Myoepithelioma of the cervical spine mimicking neurinoma in an adolescent: a rare case report

Myoepithelioma of the cervical spine mimicking neurinoma in an adolescent: a rare case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Myoepithelioma of the cervical spine mimicking neurinoma in an adolescent: a rare case report Rui-li Mao, Cheng Cheng, Kun-ming Yi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8937583/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Apr, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 12 You are reading this latest preprint version Abstract Primary spinal myoepithelioma is an exceedingly rare condition. In this case report, we present the unique instance of a 14-year-old male who presented with neck pain, left-hand numbness, and weakness, ultimately diagnosed with primary myoepithelioma of the cervical spine. The initial imaging studies, including magnetic resonance imaging (MRI) and computed tomography (CT), demonstrated a well-defined, expansile, dumbbell-shaped mass in the cervical vertebra, with no evidence of vertebral body destruction. The patient underwent a complete surgical resection of the tumor, resulting in the removal of the entire mass. Subsequent pathological analysis confirmed the diagnosis of myoepithelioma. myoepithelioma spine magnetic resonance imaging computer tomography Figures Figure 1 Introduction Myoepithelial tumors represent a diverse morphological and biological spectrum of tumors, composed of epithelial and mesenchymal elements[ 1 ]. These tumors are more commonly encountered in salivary glands or skin but can also arise in the upper airway, lung, gastrointestinal tract, breast, soft tissue, and other unusual sites including bone, and the lesions typically present in young to middle-aged adults [ 2 ]. Myoepithelioma of the spine is rare, and only a few cases have been reported[ 3 , 4 ]. Furthermore, no primary myoepithelioma of the spine in adolescents has been described hitherto. Herein, we report a rare case of primary myoepithelioma of the cervical spine mimicking a neurinoma in an adolescent. Case Presentation A 14-year-old male presented to the hospital with a one-year history of neck pain and more recent onset of left-hand numbness accompanied by weakness that had been present for over two weeks. The left-hand numbness affected the entire palm, and no obvious cause for the numbness or significant loss of muscle strength was identified. The patient experienced limited cervical spine movement due to pain, but no deformities were noted in the upper limbs. Upon examination, it was observed that the muscle strength and tone of the left upper limb were notably decreased, with a grade 1 muscle strength in the deltoid, biceps, triceps, wrist flexors, and digital flexors. Additionally, a positive Hoffmann's sign was observed on the left side. The patient also exhibited enhanced reflexes in the left knee and Achilles tendon, as well as positive clonus in the left ankle and patellar reflex. Magnetic resonance imaging (MRI) and computed tomography (CT) showed a well-demarcated, expansile lesion occupying the C3-C4 intervertebral foramen. The mass has paravertebral and intraspinal extradural components. The size of the tumor in the spinal canal was about 4.6×1.6×1.4 cm, and the extra-vertebral canal portion was about 5.1×1.6×1.5 cm. The tumor showed heterogeneous high signal intensity compared with that of the spinal cord on the T2-weighted images(T2WI)(Figure A), homogeneous isointense on T1-weighted images༈T1WI༉(Figure B), and heterogeneously hyperintense on the fat-saturated T2WI (Figure C). The dotted, latticed low signals were observed on both T2WI and fat-saturated T2WI. The spinal cord deviated to the right by the tumor, without significant abnormality of the spinal cord signal. On CT, the lesion exhibited iso-to-hypodense before injection of the contrast medium, and spotty calcification was found (Figure D, E). The tumor showed weak enhancement after administration of the contrast medium (Figure F). The patient underwent complete surgical resection of the cervical tumor. Intraoperatively, the tumor was huge, with an incomplete capsule. Necrosis and liquefaction were observed within the tumor. The capsule of the tumor adhered to part of the dura mater and nerve roots. Histopathological examination showed the neoplasm had an incomplete capsule, the presence of epithelioid neoplastic cells arranged in nests and nodules within a myxoid matrix. Additionally, it was observed that some tumor cells exhibited eosinophilic cytoplasm, and there was slight heteromorphism noted in some tumor cells(Figure G). These immunohistochemical staining patterns are consistent with the characteristics of myoepithelioma. The positive staining for cytokeratin, smooth muscle actin, epithelial membrane antigen, P63, CD31, CD34, and calponin, along with the absence of staining for brachyury, desmin, and S-100 protein, supports the diagnosis of myoepithelioma. The Ki67 labeling index of 15% indicates the proliferative activity of the tumor cells, suggesting a moderate level of cell proliferation. These immunohistochemical findings provide valuable information for confirming the diagnosis and further characterizing the myoepithelioma. After surgery, the patient’s power improved to normal without any sign of recurrence during the 20-month follow-up. Discussion Primary myoepitheliomas of the spine are extremely rare and frequently