever and weight loss. Patients with these lesions need a skeletal survey and bone scan to look for other lesions (1,44). All of these benign lesions should be surgically removed, except for eosinophilic granuloma, which can often be treated conservatively with bracing as needed (1,44,53).

Malignant tumors of the spine include primary osseous tumors, neural spinal cord tumors, and skeletal metastases. In the adolescent patient, Ewing's sarcoma, osteosarcoma, and lymphoma are the most common spinal malignancies, while in the younger patient, leukemia, neuroblastoma, and astrocytoma are more common (44). It can be difficult to diagnose these benign and malignant lesions on plain radiographs, since less than half show the typical radiographic features (53). Bone scintigraphy is helpful when radiographs are normal usually have increased uptake. Osteosarcoma, Ewing sarcoma, osteoid osteoma, osteoblastoma, and aneurysmal bone cysts (53). MRI allows better definition of the extent of the lesion and evaluation of spinal cord and adjacent soft tissue involvement; CT allows better evaluation of the extent of bony destruction (3).

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