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The natural history and management of symptomatic and asymptomatic vertebral hemangiomas
Abstract
Fifty-nine cases of vertebral hemangioma were seen at the Mayo Clinic between 1980 and 1990. Vertebral hemangiomas were discovered incidentally in 35 patients, while pain was the presenting complaint in 13 patients. Five patients presented directly with progressive neurological deficit requiring surgery, and six patients had surgery elsewhere for spinal cord compression and were referred for follow-up evaluation. To better define the natural history of these lesions, a historical review of these patients was conducted; progression of an asymptomatic or painful lesion to neurological symptoms was found in only two cases (mean follow-up period 7.4 years, range 1 to 35 years). New-onset back pain followed by subacute progression (mean time to progression 4.4 months, range 0.25 to 12 months) of a thoracic myelopathy was the most common presentation for patients with neurological deficit. Initially, all 11 patients with spinal cord compression underwent decompressive surgery with full neurological recovery. Recurrent neurological symptoms were observed in three of six patients following subtotal tumor resection and postoperative administration of 1000 cGy or less radiation therapy (mean follow-up period 8.7 years, range 1 to 17 years). No recurrences were noted in four patients who had subtotal excision plus radiotherapy between 2600 and 4500 cGy. One other patient had gross total tumor removal without radiotherapy and has not had a recurrence. Based on these patients and a review of the literature, the authors recommend annual neurological and radiological examinations for patients with hemangiomas associated with pain, especially young females with thoracic lesions in whom spinal cord compression is most likely to develop. Radiation therapy or embolization is an effective therapeutic alternative for patients with severe medically refractory pain. Regular follow-up monitoring for patients with asymptomatic lesions is unnecessary unless pain develops at the appropriate spinal level. It is concluded that management of patients with a progressive neurological deficit should include preoperative angiography and embolization, decompressive surgery with the approach determined by the degree of vertebral involvement and site of spinal cord compression, and postoperative radiation therapy in patients following subtotal tumor removal. Operative management and complications are discussed.
... Vertebral haemangiomas [VHs], although benign and often incidentally detected on magnetic resonance imaging (MRI), may result in back pain and progressive neurological deficits due to compression of the spinal cord or nerve roots, when they are termed aggressive (Laredo et al., 1986;Fox and Onofrio, 1993;Acosta et al., 2008;Hurley et al., 2008;Gaudino et al., 2015). These aggressive lesions frequently involve all three vertebral columns when conservative measures are often unsuccessful in their management. ...
... These aggressive lesions frequently involve all three vertebral columns when conservative measures are often unsuccessful in their management. Surgical decompression with or without adjuvant postoperative radiation is the preferred line of management for these aggressive haemangiomas (Fox and Onofrio, 1993;Acosta et al., 2008). A major limiting factor in the surgical management is the tumour vascularity and considerable intraoperative blood loss, prompting preoperative or intraoperative angioembolization strategies (Pavlovitch et al., 1989;Smith et al., 1993;Premat et al., 2017;Eichberg et al., 2018). ...
... The underlying principle in the management of aggressive haemangiomas remains adequate decompression of the dural tube followed by fusion (Nguyen et al., 1987;Fox and Onofrio, 1993;Acosta et al., 2011;Jiang et al., 2014;Vasudeva et al., 2016). Although aggressive VHs are benign lesions the risk of recurrence ranges from 3 to 30% with conservative approaches including alcohol injection, bone cement injection and transarterial embolization (Acosta et al., 2008;Goldstein et al., 2015;Nguyen et al., 1987). ...
Purpose
We studied the clinico-radiological features and treatment outcomes of patients with aggressive spinal haemangiomas.
Methods
We undertook a retrospective review of 24 patients with aggressive spinal haemangiomas managed at our centre from 2004 to 2016. The cohort was divided into two groups. Group1 included patients managed from 2004 to 2009 while Group 2 was those treated between 2010 and 2016. Clinicoradiological features and treatment outcomes were studied.
Results
Back pain (24/24) and myelopathy (18/24) were the most common presenting complaints. Over 80% (20/24) of patients, had involvement of the thoracic spine and more than 50% (13/24) had severe spasticity, being Nurick grade 4&5 at presentation. The various treatment modalities used were laminectomy with or without instrumented posterior fusion (10/24), corpectomy with instrumented fusion (10/24) and alcohol injection alone (4/24). Patients who were treated with surgery had significant clinical improvement at follow-up in both groups. Patients who underwent alcohol injection did not have any improvement in symptoms at follow-up. There was a change in our strategy in the later part of the series from a two staged anterior and posterior approach to a single staged posterior-only approach to address vertebral body disease with preoperative angioembolization.
Conclusion
Haemangiomas are benign lesions with locally aggressive behavior in some cases. Results of conservative approaches such as alcohol injection in management of these lesions are discouraging. Aggressive surgical decompression combined with preoperative adjuncts such as angioembolization with or without stabilization reduces intra operative blood loss and results in good neurological recovery even in patients with severe myelopathy.
... VH is typically asymptomatic and is often discovered incidentally on imaging examination [1][2][3]. However, about 0.9 %-1.2 % of VH can be symptomatic [6][7][8]15,16,25] (aggressive vertebral hemangioma) with spinal cord distension, pain and compression [4,5]. AVH can occur in cervical, thoracic, and lumbar regions and cause the enlargement of the posterior cortex of the vertebral body, destruction of the vertebral pedicle, and spinal canal stenosis, resulting in bleeding, pathological compression fractures, and neurological deficits. ...
... AVH can occur in cervical, thoracic, and lumbar regions and cause the enlargement of the posterior cortex of the vertebral body, destruction of the vertebral pedicle, and spinal canal stenosis, resulting in bleeding, pathological compression fractures, and neurological deficits. There are several options to treat patients with AVHs, although the surgical treatment strategies for AVHs are still controversial due to their rarity [6][7][8]16,28]. ...
... Excellent rates local control and long-term survival can achieved with aggressive resection, but total en bloc spondylectomy resulted in significant bleeding and intraoperative morbidity [7]. Subtotal tumor resection has been widespread for several years, but is associated with an increased recurrence and adjuvant radiation therapy makes a second operation more difficult [8]. Decompression has also been used to circumvent neurological symptoms, but palliative debulking surgery increases the rate of early or delayed recurrence [9]. ...
Purpose
We retrospectively study twenty-nine surgical cases of aggressive vertebral hemangiomas (AVHs) with neurological deficits and extradural compression to determine the optimal surgical treatment strategy for AVHs at a single institution.
Methods
Patients with AVHs with neurological deficits who underwent partial tumor resection plus decompression with or without vertebroplasty (VP), and radiotherapy between 2010 and 2021 were included in this study. Clinical characteristics, surgical outcomes, and follow-up data of the patients were reviewed retrospectively.
Results
Twenty-nine AVH cases with neurological deficits and spinal instability were included in this study and treated surgically. The mean operation time of patients with decompression surgery plus VP (Groupe A) was 215.9 (120-265 min), shorter than that of decompression surgery without VP (Group B) 240.2 (120-320 min). Intraoperative blood loss was 273.3 (100–550 mL) in group A and 635.3 (200–1600 mL) in group B. In addition, a significant reduction in blood loss was observed in group A compared to the group B (p=0.0001). All patients experienced immediate pain relief and improvement in their neurological symptoms. Neurological function was assessed by the Frankel score, ASIA score, and the visual analogue scale (VAS) pain score decreased from 7.4 (4-9) to 1.3 (0-3). Of twenty-nine patients in this study, only 7% (2/29 patients) showed signs of recurrence.
Conclusion
Decompression plus VP achieve good tumor control and decrease surgical complication. Preoperative vascular embolization and VP can reduce intraoperative bleeding in the treatment of AVH surgery. Moreover, postoperative radiotherapy seems to be a good technique to prevent tumor recurrence.
... Vertebral hemangioma (VH) has the highest incidence among vertebral column space-occupying lesions, and the estimated incidence is about 10-12% in populationbased studies [1,2]. In most cases, they are accidentally discovered without any clinical manifestations. ...
... Pathological fractures are also a common sequela of IVH due to bone weakness. The clinical manifestation includes local pain, radicular pain, and weakness ranging from minimal weakness to complete paraplegia [1,2]. ...
... Due to the extensive vascularity of invasive lesions, surgery is usually accompanied by massive bleeding if done without preoperative hemostatic techniques like embolization or vertebroplasty [1,2]. Also, inadequate removal of invasive lesions is common leading to more neurological deterioration. ...
Background
Catastrophic intraoperative bleeding is a major complication of surgical removal of invasive vertebral hemangioma. Interventional neuroradiology techniques could be more useful tools to manage such hemorrhagic lesions.
Results
Retrospective analysis of cases of invasive vertebral hemangioma revealed 17 cases treated at the Alexandria University School of Medicine from 2006 to 2020. The study included 52.9% of males with a mean age of 38.4 ± 18.6 years old. All patients reported local and sometimes radicular pain; 64.7% exhibited progressive neurological deficits. Imaging revealed thoracic spine affection in 11 cases, lumbar vertebral in four cases, and cervical vertebra in two cases. Vertebral involvement occurred in 10 cases and paravertebral extension in 13 cases. Neurointervention modalities included transarterial embolization followed by corpectomy and fixation (one case with C4 lesion), direct surgery with corpectomy and anterior fixation (one case with C7 lesion), vertebroplasty alone (four cases), vertebroplasty with fixation (seven cases), and direct transpedicular alcohol injection with immediate devascularization and necrosis of the vascular channels inside the lesions (six cases). The alcohol injection use ranged from 4 to 10 ml in each pedicle. All patients did well during the follow-period post-intervention. The neurological deficits improved over six months. All patients showed improved Nurick grade regardless of the intervention (preoperative mean 2.7 ± 1.9 vs. postoperative mean 1.1 ± 1.3, p value 0.0001). Two patients were completely paraplegic, but with intact deep sensation, they improved dramatically and can walk unsupported post-intervention.
Conclusions
Vertebral hemangioma can present in an invasive manner that necessitates intervention. Preoperative embolization, alcohol injection, or vertebroplasty are helpful methods to decrease intraoperative catastrophic hemorrhage. Alcohol injection is cost-effective with immediate devascularization of the lesion. The extensive 360 surgery utilization can be decreased with the use of alcohol and vertebroplasty. More cases are needed to validate these conclusions.
... No tenderness or swelling was present in back. On investigation -Hb-10.5 gm%, TLC-7200 cells/mm 3 ...