misdiagnosed, and mainly occur in the fourth to fifth decades of life, and females are more likely to suffer from them [ 3 ]. Most of the cases reported in previous literature involve adults[ 3 , 4 ]. The clinical manifestations of myoepithelioma are non-specific and predominantly dependent on the location of the tumor. The compression of nerve roots by the tumor can lead to specific clinical symptoms. Furthermore, myoepithelioma has been associated with alterations in several genes, including P63, CD31, CD34, and rearrangement of the EWSR1 gene. These genetic abnormalities play a significant role in the pathogenesis of myoepithelioma[ 5 ]. In this particular case, we present a unique instance of a dumbbell-shaped spinal myoepithelioma in an adolescent, which was initially misdiagnosed as a neurinoma. This misdiagnosis highlights the challenges in accurately identifying and distinguishing myoepitheliomas from other tumors in the spinal region, particularly in younger individuals. Limited reports have provided detailed descriptions of the CT and MR imaging features of myoepitheliomas. The majority of spinal myoepitheliomas arise from the vertebral body or its appendages, paravertebral soft tissues, and intervertebral foramina. Among the spinal regions, the thoracolumbar spine is more frequently affected by myoepitheliomas[ 3 , 4 ]. In cases where the tumor size exceeds 5 cm in maximal diameter, myoepitheliomas often exhibit an irregular and lobulated shape. The demarcation between the tumor and surrounding tissues tends to be indistinct, and there is a higher likelihood of osteolytic destruction in the adjacent bone. [ 4 ]. On magnetic resonance imaging (MRI), myoepitheliomas typically present as well-defined lesions with specific characteristics. They appear as T1-hypointense and T2-hyperintense lobulated masses. When gadolinium-based contrast is administered, these tumors often demonstrate heterogeneous enhancement patterns[ 4 , 6 , 8 , 9 ]. In the reported case, the morphology and growth pattern of the myoepithelioma resembled that of neurogenic tumors. The tumor was situated within the intervertebral foramen and exhibited a dumbbell shape, extending across the internal and external spinal canal along the nerve root. On T2-weighted imaging (T2WI) and fat-saturated T2WI, the tumor displayed heterogeneous high signal intensity in comparison to the spinal cord. Additionally, multiple small nodular areas of higher signal intensity were observed within the tumor. Given the secretory function of myoepithelial cells, it is reasonable to suspect that the higher signal intensity observed on MRI could be attributed to the secretions originating from these cells. The presence of these secretions within the tumor may contribute to the heterogeneous appearance and the multiple small nodular areas of higher signal intensity seen on MRI. However, further research and investigation would be required to confirm this hypothesis. The presence of dotted and latticed low signals on both T2-weighted imaging (T2WI) and fat-saturated T2WI suggests the presence of intratumoral interlaced fibrosis and collagenization. This finding is consistent with the histological features commonly associated with myoepitheliomas. On computed tomography (CT), the tumor appeared as a well-demarcated mass with characteristic features of a benign spine tumor. Calcifications were observed within the lesion, and there was no evident destruction of the surrounding bone. However, osteosclerosis, or increased bone density, was present in the vicinity of the tumor. Due to the rarity of primary spinal myoepithelioma, there is a lack of specific radiological features associated with these tumors. As a result, they often pose diagnostic challenges. They can be mistakenly identified radiologically as other tumor types, such as neurinoma, neuroma, plasmacytoma, myeloma, or chondrosarcoma. The absence of distinct radiological characteristics further complicates the accurate identification and differentiation of myoepitheliomas from these other tumor entities. Consequently, histopathological examination and immunohistochemical analysis are typically required to establish an accurate diagnosis. Although primary spinal myoepitheliomas lack specific radiological features, preoperative imaging examinations can still provide valuable information regarding the tumor's location, size, shape, margins, internal composition, enhancement patterns, and relationships with surrounding structures. This helps that that aids in differentiating myoepitheliomas from other tumors and determining the optimal management approach. This includes surgical planning, determining the extent of resection, and assessing the potential for infiltration into adjacent structures. In general, the imaging features of myoepitheliomas demonstrate a slow growth pattern, often leading to gradual enlargement of the tumor. This growth can induce reactive changes in the adjacent bone, such as osteosclerosis, but typically does not result in significant bone destruction. In some cases, the tumor may extend into the surrounding soft tissues, although this is less common. Regarding treatment, there is no established consensus due to the rarity of primary bone myoepitheliomas. Treatment approaches may include surgical resection with or without adjuvant therapies such as radiation or chemotherapy. The choice of treatment depends on factors such as tumor size, location, presence of