|Year : 2021 | Volume
| Issue : 2 | Page : 155-162
Clinical and surgical outcomes of enneking stage III aneurysmal bone cysts of the spine
Sanjeev Kumar Pandey1, Edmond Jonathan Gandham2, Krishna Prabhu2
1 Department of Neurosurgery, Himalayan Institute of Medical Sciences, Dehradun, India
2 Department of Neurological Sciences, Christian Medical College, Vellore, India
|Date of Submission||05-Apr-2020|
|Date of Decision||20-May-2020|
|Date of Acceptance||19-Aug-2020|
|Date of Web Publication||24-May-2021|
Department of Neurological Sciences, Christian Medical College and Hospital, Vellore 632004, Tamil Nadu.
Source of Support: None, Conflict of Interest: None
Objective: To study the clinicoradiological characteristics and surgical outcomes in patients with aggressive aneurysmal bone cyst (ABC) of spine. Materials and Methods: In this retrospective study, data was collected from patients with aggressive ABC of spine managed between January 2007 and December 2016. Clinical findings, radiological, and histological characteristics were studied. Follow-up was done either in the outpatient clinic or through a telephonic interview. Results: Seven patients (mean age, 15.6 years, range, 6–23 years) diagnosed with Enneking stage III aneurysmal bone cyst of the spine were included in the study. Local pain with restriction of movement was the most common presenting complaint (100%). Four patients presented with myelopathy. Thoracic spine was the most common site of involvement (43%). Of the patients, 71% had involvement of all three columns. All patients underwent surgical management; gross total resection in four patients (57%) and subtotal in three patients (43%). Of the seven patients, six required instrumented fusion. None of the patients developed any perioperative complication except for one patient who developed transient hip flexion worsening. Two patients received conformal radiation therapy (RT) postoperatively. The follow-up ranged from 40 months to 108 months (mean follow-up was 4.5 years). There were no recurrences. At last follow-up, all patients were alive and had significant improvement. Conclusions: ABC of the spine is found predominantly in the pediatric population. Intralesional en bloc resection with instrumented stabilization provides effective and fast relief from pain, early mobility, good surgical, and long-term outcomes. Conformal RT following a planned subtotal excision prevents the progression of the disease.
Keywords: Aneurysmal bone cyst, fixation, outcome, spine, surgery
|How to cite this article:|
Pandey SK, Gandham EJ, Prabhu K. Clinical and surgical outcomes of enneking stage III aneurysmal bone cysts of the spine. Indian Spine J 2021;4:155-62
|How to cite this URL:|
Pandey SK, Gandham EJ, Prabhu K. Clinical and surgical outcomes of enneking stage III aneurysmal bone cysts of the spine. Indian Spine J [serial online] 2021 [cited 2021 Dec 4];4:155-62. Available from: https://www.isjonline.com/text.asp?2021/4/2/155/316662
| Introduction|| |
Aneurysmal bone cyst (ABC) was described as a distinct entity by Jaffe and Lichtenstein in 1942 as “large-sized peculiar blood containing cyst.” It is an expanding osteolytic lesion consisting of blood-filled spaces of variable size, separated by connective tissue septa containing trabeculae or osteoid tissue and osteoclast giant cells as defined by WHO. Several authors have defined it as a pseudotumoural hyperemic–hemorrhagic lesion of unknown etiology.,,,
ABC forms 1% of primary bone tumors and 15% of primary tumors of the spine.,,
ABC is seen in children and young adults. About 70% of ABCs are primary and 30% are secondary to some other pathology. ABC has the predilection to involve the posterior spinal elements, but it may progress to involve the vertebral body in about 40% of cases., ABCs have the predilection for the lumbar and cervical spine and is observed mostly in patients with less than 20 years of age. Although ABCs are benign lesions, it may behave aggressively. Recurrences after the primary treatment are difficult to manage and result in significant neurological impairment and structural damage.
Treatment for spinal ABCs include selective arterial embolisation (SAE), curettage, en bloc resection surgery with or without spine stabilization, radiation therapy (RT), intralesional injection of bone cement, intralesional injection of mesenchymal stem cells, bisphosphonates, and Denosumab., SAE has been used in limited number of patients, mainly vertebral, pelvic, and/or extensive ABCs.