... An active lesion with spinal cord compression or nerve root compression is seen rarely. The diagnosis can usually be made by radiologic studies [ 3 ]. If at least one third of the vertebral body is involved, a honeycomb appearance is observed on radiographs. ...
... The dilated vascular channels are set in a substratum of fatty marrow. [ 3 ] Treatment of vertebral hemangiomas is indicated if symptoms such as neurological deficits or severe pain develop. The most common treatment option for painful lesions is radiotherapy. ...
Thoracic vertebral intra-osseous hemangioma with spinal cord compression: A rare presentation. Abstract Benign vascular tumors of bone are extremely infrequent. Symptomatic vascular tumors are even more infrequent. Vertebral hemangiomas represent 2-3% of all radiologically detectable spinal tumours. Symptomatic vertebral hemangiomas are rare and represent <1% of all hemangiomas. If untreated they can lead to serious neurological deficit. We report a case of a vertebral hemangioma in thoracic region causing spinal cord compression. We want to emphasize the point by reporting this case is that, although symptomatic spinal hemangioma is rare but it should always be included in the differential diagnosis of symptomatic spinal lesions especially in developing countries where tubercular lesion is more common.
... Vertebral HAs have an incidence of 10-12% in the general population [7,8] and show a coarse structure, such as vertical trabecular pattern, with bony reinforcement (thickened vertebral trabeculae) adjacent to the vascular channels that caused bone resorption [8] as the main radiographic finding. Using computed tomography (CT), the thickened vertebral trabeculae are visualized in cross-section as small spotted areas of sclerosis, often referred to as having a "polka-dot appearance"; using magnetic resonance imaging (MRI) T2-weighted images usually show areas of high signal intensity, corresponding to vascular components [4,[9][10][11][12][13][14]. ...
... Rarely, in 0.9-1.2% of cases, HAs are defined as aggressive due to spread of the spinal cord within the soft tissues and epidural region, causing radicular and/or spinal cord compression, expansion of the bone matrix, compression of large vessels due to angiogenesis, epidural haematoma or spinal instability, caused by vertebral compression fracture [7,10,15] which may cause pain, paraesthesia and other neurological signs [14]. ...
... It is generally accepted that surgery is warranted when vertebral HAs cause severe back pain and neurological diseases; however, the optimal treatment strategy is controversial [16,17]. Indeed, some surgeons opt for operations such as vertebroplasty, endovascular embolization (EVE) or percutaneous embolization, ethanol injection or radiotherapy; EVE is particularly effective in cases where the pathogenetic mechanism of compression is caused by the extension of the lesion into the epidural space-rather than by vertebral swelling-and has also been proposed as a definitive treatment for aggressive vertebral HAs without surgery [7]. ...
Hemangiomas are the most common benign tumours affecting the spine, with an incidence of 10–12% of the general population. Although most hemangiomas are asymptomatic, there are aggressive forms which can develop symptoms, leading patients to show signs of disability. This case report aims to highlight the importance of red flags screening, and to report the physiotherapist’s clinical reasoning that led him to refer his patient to other healthcare professionals. This case also illustrated the pre- and post-surgical treatment of a specific low back pain case in a patient affected by aggressive vertebral hemangioma and spinal cord compression. The patient is a 52-year-old man, who reported intense pain in his sacral region about three months prior, which worsened while in sitting position. The physiotherapist proceeded with a complete medical history investigation and clinical examination. After an impaired neurological examination, the patient was referred to another health professional, who diagnosed multiple vertebral hemangiomas in the patient’s lumbosacral tract. The therapeutic intervention included the patient’s post-surgical rehabilitation following a vascular embolization. This case report shows the importance of proper patient screening. Indeed, during patients’ assessment, it is paramount to recognize red flags and to investigate them appropriately. An early referral of patients with conditions that require the support and expertise of other professionals can lead to a timely diagnosis and avoid costly and unnecessary rehabilitation procedures. In this case, the interdisciplinary collaboration between physiotherapist and neurosurgeon was crucial in guiding the patient towards recovery.
... Latent lesions (Enneking stage 1) have mild bony destruction without symptoms, whereas active lesions (Enneking stage 2) present with pain because of bony destruction. Aggressive VHs (AVHs) (Enneking stage 3) are lesions with bony destruction and epidural soft tissue extension that are seen in 1% of affected patients [3,4]. Among all patients with AVHs, 55% present with pain, whereas the remaining 45% present with compressive myelopathy or neurological deficits, and therefore, aggressive management is indicated in this subgroup of patients [3]. ...
... Aggressive VHs (AVHs) (Enneking stage 3) are lesions with bony destruction and epidural soft tissue extension that are seen in 1% of affected patients [3,4]. Among all patients with AVHs, 55% present with pain, whereas the remaining 45% present with compressive myelopathy or neurological deficits, and therefore, aggressive management is indicated in this subgroup of patients [3]. ...
... In this study, no recurrences were observed among the patients who underwent intralesional resection. Even in patients with extensive involvement of all zones (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12) according to the WBB classification, intralesional excision resulted in satisfactory neurological outcomes without recurrence. ...
Study design:
This was a retrospective study.
Purpose:
To analyze the surgical and neurological outcomes following surgical decompression in patients with aggressive vertebral hemangioma (AVH) presenting with neurological deficit and to determine whether a less extensive approach is appropriate.
Overview of literature:
AVHs are a rare subset of benign vascular tumors frequently presenting with neurological deficit because of spinal cord compression. Though the results of surgical management have improved over time, there is a lack of consensus on the ideal management in this group of patients.
Methods:
Twenty-one patients who underwent surgery for AVH between 2009 and 2018 were analyzed. Demographic and clinical details of patients were retrieved from hospital information system. Imaging information (i.e., radiography, computed tomography, magnetic resonance imaging) of all patients was accessed and analyzed in picture archiving and communication system. Tumor staging was performed using Enneking and Weinstein-Boriani-Biagini classifications and Spinal Instability Neoplastic Score. At followup, neurological and radiological evaluations were performed.
Results:
Twenty-one patients (13 [61.9%] females and 8 [38.1%] males) were included with a mean age of 44.29 years (range, 14-72 years). All patients in the study had neurological deficit. Back pain was present in 80.9% of patients. Mean duration of symptoms was 4.6 months (range, 1 day to 10 months). Most common lesion location was thoracic spine (n=12), followed by thoracolumbar (D11- L2; n=7) and lumbar (n=2) regions. Ten patients had multiple level lesions. All patients underwent preoperative embolization. Nine patients underwent intralesional spondylectomy with reconstruction; another nine patients underwent stabilization, decompression, and vertebroplasty; three patients underwent decompression and stabilization. Neurology improved in all patients, and only one case of recurrence was noted in a mean follow-up of 55.78±25 months (range, 24-96 months).
Conclusions:
In AVH, good clinical and neurological outcomes with low recurrence rates can be achieved using less extensive procedures, such as posterior instrumented decompression with vertebroplasty and intralesional tumor resection.
... [2] They are usually asymptomatic and often present as an incidental finding on imaging studies. [3] Only 0.9-1.2% of patients with VH do become symptomatic. Symptoms range from pain to neurological complications. ...
... Symptoms range from pain to neurological complications. [3] These symptomatic lesions are usually classified into Enneking Stage 3 and are termed as "aggressive vertebral hemangiomas." [4] Due to their relatively low incidence, there is sparse reporting in the literature and lack of universal consensus on treatment protocol. ...
... [39] The choice varies depending on the position and extent of the tumor. Earlier studies by Fox and Onofrio [3] advocated subtotal resection and they reported recurrence of tumor in those patients who did not have any adjuvant radiotherapy. Later in studies by Bremnes et al., [40] Cotten et al., [27] Jayakumar et al., [41] and Fourney, [42] only laminectomy with adjuvant therapy was done and they reported good results. ...
Background: This study includes management of aggressive vertebral hemangioma (VH). VH is the most common primary tumor affecting the vertebral column. In 0.9–1.2% of patients, VH can become symptomatic and is termed as “aggressive vertebral hemangiomas.” They usually require surgery along with adjuvant modalities. Due to its relatively low incidence, there is sparse reporting in the open literature and lack of universal consensus on treatment protocol. We would like to present our institutional experience in managing aggressive VH by surgery along with adjuvant modalities and a comprehensive review of the literature. Materials and Methods: A retrospective review of records of VH cases managed surgically in the past 3 years at our institute was done. All the relevant records and imaging of the patients were retrieved. Results: Five patients were included in the study. All were male with four dorsal and one lumbar lesion. All were treated with surgery along with an adjuvant therapy. Selective arterial embolization was used in one patient, alcohol ablation in three, and vertebroplasty in one. Only one patient had gross total resection, and others had only decompression. Fixation was done in all. All showed good clinical improvement without any complications, except in one. Conclusion: Aggressive VH often requires surgery. Currently, a decompression surgery is preferred due to less morbidity with good clinical outcomes. Various adjuvant therapies have been described in literature to be used perioperatively; yet there is no universal consensus on a standard protocol. Each of them has its own advantages and limitations and thus needs to be carefully selected on an individual basis. Alcohol ablation is an established adjuvant modality, but has to be used with caution.
... These are usually confined to the vertebral body rather than the posterior bony elements of the spine. [1][2][3][4] The most common location of these tumors is the thoracic spine followed by the lumbar spine. [2,5] However, unlike vascular malformations, VH does not have arteriovenous shunting. ...
... [2] VH represents 2-3% of spinal tumors, and they are incidentally found in up to 12% of the general autopsies. [1,6] VHs are asymptomatic in most of the population and are often an incident finding on imaging. [4] On plain radiography, the palisading appearance due to the thickening of bony trabeculae resembles "corduroy cloth. ...
... [6,14,[19][20][21][22] Typical and atypical VHs differ only in histological composition; aggressive hemangiomas possess a different clinical behavior -they extend beyond the vertebral body and are associated with extensive cortical destruction. [1] In some instances, VHs might mimic primary and metastatic malignancies; pre-operative CT-guided biopsy, with a diagnostic accuracy of 89%, is highly recommended in such cases. [21,23,24] In this series, only two patients underwent preoperative CT-guided biopsy due to the unusual location and radiological characteristics, thereby confirming the diagnosis of AVH. ...
ABSTRACT
OBJECTIVES:
Vertebral hemangiomas are benign, slow-growing tumors. They represent 2–3% of spinal tumors and are incidentally found. Various treatment protocols have been described for Enneking Stage III vertebral hemangiomas. However, a comprehensive treatment protocol is still lacking. This case series aimed to describe the management of Enneking Stage III vertebral hemangiomas in two centers.