metastasis, and the patient's overall health status. The outcomes of treatment can also vary depending on these factors and the individual characteristics of the tumor. A few authors have reported different imaging findings, different treatments, and with different neoplastic outcomes for myoepitheliomas occurring in bone. Savardekar[ 3 ] reported a myoepithelioma of the dorsal spine in an adult with recurrence which eventually turned into myoepithelial carcinoma during postoperative follow-up. Ghermandi[ 4 ] reported the clinical, radiographic, and pathological features of the first case of primary myoepitheliomas arising in the vertebral bone; the patient underwent corpectomy for local recurrence 2 months later and was free of disease at 12 months from the first surgery. These cases confirmed that myoepithelioma has a high risk of recurrence. Kurzawa[ 6 ] analyzed the clinical and pathologic features of 8 primary myoepitheliomas of bone; 6 patients with intraosseous myoepithelioma did not have any evidence of disease during their follow-up period, 1 patient with necrotic tumor developed lung metastases 1 year after the operation, and 2 patients had no follow-up data. Matsumoto[ 7 ] reported a dumbbell-style spinal malignant myoepithelioma. Rekhi[ 5 ] described clinicopathological features of five cases of intraosseous myoepithelial carcinomas, mimicking primary bone tumors, and exhibiting squamous differentiation in three tumors. Shilpi Modi[ 10 ] described an extremely rare case of primary myoepithelioma arising from the clivus, which owing to its unusual location and immunohistochemical profile was diagnostically challenging. Fritchie[ 11 ] reported a case of myoepithlioma of the skull; six months after surgery, the patient is doing well with no evidence of recurrence or residual tumor was identified on a follow-up magnetic resonance imaging scan performed 4 months postoperatively. Song[ 12 ] described the clinical, radiographic, and pathologic features of myoepitheliomas of bone; these tumors have a wide age range, may involve any part of the skeleton, and have a variable spindle cell and epithelioid morphology; the bone tumors are considered in the differential diagnosis. Nambirajan[ 13 ] reported a rare occurrence of primary myoepitheliomas in a small bone of the hand that clinically and radiologically mimicked an enchondroma. Documentation of these cases and long-term follow-up studies may better elucidate the histopathological and molecular prognostic factors. Furthermore, serial imaging examinations can be useful in monitoring the growth pattern and response to treatment, thereby assisting in long-term management and follow-up of myoepithelioma cases. Despite a limited follow-up period, good results have been reported in the literature to date for myoepithelioma of the spine. In our cohort, the tumor had not recurred during the 20-month follow-up after surgery. As a treatment for myoepithelioma, surgery has been accepted as the most effective method. Gross total resection with wide resection margins in the paraspinal region should be used to tackle this rare entity, as the role of adjuvant therapy is doubtful. Long-term follow-up is warranted because these tumors may exhibit aggressive behavior. Conclusion Myoepithelioma of the spine is extremely rare. Therefore, myoepithelioma cannot be diagnosed by imaging findings alone at present, and additional examinations, especially histological examination, are required. Our experience suggests that when a slow-growing spinal mass mimics neurilemmoma, myoepithelioma should be included in the differential diagnosis. In summary, the careful evaluation of imaging findings is essential for accurate diagnosis, appropriate treatment planning, and effective management of myoepitheliomas. Abbreviations MRI: Magnetic resonance imaging; CT: Computed tomography; T1WI: T1-weighted imaging; T2WI: T2-weighted imaging. Declarations Ethics approval and consent to participate The study was approved by the ethics committee of the Daping Hospital of Army Medical University. Consent for publication Written informed consent for publication of their clinical details and/or clinical images was obtained from the parents of the patient. A copy of the consent form is available for review by the Editor of this journal. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding The study was supported by the Fund of Chongqing Clinical Research Centre of Imaging and Nuclear Medicine, China (grant no. CSTC2015YFPT-gcjsyjzx0175); and Chongqing 2019 Science and Technology Joint Medical Research Project (grant no.2019ZDXM049). Authors’ contributions Kun-ming Yi: Conceptualization, Writing-Reviewing & Editing, Supervision, and Funding acquisition. Rui-li Mao: Data curation, Investigation, Resources, and Writing- Original draft. Cheng Cheng: Data curation, Investigation. Acknowledgments Not applicable. References Papazian M, Kalantzis I, Galanopoulos G, Mani I, Tzaida O, Iacovidou I, et al. Malignant myoepithelioma of the breast: A case report and review of the literature. Mol Clin Oncol. 2016;4(5):723-7. Barca I, Novembre D, Cordaro R, Lo Faro C, Colangeli W, Boschetti CE, et al. Myoepithelioma of the parotid gland: A case report with review of the literature. Oral and Maxillofacial Surgery Cases,2020,6(1). Savardekar AR, Goudihalli S, Chatterjee D, Ahuja CK, Salunke P. Primary myoepithelioma of the dorsal spine: a case report and review of literature. Spine (Phila Pa 1976). 