Enneking et al., classified ABCs into three types: Stage 1 (latent), which remains static, or heals spontaneously; Stage 2 (active), progressive growth without cortical destruction; and Stage 3 (locally aggressive), progressive growth with significant cortical destruction. Majority of the patients in Stage 2 can be managed with curettage with or without grafting but locally aggressive ABCs are better dealt with by wide excision. In past, majority of the patients were managed with curettage, without instrumented stabilization.,, Recurrence following intralesional curettage is close to 25%.,, In last two decades, authors have attempted wide excision with instrumented fusion specially for the aggressive disease with variable success. En bloc resection with wide margins is ideal treatment of choice; however, in spine, this is not feasible because en bloc resection is associated with significant morbidity. A systematic review of the studies done for the management of cervical spine ABCs showed that 56% of the patients underwent spinal stabilization following surgery. The treatment of ABC depends on patient characteristics, size of the lesion, location of the lesion, and surgeon’s familiarity with different procedures.
The literature on the outcome following an instrumented fusion of an aggressive ABC of spine was scarce; hence, we decided to study the clinicoradiological characteristics and surgical outcomes in these aggressive tumors.
| Materials and Methods|| |
In this retrospective study, patients diagnosed with aggressive ABC of the spine (Enneking grade III) on the basis of computed tomography (CT), magnetic resonance imaging (MRI), and surgical findings, which were managed in our unit from January 2007 to December 2016, were included. There were seven patients (four males; three females; mean age, 15.6 years, range, 6–23 years). All the patients with ABCs involving vertebral elements were included, with or without the presence of the coexisting pathologies. Patients having ABC with Enneking grade I and II were excluded. Patients having ABCs, other than the vertebra, were excluded.
All the patients had pain with restriction of movement as the presenting complaint. Swelling was the second most common complaint in five patients (71.4%). Four patients (57%) had presented with motor weakness and two patients (28.6%) had bladder and bowel symptoms. Duration of presenting symptoms ranged from 1 month to 12 months; mean duration was 3.6 months.
All the patients had preoperative X-ray, CT spine with reconstruction, and MRI spine with contrast of the relevant level. Postoperatively, patients were followed up with MRI spine at the region of interest and non-contrast CT scan of the region of interest. All patients had postoperative MRI spine. All the images were accessed through the institutional picture archival and communication system.
The primary treatment of all the seven patients was surgical with attempted total excision. Six patients underwent instrumented fusion while in one it was not deemed necessary. We were able to achieve gross total excision in four patients whereas in three patients only subtotal excision was achieved. One patient with extensive lumbosacral disease underwent SAE preoperatively followed by surgery. Two patients with significant postoperative residue received radiotherapy. Average duration of the surgery and the blood loss were assessed.
Patients were followed up periodically in the outpatient clinic or through a telephonic interview to assess their functional status, ability to perform the activities of daily life independently, and survival. Patients underwent MRI, CT, and X-rays of the relevant region to ascertain the residual disease.
Surgical outcomes were assessed in terms of surgical morbidity, mobility, residual lesion, need for adjuvant therapy, change in the Frankel grade, and functional outcome.
Data was entered in Excel software (Microsoft, Seattle, WA) and was analyzed using SPSS software, version 11.5 (SPSS, Inc., Chicago, IL).
| Results|| |
Three patients (42.9%) had preoperative Frankel grade C, three (42.9%) had Frankel grade D, and one patient (14.3%) had Frankel grade E. All the Frankel grade D patients improved to grade E postoperatively. One Frankel E patient remained the same. Two of the Frankel grade C patients improved to grade E, but one patient was grade D after the surgery till the last follow-up. Four patients (57.1%) had evidence of neurological involvement, either in form of myelopathy or in the form of radiculopathy.