METHODS:
This case series was performed by retrospectively reviewing the medical records of all patients diagnosed with Enneking Stage III vertebral hemangiomas at two centers in Riyadh, Saudi Arabia, from 2010 to 2020.
RESULTS:
Eleven patients had Enneking Stage III vertebral hemangiomas. Mean follow-up was 47.5 ± 24.1 (range 9–120) months. All patients were symptomatic; the most common presentations were neurological deficits with or without myelopathy (n = 6). Ten patients underwent surgical decompression with instrumentation. One patient refused surgery and underwent vertebroplasty and repeated sclerotherapy. All patients regained full neurological recovery during their follow-ups with a mean duration of 49.4 (range, 14–120) months. No recurrence was reported.
CONCLUSION:
In all 11 patients, they showed full recovery and clinical improvement regardless of treatment variety. Therefore, a larger study comparing various treatment methods is needed to reach a gold standard approach.
... Among symptomatic VHs, up to 20-45% of cases may exhibit aggressive features including damage to surrounding bone and soft tissue or demonstrate rapid growth that extends beyond the vertebral body and invades the paravertebral and/or epidural space [1,5,10,11]. When "aggressive", VHs may compress the spinal cord and nerve roots causing severe symptoms [1,5]. ...
... XRT is gaining popularity as a postoperative adjunct therapy intended to reduce local recurrence, especially in subtotal resections [8,52,67]. There is a 50% recurrence rate in partial resections without adjunct XRT [8,11]. The extent to which XRT can reduce recurrence has not been fully elucidated and has been suggested for future study [52]. ...
Background
Vertebral hemangiomas (VHs) are the most common benign tumors of the spinal column and are often encountered incidentally during routine spinal imaging.
Methods
A retrospective review of the inpatient and outpatient hospital records at our institution was performed for the diagnosis of VHs from January 2005 to September 2023. Search filters included “vertebral hemangioma,” "back pain,” “weakness,” “radiculopathy,” and “focal neurological deficits.” Radiographic evaluation of these patients included plain X-rays, CT, and MRI. Following confirmation of a diagnosis of VH, these images were used to generate the figures used in this manuscript. Moreover, an extensive literature search was conducted using PubMed for the literature review portion of the manuscript.
Result
VHs are benign vascular proliferations that cause remodeling of bony trabeculae in the vertebral body of the spinal column. Horizontal trabeculae deteriorate leading to thickening of vertical trabeculae which causes a striated appearance on sagittal magnetic resonance imaging (MRI) and computed tomography (CT), “Corduroy sign,” and a punctuated appearance on axial imaging, “Polka dot sign.” These findings are seen in “typical vertebral hemangiomas” due to a low vascular-to-fat ratio of the lesion. Contrarily, atypical vertebral hemangiomas may or may not demonstrate the “Corduroy” or “Polka-dot” signs due to lower amounts of fat and a higher vascular component. Atypical vertebral hemangiomas often mimic other neoplastic pathologies, making diagnosis challenging. Although most VHs are asymptomatic, aggressive vertebral hemangiomas can present with neurologic sequelae such as myelopathy and radiculopathy due to nerve root and/or spinal cord compression. Asymptomatic vertebral hemangiomas do not require therapy, and there are many treatment options for vertebral hemangiomas causing pain, radiculopathy, and/or myelopathy. Surgery (corpectomy, laminectomy), percutaneous techniques (vertebroplasty, sclerotherapy, embolization), and radiotherapy can be used in combination or isolation as appropriate. Specific treatment options depend on the lesion's size/location and the extent of neural element compression. There is no consensus on the optimal treatment plan for symptomatic vertebral hemangioma patients, although management algorithms have been proposed.
Conclusion
While typical vertebral hemangioma diagnosis is relatively straightforward, the differential diagnosis is broad for atypical and aggressive lesions. There is an ongoing debate as to the best approach for managing symptomatic cases, however, surgical resection is often considered first line treatment for patients with neurologic deficit.
... Гемангиома позвонка -одна из наиболее распространенных доброкачественных вертебральных опухолей сосудистого генеза. Считается, что в ее основе лежат дизэмбриогенетические нарушения, влияющие на правильную дифференцировку кровеносных сосудов [4], в связи с чем некоторые исследователи определяют гемангиому позвонка не как опухоль, а как врожденную сосудистую мальформациюгамартому [5], то есть ткань, растущую с нормальной скоростью, но неупорядоченно. Частота гемангиом позвонков во взрослой популяции оценивается в 10-26 % [6,7], но только 0,9-1,2 % имеют клинические проявления [8]. ...
... В подавляющем большинстве гемангиомы имеют очаговый характер, протекают бессимптомно, что, по Enneking staging system (ESS) для доброкачественных опухолей позвоночника, соответствует латентной стадии (ESS S1), и требуют только наблюдения [9,10]. При симптоматических гемангиомах позвоночника у 55 % пациентов единственным симптомом является боль, что расценивается как не агрессивная, но клинически активная опухоль (ESS S2), остальные 45 % представлены агрессивным типом (ESS S3) с возможной инвазией в паравертебральное пространство или позвоночный канал, что приводит к неврологическому дефициту [4,[10][11][12][13]. ...
Objective. To analyze the features of clinical-radiological manifestations of symptomatic vertebral hemangiomas in children and the possibility of algorithmizing their treatment.
Material and Methods. As part of a monocenter cohort, 24 children aged 4 to 17 years received treatment for symptomatic vertebral hemangiomas. The clinical-radiological manifestations of the tumor and the effectiveness of various methods of invasive treatment were evaluated.
Results. Symptomatic uncomplicated and complicated vertebral hemangiomas, corresponding to stages S2 and S3 of the Enneking classification for benign tumors, occur in children with almost equal frequency. For tumors without extravertebral spread, a closed percutaneous vertebroplasty provides stable relief of complaints. For aggressive hemangiomas with extravertebral, including epidural, spread, various treatment methods are used. An algorithm for choosing therapeutic tactics is proposed.
Conclusion. Surgical treatment of symptomatic vertebral hemangiomas should be carried out using a tactical algorithm that takes into account the stage of the tumor (S2 or S3) and the possibility of performing closed or open vertebroplasty, selective arterial embolization and decompression and stabilization operations on the spine.
... Vertebral hemangioma (VH) is the most common benign tumor of the spine with an incidence of 10-12%. [1] A majority of these VHs are confined to the vertebral body. They are asymptomatic and either detected incidentally or not detected at all. ...
... Despite being the most common benign tumor of the spine, VHs are largely asymptomatic. Only less than 1% of adults report symptoms, which are most commonly pain (54%) or variable neurologic symptomatology (45%) [1]. These symptoms depend on age, degree of extension of the tumor, and the vascular component involved; and can range from radiculopathy to complete paralysis. ...
Vertebral hemangiomas (VHs) are benign vascular tumors that develop from the endoderm of blood vessels, although their exact pathogenesis is poorly understood. Most hemangiomas are small, about a third are multiple in number, and a very small number of these hemangiomas cause symptoms. Even more rare are aggressive VHs, which comprise a small number of all VHs, and are associated with expansion and extraosseous extension into the paraspinal and epidural spaces. Management of aggressive VHs involve pre-op embolization, spinal surgery, and reconstruction. Pain management, physical rehabilitation, and close neurological follow-up are imperative to near-total recovery. Aggressive VHs are most commonly seen in the thoracic region but may rarely involve a large number of vertebrae. Cutaneous hemangiomas, when seen along with VHs, are often metameric.
We present a rare and challenging case of compressive myelopathy and a large cutaneous hemangioma or a "purple shoulder", found during an exam in a young male. He was found to have an extensive VH extending through 13 vertebral levels (C7 to D12), non-metameric to the cutaneous lesion. A thorough physical examination and evaluation along with prompt surgical treatment were the cornerstone of treatment and prevention of permanent neurological deficits.
... Vertebral hemangioma (VH) is relatively common, occurring in 10% to 12% of the general population (1), and although benign, it is actually a vascular malformation (2). Most VHs are latent [Enneking stage 1 (st.1)] and do not require specific treatment, with only 1% of VHs become active and symptomatic, approximately 45% of which become aggressive and extend into the spinal canal and/ or paravertebral space, leading to neurological dysfunction (Enneking st.3) (3). ...
... They are intercompartmental lesions, with well-defined margins, that grow slowly and then stop and do not require specific treatment [6]; only 1% of VHs become active and symptomatic. Approximately 55% of these symptomatic VH cases are associated with pain alone [7]. Some VHs may become aggressive and extend into the spinal canal and/or the paravertebral space, leading to a neurologic deficit (Enneking Stage 3, st.3) [8]. ...
(1) Background: this case series and literature review aims to evaluate the efficacy and safety of electrochemotherapy in the management of aggressive spinal hemangiomas, presenting two distinct cases. (2) Methods: we present two cases of spinal aggressive hemangioma which were refractory to conventional treatments and underwent electrochemotherapy. Case 1 involves a 50-year-old female who presented with an aggressive spinal hemangioma of L1, who previously underwent various treatments including surgery, radio-chemotherapy, and arterial embolization. Case 2 describes a 16-year-old female with a T12 vertebral hemangioma, previously treated with surgery and stabilization, who faced limitations in treatment options due to her young age and the location of the hemangioma. (3) Results: in Case 1, electrochemotherapy with bleomycin was administered following the failure of previous treatments and resulted in the reduction of the lesion size and improvement in clinical symptoms. In Case 2, electrochemotherapy was chosen due to the risks associated with other treatments and was completed without any adverse events. Both cases demonstrated the potential of electrochemotherapy as a viable treatment option for spinal hemangiomas, especially in complex or recurrent cases. (4) Conclusions: electrochemotherapy with bleomycin is a promising treatment for aggressive spinal hemangiomas when conventional therapies are not feasible or have failed. Further research is needed to establish definitive protocols and long-term outcomes of electrochemotherapy in spinal hemangioma management.
... This lesion represents for only about 3% of spinal tumors and have an incidence of about 1.9-27% in the general population [6]. In these cases, the diagnosis is made accidentally through imaging methods that are used to search for other clinical conditions [7]. ...
... Often, nonsurgical approaches are favored due to the highly vascular nature of the tumor, which could result in significant morbidity if intraoperative hemorrhage were to occur. As such, radiotherapy remains an attractive option for symptomatic lesions without spinal cord compression [15] . Vascular endothelial cells are considered radiosensitive, but the exact mechanism of effect with radiotherapy remains controversial [16] . ...