2014;39(24):E1488-E92. Ghermandi R, Pala E, Gambarotti M, Colangeli S, Boriani S. Myoepithelioma of the spine: first case in the literature. Eur Rev Med Pharmacol Sci. 2014;18(1 Suppl):66-71. Rekhi B, Joshi S, Panchwagh Y, Gulia A, Borges A, Bajpai J, Jambehekar NA, Pant V, Mandholkar M, Byregowda S, Puri A. Clinicopathological features of five unusual cases of intraosseous myoepithelial carcinomas, mimicking conventional primary bone tumours, including EWSR1 rearrangement in one case. APMIS 2016; 124: 278–290. Kurzawa P, Kattapuram S, Hornicek FJ, Antonescu CR, Rosenberg AE, Nielsen GP. Primary myoepithelioma of bone: a report of 8 cases. Am J Surg Pathol. 2013;37(7):960-8. Matsumoto Y, Harimaya K, Kawaguchi K, Hayashida M, Okada S, Doi T, et al. Dumbbell Scoring System: A New Method for the Differential Diagnosis of Malignant and Benign Spinal Dumbbell Tumors. Spine (Phila Pa 1976). 2016;41(20):E1230-E6. Franchi A, Palomba A, Roselli G, Gambini C, Beltrami G, Capanna R, et al. Primary juxtacortical myoepithelioma/mixed tumor of the bone: a report of 3 cases with clinicopathologic, immunohistochemical, ultrastructural, and molecular characterization. Hum Pathol. 2013;44(4):566-77. Yeoh D, Symmans P, Smith K. Bony myoepithelioma: a rare condition presenting in the hand. J Hand Surg Eur Vol. 2017;42(1):94-5. Modi S, Goel D, Goyal P, Gupta A. Primary Myoepithelial Carcinoma of the Clivus: A Rare Presentation. Asian J Neurosurg. 2020;15(4):1024-6. Fritchie KJ, Bauman MD, Durward QJ. Myoepithelioma of the skull: a case report. Neurosurgery. 2012;71(4):E901-E4. Song W, Flucke U, Suurmeijer AJH. Myoepithelial Tumors of Bone. Surg Pathol Clin. 2017;10(3):657-74. Nambirajan A, Mridha AR, Sharma MC, Panda A, Palaniswamy A. Primary intra-osseous myoepithelioma of phalanx mimicking an enchondroma. Skeletal Radiol. 2016;45(10):1453-8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Apr, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 02 Apr, 2026 Reviews received at journal 23 Mar, 2026 Reviewers agreed at journal 23 Mar, 2026 Reviews received at journal 19 Mar, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviews received at journal 08 Mar, 2026 Reviewers agreed at journal 03 Mar, 2026 Reviewers invited by journal 03 Mar, 2026 Editor assigned by journal 03 Mar, 2026 Editor invited by journal 25 Feb, 2026 Submission checks completed at journal 24 Feb, 2026 First submitted to journal 24 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8937583","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":600550406,"identity":"345aaa62-9543-427f-85d0-ccf58019bc78","order_by":0,"name":"Rui-li Mao","email":"","orcid":"","institution":"Department of Radiology, Daping Hospital, Army Medical University","correspondingAuthor":false,"prefix":"","firstName":"Rui-li","middleName":"","lastName":"Mao","suffix":""},{"id":600550407,"identity":"b632c739-c07a-4cb3-9242-7b1c8a8a0694","order_by":1,"name":"Cheng Cheng","email":"","orcid":"","institution":"Department of Radiology, Daping Hospital, Army Medical University","correspondingAuthor":false,"prefix":"","firstName":"Cheng","middleName":"","lastName":"Cheng","suffix":""},{"id":600550408,"identity":"9e55e163-b515-4f74-82d0-f26bbc2cea4c","order_by":2,"name":"Kun-ming Yi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYFACNvYPCQY2dvxQLmMDEVrYGD5UpCVLtpGihXHGmcOMG44Rq0V3RlraY942Zmbj+92pm3kYbGQ3HGB+9gCfFrMbaceNedvY+MyO8W67zcOQZrzhAJu5AX4t6Q3SvG08zFAthxM3HOBhkyBCiwTj5jawlv/EaEk7JjnjjAHjBjawlgNEaDnzLNngQ0VCssSx3G035xgkG888zGaGX8vxNMMHCQb/7fibz2678abCTrbvePMzvFoYBBKQeaCgYsarHgj4DxBSMQpGwSgYBSMeAADmYU0rhmUmmAAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Radiology, Daping Hospital, Army Medical University","correspondingAuthor":true,"prefix":"","firstName":"Kun-ming","middleName":"","lastName":"Yi","suffix":""}],"badges":[],"createdAt":"2026-02-22 07:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8937583/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8937583/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-026-09902-x","type":"published","date":"2026-04-30T15:58:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":104258141,"identity":"0707a5b9-b184-4f8a-9636-abf9cb2424c8","added_by":"auto","created_at":"2026-03-09 17:35:56","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1055474,"visible":true,"origin":"","legend":"\u003cp\u003eMRI\u003cstrong\u003e \u003c/strong\u003eand CT\u003cstrong\u003e \u003c/strong\u003eshow a spine dumbbell tumor in the cervical vertebra. (\u003cstrong\u003eA, B\u003c/strong\u003e) The lesion demonstrates iso- to hyperintense on the sagittal T2WI and hypointense on the sagittal T1WI. (\u003cstrong\u003eC\u003c/strong\u003e) On the coronal fat-saturated T2WI, the tumor shows heterogeneous hyperintense, and granular, latticed low signals also are observed. (\u003cstrong\u003eD\u003c/strong\u003e) On the coronal CT, the mass shows heterogeneous isodense, calcifications are evident\u003c/p\u003e\n\u003cp\u003eat the margin of the tumor (arrow). (\u003cstrong\u003eE\u003c/strong\u003e) On the axial CT, enlargement of neural foramina without bone destruction of the vertebral body is evident. (\u003cstrong\u003eF\u003c/strong\u003e) On the axial contrast-enhanced CT, the tumor displays mild enhancement, the left vertebral artery displaces forward by tumor compression (arrow). (\u003cstrong\u003eG\u003c/strong\u003e) Microscopically, the cellular tumors are arranged in sheets and cords in a myxoid background (hematoxylin and eosin, ×100).