The radiological features of the tumors are summarized in [Table 1]. The patients were evaluated by an X-ray, a CT scan, and an MRI of the spine. The CT scan showed an expansile osteolytic lesion involving the vertebral elements. The tumors were common in the thoracic region (three cases, 42.9%), followed by cervical and lumbosacral (two cases each, 28.6%). Five cases (71.4%) had an involvement of all the three elements. One patient (14.3%) had an involvement of the anterior and middle elements and another patient (14.3%) had involvement of the middle and posterior elements.
Laminectomy + posterior instrumented fusion
Laminectomy comprises removing the entire disease part of the lamina, facets, and pedicles and the soft tissue till normal bone was seen all around [Table 2] and [Table 3]. Pedicle screws were placed two levels above and below the level of diseased lamina, and posterior fusion was done using the rods and caps.
|Table 3: Classification of patient cohort using the Enneking and WBB staging|
Click here to view
360° fusion (anterior and posterior approach)
One patient with extensive lumbopelvic ABC underwent this procedure that began with an anterior approach in supine position with removal of the diseased portion in the pelvis. Through a posterior approach, the disease in the posterior compartment was cleared till normal bone was seen all around. This was followed by lumbopelvic fixation. One patient with extensive ABC in the cervical region involving the C5 body and posterior elements was successfully managed through a 360° fusion with Harm’s cage and plating anteriorly supported by cervical lateral mass fixation from behind with a very good disease control [Figure 1].
|Figure 1: (A) MRI cervical spine depicting the aneurysmal bone cyst involving all the elements of C5 vertebral body. There is an epidural component with cord compression. (B) Postoperative MRI of the cervical spine at 24 months follow-up which showed no residual lesion. (C) Postoperative X-ray of the cervical spine which showed the C5 corpectomy defect, cage with anterior cervical plating, and lateral mass screws with rods and caps seen in situ|
Click here to view
360° fusion through a single-stage posterior approach alone
We had three patients who underwent this procedure. In two patients, the disease was confined to the thoracic region and one in the lumbar region. After positioning the patient prone for surgery, a midline skin incision exposed the laminae two levels above and below the region of interest. Pedicle screws were placed two levels above and below the diseased segment. A costotransversectomy at the level of the lesion on the more symptomatic side was done followed by a laminectomy to decompress the cord in the thoracic region tumors. Through the posterolateral corridor provided by the costotransversectomy, the diseased vertebra was removed using a high-speed diamond burr. A layer of anterior cortex was preserved, and a titanium mesh cage filled with autologous bone graft was placed into the corpectomy defect. On completing the ventral bone work, the rods were placed onto the screw heads and tightened [Figure 2]. In the patient with a lumbar ABC, we were able to clear the diseased body through a corridor created after facetectomy and laminectomy. Corpectomy defect was filled with a Harm’s cage followed by posterior fusion with rods and caps with a cross connector.
|Figure 2: (A, B) MRI of the thoracic spine depicting an extensive, multicystic giant aneurysmal bone cyst involving the T9 vertebral body. There is evidence of destruction of the right T9 lamina and pedicle with extension of the tumor into the spinal canal. Note the multiple fluid levels within the tumor. (C, D) Postoperative MRI of the thoracic spine, which showed no residual lesion at 48 months, follow up. (E) Postoperative x-ray of the thoracic spine with implants in situ at 56 months follow up; note there is no evidence of kyphosis|
Click here to view
The average blood loss was 750 mL, and the average duration of surgery including instrumentation was 3 hours. All patients underwent intralesional en bloc resection and the tumors were classified using the Weinstein, Boriani, and Biagini (WBB) classification. These results are summarized in [Tables 2] and .
Surgical morbidity and mortality
Postoperatively, none of the patients developed any complication except for one patient who underwent a lumbopelvic fixation and developed transient weakness of the hip flexion which resolved completely at the time of discharge. There was no perioperative surgical mortality.