Hemangiomas can arise anywhere in the body. While vertebral hemangiomas are common, atypical hemangiomas with paraspinal and epidural extension are rare. We present a case of a patient who presented with persistent cough and anorexia from a paravertebral hemangioma that invaded the adjacent vertebrae and neural foramen causing moderate spinal canal stenosis. She was treated with stereotactic body radiotherapy to prevent the development of symptomatic spinal cord compression. The hemangioma underwent significant shrinkage and her cough resolved. This case demonstrates impressive and sustained clinical and radiographic response of a paraspinal hemangioma to stereotactic body radiotherapy.
... This lesion represents for only about 3% of spinal tumors and have an incidence of about 1.9-27% in the general population [6]. In these cases, the diagnosis is made accidentally through imaging methods that are used to search for other clinical conditions [7]. ...
Vertebral hemangiomas can be defined as benign vascular bone tumors, accounting for only about 3% of spinal tumors. In general, they may demonstrate an asymptomatic clinical presentation, being found accidentally on imaging tests. They have an incidence of about 2.0-27% in the general population and do not require intervention in incidental cases.
... Observations Vertebral hemangiomas are common benign lesions that can occasionally cause pain and neurological deficits. 12,13 Resection is the gold standard for treatment, but is associated with surgical morbidity and often entails extensive reconstruction and multilevel fusion. 14 Although embolization is often performed preoperatively to reduce intraoperative blood loss, embolization without resection has also been shown to offer clinical improvement in select patients. ...
BACKGROUND
Hemangiomas are common benign vascular lesions that rarely present with pain and neurological deficits. Symptomatic lesions are often treated with endovascular embolization. However, transarterial embolization can be technically challenging depending on the size and caliber of the vessels. Moreover, embolization can result in osteonecrosis and vertebral collapse.
OBSERVATIONS
Here the authors report the first case of a T10 vertebral hemangioma treated with transpedicular Onyx embolization aided by a robotic platform that guided pedicle cannulation and Craig needle placement. An intravenous catheter was attached to the needle and dimethylsulfoxide was infused, followed by Onyx under real-time fluoroscopy. Repeat angiography demonstrated significantly reduced contrast opacification of the vertebral body without compromise of the segmental artery. A T9–11 pedicle screw fixation was performed to optimize long-term stability. The patient’s symptoms improved and was stable at the 6-month follow-up.
LESSONS
Transpedicular embolization of vertebral hemangiomas can be performed successfully under robotic navigation guidance, avoiding complications seen with the intra-arterial approach and allowing for simultaneous pedicle screw fixation to prevent collapse and delayed kyphotic deformity. During the same procedure, a biopsy specimen can be collected for pathology. This technique can help to alleviate patient symptoms while avoiding complications associated with transarterial embolization or open resection.
... Females are more likely to experience symptoms in the last trimester of pregnancy owing to the effects of the gravid uterus [10]. Symptoms of aggressive VH are back pain and progressive neurologic deficit [11]. Enneking stage 3 refers to the lesion eroding the bony structures to enter the spinal canal that leads to neurological deficits and warrants treatment [12]. ...
Vertebral hemangiomas are benign tumors of the spine, most often detected incidentally and on other instances, when signs and symptoms of the disease arise. About 10% of the population are affected worldwide with a female to male ratio of 2:1. The majority of these cases are asymptomatic and no intervention is generally required. Less often, back pain and neurological deficit may occur. Such hemangiomas are termed aggressive by the Enneking staging and warrant treatment. In this review, staging and diagnostics are discussed in detail followed by treatment options. Treatment options entail Surgical intervention, Percutaneous ethanol injection, radiofrequency ablation and Radiation Therapy. There are no set guidelines on preference or order of the treatment options. Further, in this review, studies favouring Radiation therapy regimes and their outcomes are elaborated.
... Hemosiderin, which is almost universally present within intramedullary and intraparenchymal lesions, is much less abundant in vertebral and epidural lesions. However, epidural lesions possess far greater vascularity, which may provide for the more rapid removal of hemosiderin [83]. ...
Pure epidural cavernous hemangioma (ECH) of the spine are rare and account for only 4% of all epidural spinal lesions. We report a case of epidural cavernoma at L3/4 presenting with L4 radiculopathy. Radiological, intraoperative findings and histopathology are presented.
We present the case of a 56-year-old man who was admitted with a right L4 radiculopathy including an M4 paresis of the right leg, hypoesthesia L4, and radicular pain. Magnetic resonance imaging (MRI) confirmed an extradural lesion L3/4 partially expanding into the right intervertebral foramen. The lesion had a heterogeneous signal, isointense on T1-weighted and hyperintense on proton density (PD) and T2-weighted images. At surgery, an epidural, ovoid, gray-red, soft mass, lightly adherent to the dura and extending to the right L4 foramen was observed. Findings in the histological examination indicated a cavernous hemangioma without signs of hemorrhage. Symptoms and paresis improved rapidly after surgery. The follow-up MRI showed complete resection of the lesion with no signs of radicular compression.
Spinal ECH should be considered as a cause of chronic lumbar radiculopathy with atypical radiological findings. Early diagnosis and total removal of the spinal ECH might prevent hemorrhage and neurological deficits. Fewer than 50 cases of lumbar epidural spinal hemangioma have been reported until today, and our case report is adding valuable knowledge to the existing literature.
... There has been no direct trial of different surgical modalities to determine which option provides the better long-term result. Many surgeons have advocated the use of radiotherapy after surgery to reduce the risk of recurrence [16][17][18]. ...
Background Aggressive vertebral hemangiomas are rare tumors in children, usually occurring in the thoracic spine that can cause significant neurological morbidity. They are technically difficult to treat with significant risk of blood loss during surgery. Methods We describe a case of aggressive vertebral hemangioma managed in our institution. We performed a literature review of reported cases of aggressive vertebral hemangiomas in pediatric age group. We discuss the clinical presentation, diagnosis, and management of these lesions. Results We identified 23 cases of aggressive vertebral reported in children. Neurodeficit was the most common presentation , and the most common location was the thoracic spine. Surgery was the most common modality of treatment. All the patients reported in literature had improvement in their symptoms after treatment. Conclusion Although technically challenging, aggressive vertebral hemangiomas have a good outcome after treatment. Treatment should be tailored to the individual patient. Further studies are needed to determine the optimum treatment strategy.
... Volume 10 Issue 34 should be performed in patients with rapid and progressive neurological deficits. The cure rate for VH without extraosseous soft tissue extension using laminectomy ranges from 70% to 80% [8,9]. Acosta et al [10] reported six patients who underwent decompressive laminectomy in their series, and two patients required reoperation for recurrence. ...
Background:
Aggressive vertebral hemangioma (VH) is an uncommon lesion in the adult population. The vast majority of aggressive VHs have typical radiographic features. However, preoperative diagnosis of atypical aggressive VH may be difficult. Aggressive VHs are likely to recur even with en bloc resection.
Case summary:
A 52-year-old woman presented with a 3-mo history of numbness and pain in her right lower extremity. Physical examination showed sacral tenderness and limited mobility, and the muscle strength was grade 4 in the right digital flexor. Computed tomography revealed osteolytic bone destruction from S1 to S2. Magnetic resonance imaging (MRI) showed that the mass was compressing the dural sac; it was heterogeneously hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI, and gadolinium contrast enhancement showed that the tumor was heterogeneously enhanced and invading the vertebral endplate of S1. The patient developed progressive back pain and numbness in the bilateral extremities 6 mo postoperatively, and MRI examination showed recurrence of the mass. The mass was larger in size than before the operation, and it was extending into the spinal canal.
Conclusion:
The radiographic findings of atypical aggressive VH include osteolytic vertebral bone destruction, extension of the mass into the spinal canal, and heterogeneous signal intensity on T1-, T2-, and enhanced T1-weighted MRI. These characteristics make preoperative diagnosis difficult, and biopsy is necessary to verify the lesion. Surgical decompression and gross total resection are recommended for treatment of aggressive VH. However, recurrence is inevitable in some cases.
... There has been no direct trial of different surgical modalities to determine which option provides the better long-term result. Many surgeons have advocated the use of radiotherapy after surgery to reduce the risk of recurrence [16][17][18]. ...
Background
Aggressive vertebral hemangiomas are rare tumors in children, usually occurring in the thoracic spine that can cause significant neurological morbidity. They are technically difficult to treat with significant risk of blood loss during surgery.Methods
We describe a case of aggressive vertebral hemangioma managed in our institution. We performed a literature review of reported cases of aggressive vertebral hemangiomas in pediatric age group. We discuss the clinical presentation, diagnosis, and management of these lesions.ResultsWe identified 23 cases of aggressive vertebral reported in children. Neurodeficit was the most common presentation, and the most common location was the thoracic spine. Surgery was the most common modality of treatment. All the patients reported in literature had improvement in their symptoms after treatment.Conclusion
Although technically challenging, aggressive vertebral hemangiomas have a good outcome after treatment. Treatment should be tailored to the individual patient. Further studies are needed to determine the optimum treatment strategy.
... Aggressive vertebral haemangiomas(AVH) can mimic metastases as they present with similar clinical and radiological features and are most notorious to present with severe symptoms of backpain, radiculopathy or spinal cord compression. 5,6 Literature documents various management options for AVH including medical management, CT guided alcohol ablation, External beam radiation, Percutaneous vertebroplasty and Surgery with or without preop embolization. 3,16,19,20 Due to the wide array of treatment options, clinicians has decision dilemma in choosing the optimal line of management to maximise patient outcome. ...
Study design:
Systematic review.
Objectives:
Vertebral haemangioma has been classified into typical and aggressive vertebral haemangioma (AVH). Management options for AVH are many and the clinician has decision dilemma in choosing the right one. Metastases mimic AVH in clinical and radiological presentation. Differentiating pointers between them has not been clearly delineated in literature. Aim of our review is to identify treatment options; to formulate a management algorithm for AVH based on clinical presentation and to identify radiological differentiating pointers between them.
Methods:
Systematic review was conducted according to PRISMA guidelines. We systematically reviewed all available literature from the year 2001 to 2020. Relevant articles were identified as per laid down criteria from the medical databases. After inclusion, first and second authors went through full text of each included article.