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8937583/v1/78f37789391548b3eb76fbe7.jpeg"},{"id":108437991,"identity":"e3ea25b7-f491-4f4e-b069-97b208286f00","added_by":"auto","created_at":"2026-05-04 16:05:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1190620,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8937583/v1/c1d7ea7e-bcb3-4961-887b-3ef668a4900c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Myoepithelioma of the cervical spine mimicking neurinoma in an adolescent: a rare case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMyoepithelial tumors represent a diverse morphological and biological spectrum of tumors, composed of epithelial and mesenchymal elements[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These tumors are more commonly encountered in salivary glands or skin but can also arise in the upper airway, lung, gastrointestinal tract, breast, soft tissue, and other unusual sites including bone, and the lesions typically present in young to middle-aged adults [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Myoepithelioma of the spine is rare, and only a few cases have been reported[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Furthermore, no primary myoepithelioma of the spine in adolescents has been described hitherto. Herein, we report a rare case of primary myoepithelioma of the cervical spine mimicking a neurinoma in an adolescent.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 14-year-old male presented to the hospital with a one-year history of neck pain and more recent onset of left-hand numbness accompanied by weakness that had been present for over two weeks. The left-hand numbness affected the entire palm, and no obvious cause for the numbness or significant loss of muscle strength was identified. The patient experienced limited cervical spine movement due to pain, but no deformities were noted in the upper limbs. Upon examination, it was observed that the muscle strength and tone of the left upper limb were notably decreased, with a grade 1 muscle strength in the deltoid, biceps, triceps, wrist flexors, and digital flexors. Additionally, a positive Hoffmann's sign was observed on the left side. The patient also exhibited enhanced reflexes in the left knee and Achilles tendon, as well as positive clonus in the left ankle and patellar reflex.\u003c/p\u003e \u003cp\u003eMagnetic resonance imaging (MRI) and computed tomography (CT) showed a well-demarcated, expansile lesion occupying the C3-C4 intervertebral foramen. The mass has paravertebral and intraspinal extradural components. The size of the tumor in the spinal canal was about 4.6\u0026times;1.6\u0026times;1.4 cm, and the extra-vertebral canal portion was about 5.1\u0026times;1.6\u0026times;1.5 cm. The tumor showed heterogeneous high signal intensity compared with that of the spinal cord on the T2-weighted images(T2WI)(Figure A), homogeneous isointense on T1-weighted images༈T1WI༉(Figure B), and heterogeneously hyperintense on the fat-saturated T2WI (Figure C). The dotted, latticed low signals were observed on both T2WI and fat-saturated T2WI. The spinal cord deviated to the right by the tumor, without significant abnormality of the spinal cord signal. On CT, the lesion exhibited iso-to-hypodense before injection of the contrast medium, and spotty calcification was found (Figure D, E). The tumor showed weak enhancement after administration of the contrast medium (Figure F). The patient underwent complete surgical resection of the cervical tumor. Intraoperatively, the tumor was huge, with an incomplete capsule. Necrosis and liquefaction were observed within the tumor. The capsule of the tumor adhered to part of the dura mater and nerve roots. Histopathological examination showed the neoplasm had an incomplete capsule, the presence of epithelioid neoplastic cells arranged in nests and nodules within a myxoid matrix. Additionally, it was observed that some tumor cells exhibited eosinophilic cytoplasm, and there was slight heteromorphism noted in some tumor cells(Figure G). These immunohistochemical staining patterns are consistent with the characteristics of myoepithelioma. The positive staining for cytokeratin, smooth muscle actin, epithelial membrane antigen, P63, CD31, CD34, and calponin, along with the absence of staining for brachyury, desmin, and S-100 protein, supports the diagnosis of myoepithelioma. The Ki67 labeling index of 15% indicates the proliferative activity of the tumor cells, suggesting a moderate level of cell proliferation. These immunohistochemical findings provide valuable information for confirming the diagnosis and further characterizing the myoepithelioma. After surgery, the patient\u0026rsquo;s power improved to normal without any sign of recurrence during the 20-month follow-up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrimary myoepitheliomas of the spine are extremely rare and frequently misdiagnosed, and mainly occur in the fourth to fifth decades of life, and females are more likely to suffer from them [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Most of the cases reported in previous literature involve adults[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The clinical manifestations of myoepithelioma are non-specific and predominantly dependent on the location of the tumor. The compression of nerve roots by the tumor can lead to specific clinical symptoms. Furthermore, myoepithelioma has been associated with alterations in several genes, including P63, CD31, CD34, and rearrangement of the EWSR1 gene. These genetic abnormalities play a significant role in the pathogenesis of myoepithelioma[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In this particular case, we present a unique instance of a dumbbell-shaped spinal myoepithelioma in an adolescent, which was initially misdiagnosed as a neurinoma. This misdiagnosis highlights the challenges in accurately identifying and distinguishing myoepitheliomas from other tumors in the spinal region, particularly in younger individuals.