The histopathology was consistent with ABC in all the cases. This is depicted in [Figure 3].
|Figure 3: Histopathological images showing large cystic spaces filled with blood and separated by fibrous septa, alternating with solid areas. There were no atypical cells. Cluster of osteoclast like multinucleated giant cells were also seen|
Click here to view
One patient received preoperative SAE before undergoing the gross total excision of the lumbosacral ABC and lumbopelvic fixation as the disease was extensive [Table 2]. This patient had small residue in the pelvic cavity that responded well to bisphosphonates. At last follow-up (8 years after the surgery), she had stable residue. One patient with C2 body ABC was treated with intralesional bone cement injection after laminectomy and supported by occipitocervical fusion as the disease was involving two columns and the C2 body was brittle due to tumor destruction. Two patients received postoperative radiotherapy as they underwent partial excision and had residual disease. All patients received 3D conformal RT (25–30 Gy) over 10–15 fractions. Patients tolerated RT well. They had no side effects related to radiation till their last follow-up.
At a mean follow-up of 4.5 years, all patients were disease-free with significant improvement in their neurological status. Majority of patients 6/7 (85%) had good postoperative Frankel grade E at follow-up.
| Discussion|| |
ABC is generally considered as a rare, reactive, non-neoplastic, and hyperemic lesion of the bone. Papagelopoulos et al. in 1998 studied 52 cases and found the predilection of the spinal ABC in thoracic and cervical spine with a slight male predominance in contrast to the previous studies., Our study results were consistent with Papagelopoulos et al. Although trauma has been considered as one of the causative factors for the ABC, especially due to their hemorrhagic nature,, none of our patients had any history of trauma before presenting to us. Although these lesions are considered benign, aggressive ABCs are characterized by rapid progression and destruction of the bone with or without spinal instability or cord compression with neurological deficits. Reversal of the symptoms and deficits were noted soon after the surgical management of the pathology in multiple previous series., This was observed in our series too, as all our patients had significant improvement in their symptoms after the surgery [Table 2]. Our patients could be ambulated on the first postoperative day following the instrumented stabilization and showed excellent response toward the same. Some authors,, practiced spinal fusion in case of instability resulting after the wide excision or the corpectomy in past with mixed results. We think that most extensive and aggressive lesions, involving all the three elements of the vertebra, especially in thoracic region, should be fused, as there are high chances of kyphoscoliosis without instrumentation.,,, As per the Enneking’s recommendation, both inactive and active tumors can be successfully treated with simple curettage, while locally aggressive tumors should be treated with en bloc resection. En bloc resection effectively controls the local recurrence and progression, but is associated with significant morbidity and potential neurological complications in comparison to the intralesional curettage. Hence, en bloc resection of the ABC in the spine is difficult and technically demanding. Some authors found selective arterial embolization (SAE) an effective way of managing ABC.,,,, Few authors prefer SAE as the first line of treatment of ABC; however, its contraindicated in patients with pathological fracture or with neurological deficits.,,,,,, Terzi et al. have found SAE to be a safe procedure with a healing rate of 74% with very few recurrences in their series; however, the efficacy of SAE was less than expected as 26% of their patients had deterioration in the course of therapy and warranted crossing over to surgery or to another therapy. Furthermore, the study lacked the description on the subgroup of the patients (as per the Enneking’s classification) who underwent SAE. Boriani et al. found no treatment failures in patients undergoing SAE, but they frequently had patients with incomplete treatment. Of the spinal ABC in their series, 88% required two embolization procedures and more than one-third of patients required more frequent embolization. To achieve the results, several patients required two or more sittings. Most of the patients affected by the spinal ABCs are children. Multiple angiograms increase the radiation exposure and increase the risk of carcinoma in future. At our center, most of the Enneking grade I and II, patients receive either SAE or curettage with or without grafting or both. All seven patients in this study had Enneking grade III lesions, which pose a significant challenge if treated with nonsurgical methods, as they are prone to get pathological fractures and instability. En bloc excision with spinal stabilization may be considered as a better option in this subgroup of the patients as they have gratifying results.
The use of embolization in our study was limited to reducing the vascularity before the definitive management, for embolization as a primary modality of treatment carries the disadvantage of delayed relief from the symptoms. It also carries the risk of disease progression. Some previous studies agree with the fact that, with rapidly worsening symptoms, especially if the weakness is one of the presenting complaints due to cord compression, there is hardly any time to consider embolization.