Results:
Of 139 studies reviewed, eight met our criteria for review of management and three separate studies for radiological differentiating pointers. 99 patients with 88 AVH had undergone treatment. Back pain with myelopathy is the presenting symptom in majority of patients. Patients with backpain - myelopathic symptoms had improved following surgery; patients with back pain alone had improved with either percutaneous vertebroplasty or CT guided alcohol ablation. Dynamic contrast MRI, Diffusion weighted MRI and ratio of signal intensity between T1w and fat suppression T1w MR help the clinician in differentiating them.
Conclusion:
Management of AVH can be based on the patient's clinical presentation. Patients presenting with AVH and back pain can be managed with either Percutaneous vertebroplasty or CT guided alcohol ablation. Patients presenting with AVH and neurological symptoms could be managed with surgery. Dynamic contrast enhanced MR, Diffusion weighted MR, ratio of signal intensity between T1w and Fat suppression T1w MR imaging could help the clinician in differentiating the two before contemplating biopsy.
Grade practice recommendation:
C.
... For these lesions, CT-scan and MRI are diagnostic modalities of choice but in present case report, aggressive haemangioma had unusual presentation and it was confirmed intraoperatively frozen section and histopathological examination postoperatively. Although variable treatment options such as pre-operative embolization, surgery and radiotherapy are available but in the present case, as diagnostic imaging was not much characteristic for aggressive hemangioma along with inconclusive needle biopsy so open biopsy and posterior long segment fixation was planned [10,11,12]. ...
Introduction:
Hemangioma is most common lesion frequently encountered in dorsolumbar region. Although most of these lesions are asymptomatic and are incidental findings on imaging such as computed tomography (CT)-scan and magnetic resonance imaging (MRI).
Case report:
A 24-year-old young male presenting to orthopedic outdoor with complaint of severe mid backache and lower limb paraparesis which developed after trivial trauma and increases with daily routine activities such as sitting, standing, and postural changes. For these lesion, "Enneking staging" was used.
Conclusion:
In such unusual cases, it is very important to differentiate these lesions from vertebral body metastasis, pott's spine, or aggressive bone tumors to reduce intraoperative or post-operative complications.
... For these lesions, CT-scan and MRI are diagnostic modalities of choice but in present case report, aggressive haemangioma had unusual presentation and it was confirmed intraoperatively frozen section and histopathological examination postoperatively. Although variable treatment options such as pre-operative embolization, surgery and radiotherapy are available but in the present case, as diagnostic imaging was not much characteristic for aggressive hemangioma along with inconclusive needle biopsy so open biopsy and posterior long segment fixation was planned [10,11,12]. ...
Introduction: The value of this manuscript is that it highlights a common diagnostic challenge facing orthopedic surgeons, involving the reality that both benign and malignant soft-tissue tumors can present as large cystic masses masquerading as a hematoma. This is the first report of its kind to describe a schwannoma presenting as such a large hematoma in the thigh. Case Presentation: A 64-year-old male presented with 2 days of worsening pain over a left posterior thigh mass that was enlarging for 12 years. Imaging demonstrated a cystic mass. 1.8L of serosanguinous fluid was aspirated and cytology was negative for malignancy, suggesting chronic hematoma. The fluid reaccumulated, indicating surgical management. Histopathology revealed a hemorrhagic ancient schwannoma Conclusion: Without history of trauma or anticoagulation, intramuscular hematoma should be a diagnosis of exclusion. Burden of proof is high to rule-out a neoplastic process masquerading as fluid collection. Biopsies should be taken and schwannoma with ancient change and cystic degeneration should be considered.
... This latter occurrence may indicate an aggressive nature of some VHs, which can be symptomatic at presentation. One-level involvement is the most frequent presentation, with the thoracic spine as the most frequently affected region, followed by the lumbar and cervical spine [2,3]. ...
Purpose
To discuss a treatment algorithm for vertebral hemangioma in children.
Methods
Vertebral hemangioma (VH) is a rare cause of low back pain in children. In most cases, VHs present as incidental findings and do not require invasive diagnostic procedure. In case of symptomatic presentation, different approaches can be used. Over the years, we have developed a treatment algorithm for VH in children based on our clinical experience. In this manuscript, we propose a stepwise approach to treatment of VHs based on tumor extension and the degree of spinal cord/nerves compression with or without neurological deficit.
Results
According to the proposed protocol, we discuss two cases of aggressive VH treated at our institution by a multidisciplinary team. The first case is about a young girl treated with percutaneous one-level posterior instrumentation followed by medical adjuvant therapy for an L4 “Stage 3” VH. The second case is about an 8-year-old boy with rapidly progressive myelopathy due to T11 “Stage 4” VH treated with a combined anterior and posterior surgery (i.e., posterior decompression and fusion followed by vertebrectomy and expandable cage placement) after preoperative arterial embolization.
Conclusion
Given the lack of international guidelines and consensus with regard to treatment of VHs in children, we believe our proposal for a stepwise approach combining clinical and radiological characteristics of the lesion may help guide treatment of this condition in children.
... Vertebral hemangiomas are benign lesions originating from blood vessels and are usually detected incidentally [1]. The rate of vertebral hemangioma was reported between 10 and 12% in large autopsy series and large reviews of plain spine films [2]. Although vertebral hemangiomas are mostly asymptomatic, only 0.9-1.2% ...
Purpose
This study aimed to evaluate the therapeutic effect of radiotherapy and to determine possible prognostic factors in patients with painful vertebral hemangioma.
Methods
In the last two decades, 80 patients with vertebral hemangioma who received radiotherapy in our institute were evaluated in terms of pain response, treatment-related side effects, and prognostic factors. All patients were questioned 3 months after radiotherapy for the evaluation of pain response and were divided into three groups (complete response, partial response, and no change). Moreover, the visual analog scale (VAS) was used for pain response assessment in 46 patients. Pain status was assessed to detect recurrence at each clinical examination during the follow-up period. Possible prognostic factors such as gender, size of the hemangioma, location, multilevel involvement and additional musculoskeletal disease on pain response were analyzed.
Results
In this study, 45 individuals had lesions in the lumbar spine, 28 in the thoracic, and 7 in the cervical region. Furthermore, 51 patients had additional musculoskeletal conditions such as disc herniation, degenerative diseases, spondylolisthesis, and compression fracture. Radiotherapy was performed with a median daily dose of 2 Gy and a median total dose of 40 Gy. Complete pain response occurred in 58.8% of patients, 26.2% of patients had partial pain response, and 15% of patients had no pain response. The overall response rate was 85%, and 7 patients showed recurrent pain symptoms in the overall response group at routine follow-up. Additional musculoskeletal disorders were found to be the only prognostic factor associated with pain response. The median follow-up time was 60 months. Secondary malignancy was not found in any of the patients in this short follow-up time. No acute or late radiation-associated side effects greater than grade II were observed.
Conclusion
To our best knowledge, this study is one of the largest single-institution radiotherapy series on vertebral hemangiomas reported to date. The obtained data support the efficacy and safety of radiotherapy in the treatment of painful vertebral hemangioma. Our study showed that additional musculoskeletal disease plays an important role in pain response. Other prognostic factors and treatment of vertebral hemangioma with stereotactic radiosurgery should be investigated in future studies.
... Reported cure rates of laminectomy for VHs without extraosseous soft tissue extension range from 70-80% [7,8]. Frank et al. [9] reported six VH patients who underwent decompressive laminectomy; among these, two experienced recurrence and required reoperation. For aggressive VHs that cause cord compression and neurological de cit, more radical surgical resection has been advocated. ...
Background: Aggressive vertebral hemangiomas (VHs) are uncommon in adults. Although most have typical radiographic features, some present with atypical findings, which makes their diagnosis difficult. Aggressive VHs have a high likelihood of recurrence even after resection.
Case presentation: A 52-year-old woman presented with a 3-month history of right lower extremity pain and numbness. On physical examination, the sacrum was tender, her mobility was limited, and right plantar flexion strength was 4/5 on manual muscle testing. Computed tomography (CT) revealed osteolytic bony destruction from S1 to S2. Magnetic resonance imaging (MRI) showed a sacral mass invading the S1 vertebral endplate and compressing the dural sac; the mass was heterogeneously hypointense on T1-weighted imaging, hyperintense on T2-weighted imaging, and heterogeneously enhanced. Six months after surgical resection of the mass, the patient presented with back pain and bilateral extremity numbness. MRI showed lesion recurrence with thecal sac compression.
Conclusions: Aggressive VHs may exhibit atypical radiological findings that include osteolytic vertebral bony destruction, spinal canal extension, heterogeneous signal intensity on T1- and T2-weighted imaging, and heterogeneous enhancement. These can make accurate preoperative diagnosis difficult; biopsy may be necessary. Surgical decompression and resection are recommended for aggressive VHs. Nonetheless, recurrence may still occur despite resection.
... Radiotherapy is usually suggested as an adjuvant therapy after subtotal tumor removal. [8][9][10] However, local recurrence after subtotal tumor removal combined with radiotherapy is reported and adjuvant radiotherapy can cause radionecrosis, radiation-induced myelitis, and secondary malignancy. Furthermore, radiotherapy could cause further surgeries more difficult to perform. ...
Vertebral hemangiomas are the most common benign vertebral tumors and are usually asymptomatic. Aggressive subtypes of the tumor, called aggressive VHs (AVHs), can become symptomatic with extraosseous extensions and require surgical removal. We present a case of AVH in a 36-year-old man presenting with low back pain and right leg pain that persisted for three months. Imaging studies showed a Th12 vertebral tumor that extended into the spinal canal and was squeezing the spinal cord. Computed tomography (CT)-guided biopsy indicated vertebral hemangimoa. Following preoperative arterial embolization, piecemeal gross total resection was attained under navigation guidance. He was left with no neurological deficit and remained well at the 12-month postoperative folow-up. Since AVHs are benign tumor, piecemeal removal of the tumor can be selected. However, disadvantage of the approach include difficulty of making decision how much to remove the front part of the vertebral body close to thoracic descending aorta. Furthermore, when the tumor tissue is too hard to curett, manipulation in tight spaces near the spinal cord carries the risk of damaging it. Navigation-guided drill is highly helpful for real-time monitoring of ongoing tumor resection. It enables safely resection of the tumor especially in the anterior cortical surface of the vertebral body and easily resection even hard tumors. This method results in reducing residual tumor and maintaining safety resection.
... Less common causes include intramedullary tumors like hemangioblastoma, ependydoma and astrocytoma, infection and sickle cell crisis. Therefore, careful evaluation of these patients is of paramount importance, and VH has to be differentiated from these pathologies [8][9][10][11]. Management of these cases also varies depending upon the aggressiveness of the VH. There is an inverse relationship between the amount of intraosseous fatty stroma and aggressiveness of the lesion [12]. ...
