A 29-year-old male patient presented with right side weakness and left side numbness that occurred just after a car accident. Upon physical examination, there was no abnormal finding, except for tenderness in the upper cervical area. Routine laboratory tests demonstrated normal results. Motor weakness of right side extremity was disclosed as 1/5 for arm and 2/5 for leg with slightly hyperactivity of deep tendon reflex. Sensory examination showed significantly decreased pain, temperature, vibration, and discriminatory touch sensations below the left C2 dermatome. Babinski's reflex and Hoffman's sign were present on the left side. Based on the symptoms and neurological findings, the assumptive diagnosis of Brown-Sequard syndrome was made. The patient had no symptoms or past medical history related to a cervical spine lesion before the trauma. Cervical plain films revealed straightening of the cervical spine with loss of normal lordosis and widening between the posterior arch of the atlas and spinous process of the axis. A computed tomography (CT) scan of the upper cervical spine revealed a large round mass which measured 25×18×24 mm with relatively homogeneous strong enhancement and was located between the C1 and C2 interspinous space. In addition, the CT scan showed cortical osseous erosions at the lower C1 posterior arc and upper C2 spinous process. Cervical magnetic resonance images (MRI) revealed an epidural dumbbell-shaped mass traversing the C1 to C2 interspinous space, compressing the surrounding structures (). The spinal cord was compressed by the lesion which was isointense on T1-weighted image (WI) and mixed hypointense on T2WI with homogenous strong enhanced after gadolinium administration. Radiologic analysis indicated possible lymphoma, meningioma, schwannoma or other neuronal tumors.\nThe patient underwent a surgery immediately for decompression of the spinal cord. A total tumor resection was performed with only a partial laminectomy from the lower half of the C1 to upper half of C2 without any instrumentation and access to the tumor. After partial lamicectomy, an extradural and yellowish mass was exposed with well-demarcated from the surrounding structures but adhesive at the epidural area. Under microscopy, the tumor was delicately dissected, and en bloc removal was achieved (). The mass was ovoid, soft like gelatin, avascular, and well-encapsulated, measuring 25 mm at the largest diameter, and was adherented to the outer layer of the dura mater. And, there was no root invasion. On the basis of the clinical and operative features, we thought that the lesion originated from the outer aspect of the dura mater. Upon sectioning, the mass was particularly yellow and white with cystic components ().\nAfter surgery, the patient's right hemiparesis fully recovered in 2 weeks. However, a slightly tingling numbness on his left arm remained and was controlled through medication in the outpatient clinic for 4 months. Currently, the patient has no symptoms without instability of cervical spine. Cervical MRI with gadolinium enhancement at 2 years after surgery demonstrated no recurrent lesion ().\nHistological examination of the tumor uncovered focal aggregation cells with ample, clear, and foamy cytoplasm in a background of loose, fibrous stroma of xanthic appearance. Large, round cells had irregular vesicular nuclei which were regular and small with condensed chromatin (). The specimen was underwent to immunohistochemical testing, yielding strongly positive for CD 68 and lysozyme stain, which confirmed that the large foam cells were histiocytes. The test with CD-1a was negative, thus ruling out Langerhans' cell histiocytosis. GFAP stain and S-100 protein were negative. Thus, a diagnosis of xanthogranuloma was established.
A 15-year-old male presented with pain in the nape of the neck and gradually progressive ascending weakness of all four limbs along with bladder and bowel involvement for 3 years. On examination, tone was increased in all four limbs with 4/5 power in bilateral upper limbs and 2/5 power in both lower limbs, along with exaggerated deep tendon reflexes in all four limbs. Superficial abdominal reflexes were absent and, bilateral planters were extensor. He had 70–80% sensory loss below T4 level. His routine laboratory studies including hematological and biochemical parameters were within normal limits.\nComputerised tomography scan of the cervical spine revealed a large osseo-destructive lesion involving body of C5and C6 vertebra which was causing spinal canal compromise [Figure and ]. The lesion was involving surrounding structures with extension into the submuscular plane anteriorly. On magnetic resonance imaging (MRI) evaluation, the mass was isointense on T1 and T2 weighted sequences with minimal contrast enhancement. It was causing distrucation of C5 and C6 vertebra body with compression of thecal sac [Figure –].\nUsing anterior cervical approach, the tumor resection was performed. Intra-operatively, the tumor involved whole of the C5 and C6 vertebral body. There was a soft tissue component of the tumor, which was extending into the submuscular plane. Inside the capsule, the tumor consisted of cheesy material that was minimally vascular. Total tumor excision was done with tricorticate iliac crest bone grafting and plate and screw fixation between C4 and C7 vertebral bodies.\nMicroscopic examination showed spindle cells disposed of in intersecting fascicles intermingled with mononuclear xanthomatous cells displaying round nuclei with dense chromatin inconspicuous nucleoli and pale eosinophilic finely vacuolated chromatin. Spindle cells display bland appearing nuclear chromatin and eosinophilic cytoplasm. Occasional cells displayed nuclear atypia and enlargement. Scattered neutrophils were seen admixed with these cells. Focal areas of calcification and occasional osteoclasts like giant cells were also seen. Interspersed areas showed degenerated bony trabeculae and cartilage [Figure and ].\nPostoperatively, patient had significant improvement in neck pain and spasticity in all four limbs. At follow-up of 6 months, he was doing well.