Traditionally treatment of Enneking grade III ABC has been surgical as it gives the best chance of immediate neurological improvement. Aggressive surgery decreases the chance of recurrence. As most of the recurrences are seen at the end of first year after surgery, a closer follow-up is warranted in all patients who underwent less than en bloc resection. Intralesional en bloc resection of the lesion is most important to obviate the risk of recurrence. Hence, we adopted this strategy for all our patients aiming for an intralesional en bloc resection to the extent possible. This is supported by instrumentation as adolescents have high incidence of postlaminectomy kyphosis and scoliois. Recent metanalysis by Parker et al. reports recurrence rates of 42.3% with decompression and laminectomy, 37.5% with partial excision, and 25% recurrence rates with curettage as compared to 8.2% with complete excision. The results of their study revealed good surgical results, almost 0% recurrence rates in patients who have undergone curettage along with an adjuvant therapy that includes radiotherapy, phenol, or cryotherapy.
ABCs are radiosensitive. RT should be reserved for the progressive residue, rather than a routine postoperative adjuvant therapy as there is risk of post radiation sarcoma to the site and risk of myelopathy. In our study, two patients received postoperative radiation due to a significant surgical residue. RT following the SAE can be considered as a method for the inoperable cases., With advancement, novel approaches have been tried for treatment of ABC with varied results. Basu et al. have described the usage of bone cement augumentation in two cases treated with curettage. Setting of bone cement is an exothermic reaction that results in thermal coagulation of the surrounding tissue, thus decreasing the blood loss during curettage and it also exerts the antitumor effect. We have successfully used this technique in one patient with C2 body ABC after intralesional curettage.
Recent studies have thrown light on specific genetic translocations that occur in ABCs that offer a potential target for gene therapy. As ABCs share same pathophysiology as giant cell tumor, encouraging results have been published by few authors who report the usage of denosumab, a monoclonal antibody that blocks RANKL interaction with RANK., The usage of denosumab has been approved for treatment of osteoporosis, multiple myeloma, and giant cell tumors. Long-term studies are required to study the efficacy and side-effects of these novel drugs.
| Conclusion|| |
ABCs are benign lesions with aggressive local behavior. Aggressive ABCs pose a significant challenge due to faster growth, risk of spine instability, and postoperative recurrence. There are various treatment options, including intralesional curettage, en bloc resection, and SAE. En bloc excision with negative margin with or without instrumented stabilization provides effective and fast pain relief, early mobility, and is associated with good surgical and long-term outcomes. Clinical profile of the patient, expertise of surgeon, or interventional radiologist, location, size, and aggressiveness of lesion should be taken into account to individualize the primary treatment modality in spinal ABC.
Financial support and sponsorship
Conflicts of interest
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
| References|| |
Jaffe HL, Lichtenstein L. Solitary unicameral bone cyst with emphasis on the roentgen picture, the pathologic appearance and the pathogenesis. Arch Surg 1942;44:1004-25.
Schajowicz F. Histologic Typing of Bone Tumours. Berlin: Springer Verlag; 1992. p. 37.
Aho HJ, Aho AJ, Einola S. Aneurysmal bone cyst, a study of ultrastructure and malignant transformation. Virchows Arch A Pathol Anat Histol 1982;395:169-79.
Buraczewski J, Dabska M. Pathogenesis of aneurysmal bone cyst. Relationship between the aneurysmal bone cyst and fibrous dysplasia of bone. Cancer 1971;28:597-604.
Campanacci M, Bertoni F, Bacchini P. Aneurysmal bone cyst. In: Campanacci M, Bertoni F, Bacchini P, editors. Bone and Soft Tissue Tumours. Vienna: Springer-Verlag; 1990. p. 725-51.
Tillman BP, Dahlin DC, Lipscomb PR, Stewart JR. Aneurysmal bone cyst: An analysis of ninety-five cases. Mayo Clin Proc 1968;43:478-95.
Zenonos G, Jamil O, Governale LS, Jernigan S, Hedequist D, Proctor MR. Surgical treatment for primary spinal aneurysmal bone cysts: Experience from Children’s Hospital Boston. J Neurosurg Pediatr 2012;9:305-15.