Primary spinal tumors are a group of neoplasms that are comprised of a large group of various benign and malignant entities. These can arise from the spinal cord itself (intramedullary), the dural sheath (intradural extramedullary), or from surrounding soft tissues and bone (extradural). In this chapter, the authors will focus on extradural primary spinal tumors. Unlike the more common entities of myeloma, lymphoma, or secondary metastatic lesions of the spine, primary spinal tumors only represent approximately 5% of all skeletal tumors. In this chapter, an overview of the pathophysiology, diagnosis, and treatment of this group of rare tumors will be provided.
BACKGROUND AND OBJECTIVES
We present our experience in the management of symptomatic vertebral hemangiomas with epidural extension (SVHEE) using spine stereotactic radiosurgery (SSRS).
METHODS
An Institutional Review Board approved retrospective review of all SVHEE patients treated with SSRS at our institution (2007-2022) was performed. Baseline patient demographics, clinical presentation, lesion volume, and Bilsky grade (to directly evaluate the epidural component) were determined. Clinical and radiographic response and treatment outcomes were subsequently evaluated at first (∼6 months) and final follow-up.
RESULTS
Fourteen patients with SVHEE underwent SSRS (16-18 Gy/1-fraction); the mean follow-up was 24 months. The median lesion volume (cc) was 36.9 (range: 7.02-94.1), 31.5 (range: 6.53-69.7), and 25.15 (range: 6.01-52.5) at pre-SSRS, first, and final follow-up, respectively. Overall volume reduction was seen in the last follow-up in all 14 patients, median 29.01% (range: 6.58%-71.58%). Bilsky score was stable or improved in all patients at the last follow-up when compared with pre-SSRS score. Patients who underwent both surgical decompression and SSRS (n = 9): 8 had improved myelopathic symptoms and pain and 1 had stable radiculopathy postintervention. In the 5 patients treated with SSRS monotherapy, 2 had stable radicular pain and the other 3 improved pain and numbness. No patients experienced adverse outcomes.
CONCLUSION
To our knowledge, this represents the largest series of SVHEE patients treated with SSRS, either as monotherapy or part of a multimodal/separation surgery treatment approach. We demonstrate that SSRS represents a potentially safe and effective treatment option in these patients. However, larger prospective studies and longer follow-ups are necessary to further assess the role, durability, and toxicity of SSRS in the management of these patients.
Rationale
Aggressive vertebral hemangiomas (AVHs) destroy continuous vertebral bodies and intervertebral discs and resulting in spinal kyphosis is extremely rare. The very aggressive behavior was attributable to its significant vascular component and contained no adipose tissue.
Patient concerns
We report a case of thoracic spine kyphosis of AVHs with multiple vertebral bodies and intervertebral disc destruction in a 45-year-old woman.
Diagnoses
Based on the imaging studies, the patient underwent surgical removal of this lesion and spinal reconstruction. Histopathology consistent with vertebral hemangioma and contained no adipose.
Interventions
The patient underwent surgical removal of the lesion and spinal reconstruction. After subperiosteal dissection of the paraspinal muscles and exposure of the laminae, the laminae of the T5–7 vertebrae were removed and exposing the lesion. The lesion was soft and showed cystic changes, completely curetted and autogenous bone was implanted. Vertebroplasty was performed through T3-T9 pedicles bilaterally. Pedicle screw fixation was performed for segmental fixation and fusion.
Outcomes
After 9 days of operation, the incision healed cleanly and free of pain. She was discharged in good general condition. The patient remained asymptomatic after follow-up 6 months of postoperative.
Lessons
AVHs destroy multiple vertebral bodies and intervertebral discs and resulting in spinal kyphosis is extremely rare.
Purpose
Preoperative elastoplasty could be an alternative strategy for treating aggressive vertebral hemangiomas (VHs) in frail patients needing for spinal cord decompression, combining the advantages of embolization and vertebroplasty.
Methods
Three elderly patients with spinal cord compression from thoracic aggressive VHs underwent XperCT-guided percutaneous injection of silicone (VK100), filling the whole affected vertebra, followed by a decompressive laminectomy. At 12-months follow-up no recurrences, vertebral collapse or segmental kyphosis were noted at the CT scans, with patients reporting an improvement of preoperative neurological deficits, VAS and Smiley-Webster pain scale (SWPS) parameters.
Results
With its elastic modulus, non-exothermic hardening, and lower viscosity than PMMA, VK100 allowed a preoperative augmentation of the affected vertebral body, pedicles, and laminae without complications, with a controlled silicone delivery even in part of VH’s epidural components thanks to XperCT-guidance.
Conclusion
When facing highly bony erosive VH encroaching the spinal canal, VK100 combines the advantages of embolization and vertebroplasty especially in elderly patients, permeating the whole VH’s angioarchitecture, significantly reducing tumor.
Vertebral hemangiomas and angiomatous neoplasms consist of a group of vascular tumors that arise from the abnormal proliferation of blood vessels within the bone.
Vertebral hemangiomas are common, benign vascular tumors and are often discovered incidentally during routine imaging studies. These tumors are typically slow-growing and asymptomatic. Conventional radiography (CR) and computed tomography (CT) typically show a well-demarcated mass-like lesion of reduced bone density with thickened trabeculae. CR is not sensitive in the detection of these lesions. Thickened trabeculae are best seen on CT. On magnetic resonance imaging (MRI), the thickened trabeculae appear as low signal foci. Typical vertebral hemangiomas are of high signal intensity (SI) on T1- and T2-weighted images (WI). Atypical vertebral hemangiomas have a lower fat content and are of low SI on T1-WI and of high SI on T2-WI. Aggressive vertebral hemangiomas display aggressive behavior on imaging causing pain and neurological deficit. In general, aggressive vertebral hemangiomas are of low SI on T1-WI and of high SI on T2-WI.
Epithelioid hemangioma is a rare mesenchymal tumor of vascular origin. CT shows well-defined, septate, lytic lesions with cortical destruction and bony expansion. On MRI, lesions are hypointense or iso-intense to muscle on T1-WI, and hyperintense on T2-WI.
Epithelioid hemangioendothelioma is an intermediate-grade malignant vascular neoplasm. It presents as a mild expansile osteolysis, with ill-defined boundaries and a surrounding soft-tissue mass and uncommonly a sclerotic rim.
Angiosarcoma is a rare, aggressive, vascular malignancy with only rare cases reported in the spine. Angiosarcoma and epithelioid hemangioendothelioma show similar features radiologically.
Vertebral hemangiomas are the most common benign lesion of the spine which are often an asymptomatic incidental finding. However, a few hemangiomas are aggressive and characterized by bone expansion and extraosseous extension into the paraspinal and epidural spaces. We report the case of a patient presenting an aggressive vertebral hemangioma causing back pain and bilateral numbness of the legs. Among various treatment modalities, a minimally invasive percutaneous sclerotherapy procedure using ethanolamine oleate under computed tomography and fluoroscopic guidance was safely and successfully performed with good clinical outcomes.
The authors report total resection of aggressive hemangioma of Th7 vertebra in a patient with severe conduction disorders in the lower extremities. Total Th7 spondylectomy (Tomita procedure) was performed. This method provided simultaneous en bloc resection of the vertebra and tumor via the same approach, eliminate spinal cord compression and perform stable circular fusion. Postoperative follow-up period was 6 months. Neurological disorders were evaluated using the Frankel scale, pain syndrome - visual analogue scale, muscle strength - MRC scale. Pain syndrome and motor disorders in the lower extremities regressed in 6 months after surgery. CT confirmed spinal fusion without signs of continued tumor growth. Literature data on surgical treatment of aggressive hemangiomas are reviewed.
Vertebral hemangiomas (VHs), formed from a vascular proliferation in bone marrow spaces limited by bone trabeculae, are the most common benign tumors of the spine. While most VHs remain clinically quiescent and often only require surveillance, rarely they may cause symptoms. They may exhibit active behaviors, including rapid proliferation, extending beyond the vertebral body, and invading the paravertebral and/or epidural space with possible compression of the spinal cord and/or nerve roots ("aggressive" VHs). An extensive list of treatment modalities is currently available, but the role of techniques such as embolization, radiotherapy, and vertebroplasty as adjuvants to surgery has not yet been elucidated. There exists a need to succinctly summarize the treatments and associated outcomes to guide VH treatment plans. In this review article, a single institution's experience in the management of symptomatic VHs is summarized along with a review of the available literature on their clinical presentation and management options, followed by a proposal of a management algorithm.
Vertebral hemangiomas are among the most frequent findings of the spinal radiographic evaluation. The majority of them do not cause any harm to the patient and stay dormant throughout the patients’ lifetime. When diagnosed, a careful differential should be performed considering all of the spinal red flags in mind. For symptomatic patients, according to the patient’s presentation, there are various options for treatment. This chapter summarizes the pathology and potential treatment options.KeywordsVertebral hemangiomaVascular tumorsSpinal columnCavernous hemangioma
This chapter focuses on the vascular lesions of the spine involving the bone and epidural space, specifically vertebral hemangiomas, aneurysmal bone cysts, and arteriovenous lesions with extradural involvement. While these lesions are often asymptomatic, they can present with progressive pain and neurologic impairment resulting from neural element compression and compromise. Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and catheter angiography are valuable diagnostic tools, and in their current technological iteration allow the meticulous anatomical depiction of these vascular lesions. Treatment often includes bony decompression of the neural elements, partial or complete lesionectomy, percutaneous and endovascular embolization, and radiation therapy. In this chapter we attempted to provide the reader with insight regarding the epidemiologic data, histologic and imaging findings, clinical presentation, and management strategies of those spinal anomalies.KeywordsVertebral hemangiomasAneurysmal bone cystsSpinal arteriovenous lesions
Spinal hemangiomas constitute a large heterogeneous group of lesions. According to their anatomic location, spinal hemangiomas can be classified into two categories: non-osseous and osseous vertebral hemangiomas (VH). Non-osseous hemangiomas are rare. Vertebral hemangiomas are common vascular lesions in the spine with the majority being incidental findings. Approximately 1% of those lesions become symptomatic by causing pain, neurologic deficit, or both and are considered aggressive hemangiomas. These lesions require treatment.