\u003c/p\u003e \u003cp\u003eLimited reports have provided detailed descriptions of the CT and MR imaging features of myoepitheliomas. The majority of spinal myoepitheliomas arise from the vertebral body or its appendages, paravertebral soft tissues, and intervertebral foramina. Among the spinal regions, the thoracolumbar spine is more frequently affected by myoepitheliomas[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In cases where the tumor size exceeds 5 cm in maximal diameter, myoepitheliomas often exhibit an irregular and lobulated shape. The demarcation between the tumor and surrounding tissues tends to be indistinct, and there is a higher likelihood of osteolytic destruction in the adjacent bone. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. On magnetic resonance imaging (MRI), myoepitheliomas typically present as well-defined lesions with specific characteristics. They appear as T1-hypointense and T2-hyperintense lobulated masses. When gadolinium-based contrast is administered, these tumors often demonstrate heterogeneous enhancement patterns[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In the reported case, the morphology and growth pattern of the myoepithelioma resembled that of neurogenic tumors. The tumor was situated within the intervertebral foramen and exhibited a dumbbell shape, extending across the internal and external spinal canal along the nerve root. On T2-weighted imaging (T2WI) and fat-saturated T2WI, the tumor displayed heterogeneous high signal intensity in comparison to the spinal cord. Additionally, multiple small nodular areas of higher signal intensity were observed within the tumor. Given the secretory function of myoepithelial cells, it is reasonable to suspect that the higher signal intensity observed on MRI could be attributed to the secretions originating from these cells. The presence of these secretions within the tumor may contribute to the heterogeneous appearance and the multiple small nodular areas of higher signal intensity seen on MRI. However, further research and investigation would be required to confirm this hypothesis. The presence of dotted and latticed low signals on both T2-weighted imaging (T2WI) and fat-saturated T2WI suggests the presence of intratumoral interlaced fibrosis and collagenization. This finding is consistent with the histological features commonly associated with myoepitheliomas. On computed tomography (CT), the tumor appeared as a well-demarcated mass with characteristic features of a benign spine tumor. Calcifications were observed within the lesion, and there was no evident destruction of the surrounding bone. However, osteosclerosis, or increased bone density, was present in the vicinity of the tumor.\u003c/p\u003e \u003cp\u003eDue to the rarity of primary spinal myoepithelioma, there is a lack of specific radiological features associated with these tumors. As a result, they often pose diagnostic challenges. They can be mistakenly identified radiologically as other tumor types, such as neurinoma, neuroma, plasmacytoma, myeloma, or chondrosarcoma. The absence of distinct radiological characteristics further complicates the accurate identification and differentiation of myoepitheliomas from these other tumor entities. Consequently, histopathological examination and immunohistochemical analysis are typically required to establish an accurate diagnosis.\u003c/p\u003e \u003cp\u003eAlthough primary spinal myoepitheliomas lack specific radiological features, preoperative imaging examinations can still provide valuable information regarding the tumor's location, size, shape, margins, internal composition, enhancement patterns, and relationships with surrounding structures. This helps that that aids in differentiating myoepitheliomas from other tumors and determining the optimal management approach. This includes surgical planning, determining the extent of resection, and assessing the potential for infiltration into adjacent structures. In general, the imaging features of myoepitheliomas demonstrate a slow growth pattern, often leading to gradual enlargement of the tumor. This growth can induce reactive changes in the adjacent bone, such as osteosclerosis, but typically does not result in significant bone destruction. In some cases, the tumor may extend into the surrounding soft tissues, although this is less common.\u003c/p\u003e \u003cp\u003eRegarding treatment, there is no established consensus due to the rarity of primary bone myoepitheliomas. Treatment approaches may include surgical resection with or without adjuvant therapies such as radiation or chemotherapy. The choice of treatment depends on factors such as tumor size, location, presence of metastasis, and the patient's overall health status. The outcomes of treatment can also vary depending on these factors and the individual characteristics of the tumor.