Liu JK, Brockmeyer DL, Dailey AT, Schmidt MH. Surgical management of aneurysmal bone cysts of the spine. Neurosurg Focus 2003;15:E4.
Turker RJ, Mardjetko S, Lubicky J. Aneurysmal bone cysts of the spine: Excision and stabilization. J Pediatr Orthop 1998;18:209-13.
Fletcher C, Unni K, Mertens F. Pathology and genetics of tumors of soft tissue and bone. In: Fletcher C, Unni K, Mertens F , editors. WHO Classification of Tumors. 3rd ed. Lyon: IARC Press; 2006. p. 338-40.
Carlson DH, Wilkinson RH, Bhakkavisziam A. Aneurysmal bone cyst in children. AMJ Roentgenol 1972;116:644-50.
Nicastrol JF, Leatherman KD. Two stage resection and spinal stabilization for aneurysmal bone cyst: A report of two cases. Clinorthop 1983;180:173-8.
Boriani S, De Iure F, Campanacci L, Gasbarrini A, Bandiera S, Biagini R, et al
. Aneurysmal bone cyst of the mobile spine: Report on 41 cases. Spine (Phila Pa 1976) 2001;26:27-35.
Wang C, Liu X, Jiang L, Yang S, Wei F, Wu F, et al
. Treatments for primary aneurysmal bone cysts of the cervical spine: Experience of 14 cases. Chin Med J (Engl) 2014;127:4082-6.
Szendröi M, Cser I, Kónya A, Rényi-Vámos A. Aneurysmal bone cyst. A review of 52 primary and 16 secondary cases. Arch Orthop Trauma Surg 1992;111:318-22.
Barbanti-Brodano G, Girolami M, Ghermandi R, Terzi S, Gasbarrini A, Bandiera S, et al
. Aneurysmal bone cyst of the spine treated by concentrated bone marrow: Clinical cases and review of the literature. Eur Spine J 2017;26:158-66.
Enneking WF, Spanier SS, Goodman MA. A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res 1980;153:106-20.
Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res 1986;204:9-24.
Papagelopoulos PJ, Currier BL, Shaughnessy WJ, Sim FH, Ebsersold MJ, Bond JR, et al
. Aneurysmal bone cyst of the spine. Management and outcome. Spine (Phila Pa 1976) 1998;23:621-8.
Ameli NO, Abbassioun K, Saleh H, Eslamdoost A. Aneurysmal bone cysts of the spine. Report of 17 cases. J Neurosurg 1985;63:685-90.
Hay MC, Paterson D, Taylor TK. Aneurysmal bone cysts of the spine. J Bone Joint Surg Br 1978;60-B:406-11.
de Kleuver M, van der Heul RO, Veraart BE. Aneurysmal bone cyst of the spine: 31 Cases and the importance of the surgical approach. J Pediatr Orthop B 1998;7:286-92.
Protas M, Jones LW, Sardi JP, Fisahn C, Iwanaga J, Oskouian RJ, et al
. Cervical spine aneurysmal bone cysts in the pediatric population: A systematic review of the literature. Pediatr Neurosurg 2017;52:219-24.
Capanna R, Albisinni U, Picci P, Calderoni P, Campanacci M, Springfield DS. Aneurysmal bone cyst of the spine. J Bone Joint Surg Am 1985;67:527-31.
Ruiter DJ, Lindeman J, Haverkate F, Hegt VN. Fibrinolytic activity in aneurysmal bone cysts. Am J Clin Pathol 1975;64:810-6.
Parmar HN, Agrawal VA, Shah MS, Nanda SN. Locally aggressive aneurysmal bone cyst of C4 vertebra treated by total en bloc excision and anterior plus posterior cervical instrumentation. J Craniovertebr Junction Spine 2015;6:130-3.
Bridwell KH, Jenny AB, Saul T, Rich KM, Grubb RL. Posterior segmental spinal instrumentation (PSSI) with posterolateral decompression and debulking for metastatic thoracic and lumbar spine disease. Limitations of the technique. Spine (Phila Pa 1976) 1988;13:1383-94.