Different image-guided interventional procedures can be applied to patients with benign and malignant bone tumors, either to diagnose or treat, for palliation and pain management, or to facilitate other therapies such as surgery. We illustrate and review the most commonly used interventional radiologic procedures and their contribution to the management of bone tumors. In-depth descriptions of the various techniques are provided as how the authors perform the procedures. The authors' experiences of patient selection, specific areas of consent, and pitfalls are also included where relevant. This chapter is divided into four areas, concentrating on image-guided bone biopsies, transarterial tumor embolization, thermal ablation of bone tumors, and cementoplasty, describing the current state of research, debate, and practice.
Purpose:
Compressive vertebral hemangiomas with neurological deficits (CVHND) form a rare, unique subset of lesions comprising of differing clinico-imaging findings, pathologic behavior and treatment, when compared to the commoner and usually incidental intra-osseus vertebral hemangiomas (VH). Though various surgical strategies and a broad array of adjuncts have evolved and changed over the years, there is paucity of comprehensive data from sizeable series of such patients treated surgically with long term follow up. The purpose of this study is to device an optimum management strategy in CVHND based on our surgical experience.
Materials and methods:
The data from electronic medical records of 26 consecutive patients operated in our department from 2009 to 2019 were retrospectively analyzed.
Results:
There were 11 males and 15 females with a mean age of 34.7 years. Neurological examination revealed paraparesis or paraplegia with myelopathy in all patients with Frankel score of B, C and D in 1 (3.9%), 11 (42.3%) and 14 (53.8%) patients respectively. Sixteen patients (61%) underwent laminectomy and gross total excision of extradural soft tissue component, 7 (27%) laminectomy with posterolateral fusion, three (12%) underwent additional anterior interbody support. The mean follow up was 72.4 months and at last follow-up 24 patients (92%) were Frankel E. Symptomatic recurrence was seen in two patients operated early in the series, they underwent re-surgery, gross total excision with posterolateral fusion, remaining neurologically intact at last follow up.
Conclusions:
Pre-operative embolization, surgical excision of extradural component and intra-operative vertebroplasty form the mainstay of treatment for CVHND. Instrumented posterolateral fusion with optional anterior interbody support accomplished through the same approach is required only in a minority of cases. The long-term outcome following timely and appropriate treatment is excellent. Anterior or anterolateral approaches for intervertebral support and radical procedures like total en-bloc spondylectomy (TES) are not usually required.
A 27-year-old woman presented with vertebral hemangioma manifesting as sudden onset of paraplegia, and bladder and bowel dysfunction during pregnancy. Magnetic resonance imaging revealed a mass lesion that had infiltrated into the entire T2 vertebral body and expanded to the vertebral canal. Laminectomy from T1 to T3 and biopsy of the lesion were performed. Biopsy confirmed the diagnosis of vertebral hemangioma, but laminectomy resulted in no neurological changes. The patient was transferred to our hospital, where radical treatment comprising embolization of the feeding arteries, posterior stabilization of the vertebrae, and anterior excision of the tumor was performed. Symptoms resolved gradually but steadily, and she made a full recovery by 18 months postoperatively. Radical operation might be extremely effective for extradural vertebral hemangioma, even in the delayed phase or in the presence of severe neurological deficit.
An unusual case of hemangioma involving three adjacent dorsal vertebrae with a clinical picture of progressive paraparesis is presented. Radiological verification of the lesion can be expected if possible, using plain X-Rays, tomography, CT scan and myelography. The roentgenographic appearances of vertebral hemangioma were characteristic, but only CT revealed the true extent of the disease. Reports of such a case have appeared infrequently in the literature. [Karshner 1936, Bailey 1955, Reeves 1964, Robbins 1958].
Neural compression complicating vertebral hemangioma is associated with: compression fracture, hematoma, epidural extension of tumor, and/or bony expansion or "ballooning." Four cases of symptomatic vertebral hemangioma are presented. Discussion includes imaging modalities, preoperative embolization, and surgical approach.
The vertebral hemangioma is a vascular malformation giving rise to widely varying clinical pictures. The majority of vertebral hemangiomas remain asymptomatic and are discovered during a post mortem investigation or a routine radiologic examination. Some become apparent through spinal pain or medullary and/or radicular symptoms.
Sixty-nine cases of bone tumors of vascular origin, excluding cases of lymphangiomas and massive osteolysis, were found in a complete review of the surgical files of the Mayo Clinic. There were 56 hemangiomas, and these often produced roentgenologic diagnostic problems. Most were easily managed surgically, although some vertebral hemangiomas required radiation therapy. There were known multicentric lesions in only 2 of the 56 cases. Hemangiopericytomas accounted for 4 of the 69 cases. In these 4, the clinical courses were characteristically unpredictable. There were 9 hemangioendotheliomas. These 9 were added to 13 cases in which specimens were submitted for review. In 6 of the 22 cases, there was multifocal involvement. In this group of 22 cases, it was impractical to differentiate a separate group and designate it as angiosarcoma. Half of the 22 patients died, 1 of known unrelated disease. Surgical extirpation, when possible, and irradiation of lesions incompletely excised or surgically inaccessible seem logical principles in treatment. In these cases of hemangioendotheliomas, the most important indicator of prognosis was the grade of anaplasia.
Hemangioma is the most common primary tumor of the spine. Pregnancy is a risk factor increasing the possibility of disclosure or exacerbation of symptoms of spinal hemangioma. This paper presents a case of 32-year-old woman with hemangioma of Th6 vertebrae, which was revealed by paresis of the lower limbs and sphincters dysfunction at 34 weeks gestation. Pregnancy has ended with a cesarean section. Then posterolateral thoracotomy and removal of hemangioma were performed. Spinal cord was decompressed and stabilization of the spine with metal implants was carried out. Histological examination discovered cavernous hemangioma weaving. The patient is followed up in the outpatient clinic. Despite the improvement of neurological status--enhancement of the sensory function and development of bladder and rectal sphincter automatism--she did not regain the ability to walk alone.
Arteriovenous malformations complicating benign bone tumours may not be amenable to surgical treatment either because of their extensive size and likelihood of recurrence or because of their location. Transcatheter embolisation may then be used either as the definitive treatment or as a prelude to safe surgical intervention. Patients presenting with arteriovenous malformations in association with polyostotic fibrous dysplasia and vertebral haemangioma are presented who were treated by transcatheter embolisation, using Oxycel and Gelfoam. A haemodynamically significant shunt was obliterated in one patient and in the other an excellent clinical response was obtained facilitating subsequent surgical management.
Seven cases of symptomatic spinal hemangiomas are discussed. Special emphasis is given to a patient in whom pre-operative embolization was necessary. A marked reduction in the blood supply was achieved, with the result that the subsequent laminectomy was carried out without great difficulty.
A case of acute flaccid paraplegia is reported, due to epidural bleeding in the dorso-lumbar region. A hitherto undiagnosed and asymptomatic hemangioma of a dorsal vertebra was considered to be the source of the haemorrhage. Recovery followed early laminectomy and evacuation of blood clots.
Preoperative arterial embolization of a vertebral hemangioma allowed surgical excision of the vertebral body, restoration of normal anatomic continuity of the spinal canal, and improvement in myelopathy.
Asymptomatic vertebral hemangiomas occur frequently in adults but the discovery of a similar lesion in the pediatric are group is uncommon. A case which involves all the neural arch components with resultant spinal cord compression is rare and is reported with a review of pertinent literature.
The authors describe a case in which a subarachnoid block caused by a thoracic vertebral hemangioma was relieved during percutaneous embolization of the tumor.
Eight cases of vertebral haemangioma causing spinal cord or nerve root compression are described, together with one other which was not causing organic signs or symptoms. The compression was due to extradural tumour in 5 cases, bony expansion encroaching on the neural canal in 2 cases, and a combination of bony expansion and extradural tumour in one case. When present the classical radiological appearance of accentuated vertical striation or honeycomb pattern is easily recognized, but atypical features, such as apparent pedicular erosion, paravertebral soft tissue mass and bony expansion, may occur, making diagnosis more diffcult. In 2 cases the correct diagnosis was not made before surgery. In one of these there were no plain film changes and in the other a metastasis was considered the more likely diagnosis. In the asymptomatic case the absence of extra-osseous extension was an important factor in excluding any possible clinical significance of the haemangioma. The great importance of pre-operative spinal angiography is stressed.
A series of nine cases of radiation myelopathy seen at the University of California, San Francisco (UCSF) is reviewed, and their treatment data converted into nominal single doses (NSD) and equivalent single doses (ED). The 1% incidence level of myelopathy in the thoracic cord is 1015 rets (ED), and the 50% incidence level is 1476rets (ED). Caution should be used when utilizing a rapid fractionation schedule; it appears that 2000 rads in 5 fractions and 3000 rads in 10 fractions is a safe regimen for the thoracic spinal cord.
Hemangiomas of bone are extremely common vascular tumors that are most commonly discovered as incidental findings in the vertebral column. Infrequently, these benign lesions may cause local or radicular pain and neurologic deficits, from myeloradiculopathy to paralysis. This report describes the occurrence of a symptomatic vertebral hemangioma during pregnancy, in order to illustrate current methods for diagnosis and treatment of these lesions when associated with spinal cord compression. The possible mechanisms by which they may become symptomatic during pregnancy are reviewed.
Thirty-two vertebral hemangiomas (VHs) were evaluated with nonenhanced computed tomography (CT), T1-weighted magnetic resonance (MR) imaging, CT enhanced with contrast material, and selective spinal arteriography. The stroma between the osseous trabeculae was found to correspond to either fatty tissue or soft tissue or both. All 11 asymptomatic VHs showed complete fatty stroma at CT and increased signal intensity at MR imaging. In contrast, all four compressive VHs had soft-tissue attenuation at CT. Three compressive VHs showed low signal intensity on MR images. Predominantly fatty stroma at CT and increased signal intensity at MR imaging were associated with normal or only slightly increased vascularization at selective spinal arteriography or contrast-enhanced CT, while soft-tissue stroma at CT and low signal intensity at MR imaging were associated with distinct hypervascularization. The authors' experience suggests that fatty VHs may represent inactive forms of VH, while soft-tissue content at CT and low signal intensity at MR imaging may indicate a more active vascular lesion with potential to compress the spinal cord. CT and MR imaging may be especially valuable for evaluating patients with clinical signs or symptoms of uncertain origin and findings compatible with VH at plain radiography.
Five new cases of vertebral hemangioma with cord compression are reported. The role of preoperative selective angiography with embolization in the management of these lesions is discussed in the light of the most important literature on this topic.
