Working Diagnosis:
Ewing Sarcoma of C2 vertebra

Treatment:
At the clinic, an MRI was ordered to further investigate his neck pain. He was prescribed a course of methylprednisolone and physical therapy. He followed up with consultants following his MRI findings.

Outcome:
The patient underwent resection of C2 mass involving spinous process, lamina, and pedicles with C1-C4 fusion. Case Photo #3 Intraoperative frozen section was suggestive of Ewing Sarcoma. PET scan was without evidence of metastasis. He is currently undergoing chemoradiation at a local pediatric cancer center with VDC/IE (vincristine sulfate, doxorubicin hydrochloride, cyclophosphamide followed by ifosfamide and etoposide phosphate) chemotherapy. Return to play is to be determined in conjunction with surgeons. Return to contact sports is contraindicated.

Author's Comments:
ES is a rare childhood tumor occurring in 3/1,000,000 individuals. Only about 8% of ES occurs in the C-spine. The differential for cervical pain with neurologic symptoms can be broad. One must rule out malignancy, CNS, and vascular pathology.

Editor's Comments:
The author presents a very rare cause of neck pain in the athlete. Ewing Sarcoma is primarily a tumor of the appendicular skeleton, rarely affecting the axial skeleton with the rarest area being the cervical spine. It is an important diagnosis to keep on the differential, especially in the setting of intractable neck pain.

It is vital that the reader can identify red flags of neck pain brought up in this case that warranted further investigation with additional imaging.

References:
Morton DA, Foreman K, Albertine KH. eds. The Big Picture: Gross Anatomy, Medical Course & Step 1 Review, 2nd Edition. McGraw-Hill Education; 2018. Accessed March 26, 2024.

Ginsberg JP, Woo SY, Hicks MJ, Horowitz ME. Ewing’s sarcoma family of tumors: Ewing’s sarcoma of bone and soft tissue and the peripheral primitive neuroectodermal tumors. Principles and Practice of Pediatric Oncology, 4th, Pizo PA, Poplack DG, Lippincott, Williams and Wilkins, Philadelphia, 2002.

Cotterill SJ, Ahrens S, Paulussen M, Jurgens HF, Voute PA, Gadner H, Craft AW. Prognostic factors in Ewing's tumor of bone: analysis of 975 patients from the European Intergroup Cooperative Ewing's Sarcoma Study Group. J Clin Oncol. 2000 Sep;18(17):3108-14. doi: 10.1200/JCO.2000.18.17.3108. PMID: 10963639.

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