Kostunica JP, Errico TJ, Gleason TF, Errico CC. Kostuik JP, Weinstein JN.Cited by Differential diagnosis and surgical treatment of metastatic spine tumours. In: Frymoyer JW, editor. The Adult Spine: Principles and Practice. Vol. 1. New York: Raven Press; 1991. p. 861-88.
Taneichi H, Kaneda K, Takeda N, Abumi K, Satoh S. Risk factors and probability of vertebral body collapse in metastases of the thoracic and lumbar spine. Spine (Phila Pa 1976) 1997;22:239-45.
Papagelopoulos PJ, Peterson HA, Ebersold MJ, Emmanuel PR, Choudhury SN, Quast LM. Spinal column deformity and instability after lumbar or thoracolumbar laminectomy for intraspinal tumors in children and young adults. Spine (Phila Pa 1976) 1997;22:442-51.
Yasuoka S, Peterson HA, Laws ER Jr, MacCarty CS. Pathogenesis and prophylaxis of postlaminectomy deformity of the spine after multiple level laminectomy: Difference between children and adults. Neurosurgery 1981;9:145-52.
Boriani S, Lo SF, Puvanesarajah V, Fisher CG, Varga PP, Rhines LD, et al
; AOSpine Knowledge Forum Tumor. Aneurysmal bone cysts of the spine: Treatment options and considerations. J Neurooncol 2014;120:171-8.
Boriani S, Bandiera S, Donthineni R, Amendola L, Cappuccio M, De Iure F, et al
. Morbidity of en bloc resections in the spine. Eur Spine J 2010;19:231-41.
De Cristofaro R, Biagini R, Boriani S, Ricci S, Ruggieri P, Rossi G, et al
. Selective arterial embolization in the treatment of aneurysmal bone cyst and angioma of bone. Skeletal Radiol 1992;21:523-7.
DeRosa GP, Graziano GP, Scott J. Arterial embolization of aneurysmal bone cyst of the lumbar spine: A report of two cases. J Bone Joint Surg 1990;72:777-80.
Kónya A, Szendröi M. Aneurysmal bone cysts treated by superselective embolization. Skeletal Radiol 1992;21:167-72.
Murphy WA, Strecker EB, Schoenecker PL. Transcatheterembolisation therapy of an ischial aneurysmal bone cyst. J Bone Joint Surg 1982;64:166-8.
Terzi S, Gasbarrini A, Fuiano M, Barbanti Brodano G, Ghermandi R, Bandiera S, et al
. Efficacy and safety of selective arterial embolization in the treatment of aneurysmal bone cyst of the mobile spine: A retrospective observational study. Spine (Phila Pa 1976) 2017;42:1130-8.
Eun J, Oh Y. A case report of aneurysmal bone cyst of the thoracic spine treated by serial anterior and posterior fusion. Medicine (Baltimore) 2019;98:e17695.
Parker J, Soltani S, Boissiere L, Obeid I, Gille O, Kieser DC. Spinal aneurysmal bone cysts (ABCS): Optimal management. Orthop Res Rev 2019;11:159-66.
Basu S, Patel DR, Dhakal G, Sarangi T. Results of cement augmentation and curettage in aneurysmal bone cyst of spine. Indian J Orthop 2016;50:99-102.
] [Full text]
Belkoff SM, Molloy S. Temperature measurement during polymerization of polymethylmethacrylate cement used for vertebroplasty. Spine (Phila Pa 1976) 2003;28:1555-9.
Huret JL. Bone: Aneurysmal bone cysts. Atlas Genet Cytogenet Oncol Haematol 2012;16:368-71.
Lange T, Stehling C, Fröhlich B, Klingenhöfer M, Kunkel P, Schneppenheim R, et al
. Denosumab: A potential new and innovative treatment option for aneurysmal bone cysts. Eur Spine J 2013;22:1417-22.
Kurucu N, Akyuz C, Ergen FB, Yalcin B, Kosemehmetoglu K, Ayvaz M, et al
. Denosumab treatment in aneurysmal bone cyst: Evaluation of nine cases. Pediatr Blood Cancer 2018;65:10.1002.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]