We present a patient with a spinal epidural hematoma (SEH), caused by a vertebro-epidural hemangioma (VEH). A VEH has been rarely reported as a cause for a SEH and it was remarkable that the VEH was located several vertebrae above the actual hematoma. This emphasises the need for extensive spinal angiography at different levels. The VEH was treated successfully with embolization.
45 cases of vertebral hemangiomas with neurologic involvement are reported. This series corresponds to the french experience between 1969 to 1988 (series of the "Société Française de Neuro-Chirurgie" (S.F.N.)). In this report, the therapeutic results are detailed. 16 patients were treated by a simple laminectomy, 6 by laminectomy associated with radiotherapy, 4 by radiotherapy alone. In 9 patients, a large removal of the hemangioma was performed by mean of a lamino-arthrectomy (7 cases) or a corporectomy (2 cases). 7 patients were treated by embolization or vertebroplasty. Both techniques were used alone or in association with surgery or radiotherapy. 3 patients had no therapy. Results of the S.F.N. series demonstrated that 75.5% of the patients had a long term favorable clinical course. 13.4% of the patients were not improved. Mortality was of 11.1%. The mean follow up time was of 51.6 months. Recurrence was encountered in 13 cases. It was mainly observed in the first two years. In cases of total involvement of the vertebrae by hemangioma, laminectomy associated with radiotherapy was the best mean of therapy: 93% of recovery without recurrence. Treatment of body localization appeared to be difficult. Corporectomy could be unefficient if a complete removal of the hemangioma could not be performed. In contrast, posterior arch localization was successfully treated by a simple laminectomy without radiotherapy, even in cases of incomplete removal of the hemangioma: all such cases (10 cases) had a complete recovery without recurrence.
The interest of radiotherapy in the treatment of compressive vertebral hemangiomas (H.V.C.) is discussed from a literature review. Recent advances in imaging permit to precisely define the target-volume. The dose of 35 grays with standard fractioning affords optimal results on H.V.C. with no risk of spinal cord damage.
Resection (total or subtotal excision of vertebra) of vertebral hemangiomas appears to be the logical course when there are neurological signs. This is a rather complicated surgery with the aim of reduction of recurrence rate. We report two such cases with surgical technique and results at 2 and 4 years post-operatively.
A series of 19 cases of vertebral hemangiomas treated by hyperselective embolization is reported. Localization is thoracic in 12 cases and lumbar in 7. Patients were referred for back pain in 10 cases, neurological signs of spinal cord compression in 5 and of radicular compression in 4. The first step is a precise analysis of the vascular pattern of each case with identification of the feeders of the spinal cord. Embolization as the only treatment, was proposed in 12 cases with painful manifestations. In 5 cases with symptoms of spinal cord compression, it was associated with surgery. The last 2 cases were not treated because of the close proximity of an Adamkiewicz artery. Results on painful symptoms were excellent in 9 cases and good in 3. There was no complications in this series. Therefore, we consider embolization to be a safe tool in the treatment of vertebral hemangiomas, with good efficiency on painful symptom and pre-operatively in case of spinal cord compression.
45 cases of vertebral hemangiomas with neurologic involvement are reported. This series corresponds to the french experience between 1969 and 1988 (series of the "Société Française de Neurochirurgie" (S.F.N.)). In this report the clinical presentation and the results of the radiological examination are detailed. Local vertebral pain was present in half of the cases. The neurological symptoms were related to spinal cord compression in 33/45 of the patients and to radicular suffering in the other cases. Evolution of the neurological symptoms appeared to be slow: the mean evolution time before diagnosis was of 10 months. Hemangioma involved the thoracic column in 73% of the cases. Neurologic symptoms was due to a diffuse narrowing of the spinal canal in 28.8% of the cases, to a local bony expansion in 60% of the cases. Hemangioma was found to involve the whole vertebra in 44.4% of the cases, the vertebral body alone in 24.4% of the cases and the posterior arch alone in 22.2% of the cases. An incomplete involvement of both vertebral body and posterior arch was found in 6.6% of the cases. 2.2% of the cases corresponded to pure epidural hemangioma. Preoperative diagnosis was established in 58% of the patients. In these cases, the diagnosis was based on standard radiography and CT datas. Results of the S.F.N. serie are compared with those of the main series of the literature.
Twenty-three patients with severely symptomatic hemangiomas of the vertebral column were treated by irradiation. Pain in the back and numbness in the limbs were markedly or completely relieved in most of the patients (88% and 80%, respectively). Five out of 7 paraplegic patients recovered sufficiently to be able to walk again. For patients with a severe compression syndrome of the spinal cord, irradiation could be chosen as the primary treatment without preceding surgical decompression. The result of multiple treatment courses with lower doses was not superior to a single course, for which an optimum dose of 30 Gy to 40 Gy/4 to 6 weeks is recommended by the authors.
A new method, intraoperative retrograde embolization with a methyl methacrylate polymer injected into a vertebral hemangioma, is described. This method achieves complete intraoperative hemostasis and postoperative stabilization. No further stabilization procedures and radiation therapy are necessary. Preoperative selective angiography with embolization and consecutive laminectomy are required for this method.
Vertebral hemangiomas, unlike most bone lesions, show increased signal on T1- and T2-weighted magnetic resonance (MR) images. To define the basis for these signal characteristics, a retrospective review was done of the MR imaging findings in ten vertebral hemangiomas (eight patients), and these were correlated with the findings from plain radiographic, computed tomographic (CT), and histopathologic studies. MR images showed mottled increased signal in T1- and T2-weighted images from the osseous portions of the tumors. In three patients, the extraosseous components failed to show increased signal on T1-weighted images. Chemical shift images and histologic studies demonstrated that adipose tissue caused the increased signal on T1-weighted images. The extraosseous components of the tumor contained little, if any, adipose tissue, which explained the lack of high-intensity signal on T1-weighted images. These signal changes appear to make a specific constellation of findings for the diagnosis of vertebral hemangioma with MR imaging.
Vertebral hemangiomas have usually been treated by resection following preoperative arterial embolization. A case is presented in which no feeding tumor vessels were demonstrable angiographically. The tumor was resected by an anterolateral transthoracic approach without preoperative embolization. There was progressive postoperative improvement of the myelopathy.
Two cases of vertebral haemangiomas are reported which presented as spinal cord syndromes during pregnancy. Eleven additional cases of epidural haemangiomas in the literature which became symptomatic during pregnancy are reviewed. In 11 out of 13 cases symptoms presented during the third trimester of pregnancy and in all but two cases the epidural lesions were in the upper six thoracic vertebrae. These features can be explained by the effect of the gravid uterus on the relatively sparse vascular supply of the upper thoracic spinal cord.
Two teenagers with spinal cord compression due to a thoracic vertebral hemangioma are presented. Myelography showed a complete block in both patients. Selective intercostal arteriography was normal or non-conclusive. Only computed tomography (CT) gave precise information about the extent and nature of the compressive lesion. In the first case it showed angiomatous involvement of the body and all parts of the neural arch of T4, and a posterior epidural ossified angiomatous mass. In the second case it showed angiomatous involvement of the vertebral body and an anterior extradural soft tissue mass; this latter was considered to represent a resolving extradural hematoma. CT, preferably performed after intrathecal contrast injection, is the diagnostic procedure of choice for spinal hemangioma with cord involvement.
Radiologic studies of 57 solitary vertebral hemangiomas (VHs) were reviewed to find radiographic and computed tomographic (CT) criteria by which to distinguish asymptomatic lesions from those compressing the spinal cord. Six features were seen significantly more often in those compressing the cord: location between T-3 and T-9, involvement of the entire vertebral body, extension to the neural arch, an expanded cortex with indistinct margins, an irregular honeycomb pattern, and soft-tissue mass. Contrast material-enhanced CT scans and selective spinal angiograms demonstrated extension into the spinal canal. In patients with a VH and back pain of uncertain origin, the presence of three or more of these signs may indicate a potentially symptomatic VH. In such patients, spinal angiography and, in some cases, embolization, are indicated.
In this journal a case report was published in 1972 concerning a patient with paraplegia due to spinalcord compression caused by a vertebral haemangioma [1]. The patient was treated by embolisation and additional radiotherapy. At that time the results 7 months after embolisation were reported. The patient was in excellent condition. Recently the neurologist who had referred the patient and the neuroradiologist who performed the embolisation, both now employed in the same hospital, saw the patient as an out-patient. She is still in excellent condition. There is no motor deficit, slight hypalgesia of the right leg is present, while vibration sense is slightly diminished in the right leg and both ankles. Knee jerk reflexes are normal, ankle reflexes are absent. At the time, treatment of vertebral haemangioma compromising the spinal cord by embolisation was
Six cases of spinal hemangiomas with neurologic symptoms are reported. In three of them the diagnosis was obtained before surgery using plain x-rays and spinal computed tomography scan or biopsy. In the other cases the diagnosis was not done before surgery. In two cases preoperative embolization had minimized blood loss during surgery. Laminectomy was performed in three cases. Large removal and/or vertebrectomy was carried out in the other cases. Our results and a review of the literature about the investigations and treatment of vertebral hemangiomas led us to propose a stereotypical management of spinal hemangiomas with neurologic symptoms.
Symptomatic vertebral hemangiomas are not common. Although radiotherapy has been used as treatment, the data are sparse concerning total dose, fractionation and results. We report nine patients with vertebral hemangioma treated with 3000-4000 rad, 200 rad/day, 5 fractions per week, followed from 6 to 62 months. Seventy-seven percent had complete or almost complete disappearance of the symptoms. Radiotherapy schedules are discussed.
A patient with paraplegia caused by spinal-cord compression due to extension into the spinal canal of angiomatous tissue from a haemangioma of the seventh dorsal vertebra, was treated, with good short-term objective results, by non-surgical (percutaneous catheter method) embolisation of the intercostal (osseous) arteries feeding the tumour. Embolisation of feeding arteries is proposed as an alternative to laminectomy in those cases of vertebral haemangioma in which decompression is indicated.
The authors report one case of dorsal haemangioma in an eleven year old boy who became paraparetic following slight trauma. Myelography revealed a complete block at the level of the angiomatous vertebra. — Selective medullary angiography gave complete visualization of the haemangioma and of its vascular peduncles which started from the right and left 9th inter costal arteries. After having visualized Adamkiewicz's artery, which started from Th7 on the left, the angioma was embolised with sponge fragments. This made decompressive laminectomy much easier since it reduced the risk of profuse bleeding. The child was walking normally two months after operation.