\u003c/p\u003e \u003cp\u003eA few authors have reported different imaging findings, different treatments, and with different neoplastic outcomes for myoepitheliomas occurring in bone. Savardekar[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] reported a myoepithelioma of the dorsal spine in an adult with recurrence which eventually turned into myoepithelial carcinoma during postoperative follow-up. Ghermandi[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] reported the clinical, radiographic, and pathological features of the first case of primary myoepitheliomas arising in the vertebral bone; the patient underwent corpectomy for local recurrence 2 months later and was free of disease at 12 months from the first surgery. These cases confirmed that myoepithelioma has a high risk of recurrence. Kurzawa[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] analyzed the clinical and pathologic features of 8 primary myoepitheliomas of bone; 6 patients with intraosseous myoepithelioma did not have any evidence of disease during their follow-up period, 1 patient with necrotic tumor developed lung metastases 1 year after the operation, and 2 patients had no follow-up data. Matsumoto[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported a dumbbell-style spinal malignant myoepithelioma. Rekhi[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] described clinicopathological features of five cases of intraosseous myoepithelial carcinomas, mimicking primary bone tumors, and exhibiting squamous differentiation in three tumors. Shilpi Modi[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] described an extremely rare case of primary myoepithelioma arising from the clivus, which owing to its unusual location and immunohistochemical profile was diagnostically challenging. Fritchie[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] reported a case of myoepithlioma of the skull; six months after surgery, the patient is doing well with no evidence of recurrence or residual tumor was identified on a follow-up magnetic resonance imaging scan performed 4 months postoperatively. Song[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] described the clinical, radiographic, and pathologic features of myoepitheliomas of bone; these tumors have a wide age range, may involve any part of the skeleton, and have a variable spindle cell and epithelioid morphology; the bone tumors are considered in the differential diagnosis. Nambirajan[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] reported a rare occurrence of primary myoepitheliomas in a small bone of the hand that clinically and radiologically mimicked an enchondroma. Documentation of these cases and long-term follow-up studies may better elucidate the histopathological and molecular prognostic factors. Furthermore, serial imaging examinations can be useful in monitoring the growth pattern and response to treatment, thereby assisting in long-term management and follow-up of myoepithelioma cases. Despite a limited follow-up period, good results have been reported in the literature to date for myoepithelioma of the spine. In our cohort, the tumor had not recurred during the 20-month follow-up after surgery. As a treatment for myoepithelioma, surgery has been accepted as the most effective method. Gross total resection with wide resection margins in the paraspinal region should be used to tackle this rare entity, as the role of adjuvant therapy is doubtful. Long-term follow-up is warranted because these tumors may exhibit aggressive behavior.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMyoepithelioma of the spine is extremely rare. Therefore, myoepithelioma cannot be diagnosed by imaging findings alone at present, and additional examinations, especially histological examination, are required. Our experience suggests that when a slow-growing spinal mass mimics neurilemmoma, myoepithelioma should be included in the differential diagnosis. In summary, the careful evaluation of imaging findings is essential for accurate diagnosis, appropriate treatment planning, and effective management of myoepitheliomas.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMRI: Magnetic resonance imaging; CT: Computed tomography; T1WI: T1-weighted imaging; T2WI: T2-weighted imaging.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethics committee of the Daping Hospital of Army Medical University.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of their clinical details and/or clinical images was obtained from the parents of the patient. A copy of the consent form is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported by the Fund of Chongqing Clinical Research Centre of Imaging and Nuclear Medicine, China (grant no. CSTC2015YFPT-gcjsyjzx0175); and Chongqing 2019 Science and Technology Joint Medical Research Project (grant no.2019ZDXM049).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKun-ming Yi: Conceptualization, Writing-Reviewing \u0026amp; Editing, Supervision, and Funding acquisition. Rui-li Mao: Data curation, Investigation, Resources, and Writing- Original draft. Cheng Cheng: Data curation, Investigation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePapazian M, Kalantzis I, Galanopoulos G, Mani I, Tzaida O, Iacovidou I, et al. Malignant myoepithelioma of the breast: A case report and review of the literature. Mol Clin Oncol. 2016;4(5):723-7.\u003c/li\u003e\n\u003cli\u003eBarca I, Novembre D, Cordaro R, Lo Faro C, Colangeli W, Boschetti CE, et al. Myoepithelioma of the parotid gland: A case report with review of the literature. Oral and Maxillofacial Surgery Cases,2020,6(1).\u003c/li\u003e\n\u003cli\u003eSavardekar AR, Goudihalli S, Chatterjee D, Ahuja CK, Salunke P. Primary myoepithelioma of the dorsal spine: a case report and review of literature. Spine (Phila Pa 1976). 2014;39(24):E1488-E92.\u003c/li\u003e\n\u003cli\u003eGhermandi R, Pala E, Gambarotti M, Colangeli S, Boriani S. Myoepithelioma of the spine: first case in the literature. Eur Rev Med Pharmacol Sci. 2014;18(1 Suppl):66-71.\u003c/li\u003e\n\u003cli\u003eRekhi B, Joshi S, Panchwagh Y, Gulia A, Borges A, Bajpai J, Jambehekar NA, Pant V, Mandholkar M, Byregowda S, Puri A. Clinicopathological features of five unusual cases of intraosseous myoepithelial carcinomas, mimicking conventional primary bone tumours, including EWSR1 rearrangement in one case. APMIS 2016; 124: 278\u0026ndash;290.\u003c/li\u003e\n\u003cli\u003eKurzawa P, Kattapuram S, Hornicek FJ, Antonescu CR, Rosenberg AE, Nielsen GP. Primary myoepithelioma of bone: a report of 8 cases. Am J Surg Pathol. 2013;37(7):960-8.\u003c/li\u003e\n\u003cli\u003eMatsumoto Y, Harimaya K, Kawaguchi K, Hayashida M, Okada S, Doi T, et al. Dumbbell Scoring System: A New Method for the Differential Diagnosis of Malignant and Benign Spinal Dumbbell Tumors. Spine (Phila Pa 1976). 2016;41(20):E1230-E6.\u003c/li\u003e\n\u003cli\u003eFranchi A, Palomba A, Roselli G, Gambini C, Beltrami G, Capanna R, et al. Primary juxtacortical myoepithelioma/mixed tumor of the bone: a report of 3 cases with clinicopathologic, immunohistochemical, ultrastructural, and molecular characterization. Hum Pathol. 2013;44(4):566-77.\u003c/li\u003e\n\u003cli\u003eYeoh D, Symmans P, Smith K. Bony myoepithelioma: a rare condition presenting in the hand. J Hand Surg Eur Vol. 2017;42(1):94-5.\u003c/li\u003e\n\u003cli\u003eModi S, Goel D, Goyal P, Gupta A. Primary Myoepithelial Carcinoma of the Clivus: A Rare Presentation. Asian J Neurosurg. 2020;15(4):1024-6.\u003c/li\u003e\n\u003cli\u003eFritchie KJ, Bauman MD, Durward QJ. Myoepithelioma of the skull: a case report. Neurosurgery. 2012;71(4):E901-E4.\u003c/li\u003e\n\u003cli\u003eSong W, Flucke U, Suurmeijer AJH. Myoepithelial Tumors of Bone. Surg Pathol Clin. 2017;10(3):657-74.\u003c/li\u003e\n\u003cli\u003eNambirajan A, Mridha AR, Sharma MC, Panda A, Palaniswamy A. Primary intra-osseous myoepithelioma of phalanx mimicking an enchondroma. Skeletal Radiol. 2016;45(10):1453-8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"myoepithelioma, spine, magnetic resonance imaging, computer tomography","lastPublishedDoi":"10.21203/rs.3.rs-8937583/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8937583/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePrimary spinal myoepithelioma is an exceedingly rare condition. In this case report, we present the unique instance of a 14-year-old male who presented with neck pain, left-hand numbness, and weakness, ultimately diagnosed with primary myoepithelioma of the cervical spine. The initial imaging studies, including magnetic resonance imaging (MRI) and computed tomography (CT), demonstrated a well-defined, expansile, dumbbell-shaped mass in the cervical vertebra, with no evidence of vertebral body destruction. The patient underwent a complete surgical resection of the tumor, resulting in the removal of the entire mass. Subsequent pathological analysis confirmed the diagnosis of myoepithelioma.\u003c/p\u003e","manuscriptTitle":"Myoepithelioma of the cervical spine mimicking neurinoma in an adolescent: a rare case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-09 17:35:47","doi":"10.21203/rs.3.rs-8937583/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-02T05:41:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-23T18:58:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304166144623716292797411476636307908282","date":"2026-03-23T18:39:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-19T20:30:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83502756100650366438967950951163085429","date":"2026-03-19T17:07:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-08T08:04:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266211047043916354172675545504291845552","date":"2026-03-03T18:34:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-03T18:27:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-03T18:22:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-25T06:02:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-24T17:08:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-02-24T17:03:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bea8740b-b6e8-4f3d-adcb-af7d0c20ddc9","owner":[],"postedDate":"March 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:05:12+00:00","versionOfRecord":{"articleIdentity":"rs-8937583","link":"https://doi.org/10.1186/s12891-026-09902-x","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2026-04-30 15:58:04","publishedOnDateReadable":"April 30th, 2026"},"versionCreatedAt":"2026-03-09 17:35:47","video":"","vorDoi":"10.1186/s12891-026-09902-x","vorDoiUrl":"https://doi.org/10.1186/s12891-026-09902-x","workflowStages":[]},"version":"v1","identity":"rs-8937583","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8937583","identity":"rs-8937583","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}