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Lumbar vertebral hemangioma presenting with the acute onset of neurological symptoms: Case report
Abstract
Vertebral hemangiomas are common entities that rarely present with neurological deficits. The authors report the unusual case of a large L-3 vertebral hemangioma with epidural extension in a 27-year-old woman who presented with hip flexor and quadriceps weakness, foot drop, and leg pain. The characteristics of the mass on magnetic resonance imaging suggested an aggressive, hypervascular lesion. The patient underwent embolization of the lesion followed by direct intralesional injection of ethanol. Significant resolution of clinical symptoms was observed immediately after the procedure and at her follow-up visits. Follow-up imaging studies obtained 9 months after the procedure also documented a considerable reduction in the size of the hemangioma with minimal loss of vertebral height and a mild kyphosis at the affected level. On repeated imaging studies obtained 21 months postoperatively, the size of the hemangioma and the degree of vertebral body compression were stable. As demonstrated in this case, patients with vertebral hemangiomas can present with acute nerve root compression and signs and symptoms similar to those of disc herniation. Vertebral hemangiomas can be treated effectively with interventional techniques such as embolization and ethanol injection.
... The most common benign neoplasms of the spine are vertebral hemangiomas (VH). VHs can be defined as benign vascular lesions with an incidence of 10-12% (1)(2)(3)(4)(5)(6) . In general, VHs are asymptomatic and no specific treatment is needed. ...
... In general, VHs are asymptomatic and no specific treatment is needed. Only 1% of VHs cause axial pain and rarely cause compression fractures (2,3,(6)(7)(8) . If VH extends to the spinal canal or a compression fracture occurs, neurologic injury may be possible (4,9) . ...
... VHs are benign lesions that rarely become symptomatic unless they behave like an aggressive tumour and extend to the spinal canal and posterior elements of the spine. The most common symptom is axial pain (3,4,6,9) . Numerous methods are used in the treatment of symptomatic VHs. ...
... Characteristically, the vertebral hemangiomas are incidentally observed in imaging studies. They are, however, symptomatic in almost 1% of adults [1,2] and are very rare in children. [2] These rare type of symptomatic lesions are known as aggressive hemangiomas and are characterized by expansion of the bone, extension outside bony margins, disturbance of local blood flow, and rarely vertebral compression fractures. ...
... ved in imaging studies. They are, however, symptomatic in almost 1% of adults [1,2] and are very rare in children. [2] These rare type of symptomatic lesions are known as aggressive hemangiomas and are characterized by expansion of the bone, extension outside bony margins, disturbance of local blood flow, and rarely vertebral compression fractures. [1,3] Approximately 45% of patients with aggressive vertebral hemangiomas have neurologic deficits, the rest suffer only from back pain. [3] Our case also had back pain only without any neurological deficits. Imaging of vertebral hemangiomas revealed thick and vertical bony trabeculae, thus preserving the functional ability of the vertebrae ...
... [6] The T2-hyperintensity is often greater than that of fat, thereby differentiating hemangiomas from focal fat deposition. [3,7] Aggressive hemangiomas characteristically have reduced fat content and more vascular component causing hypointensity on T1-weighted MRI. [1,4,8] This appearance may resemble vertebral metastasis, however, metastatic foci commonly reveal hypointensity on T1-weighted images and hyperintensity on T2-weighted images. [7] In addition, the morphology, including the presence of coarsened trabeculae can be used for differentiation. ...
... Characteristically, the vertebral hemangiomas are incidentally observed in imaging studies. They are, however, symptomatic in almost 1% of adults [1,2] and are very rare in children. [2] These rare type of symptomatic lesions are known as aggressive hemangiomas and are characterized by expansion of the bone, extension outside bony margins, disturbance of local blood flow, and rarely vertebral compression fractures. ...
... [2] These rare type of symptomatic lesions are known as aggressive hemangiomas and are characterized by expansion of the bone, extension outside bony margins, disturbance of local blood flow, and rarely vertebral compression fractures. [1,3] Approximately 45% of patients with aggressive vertebral hemangiomas have neurologic deficits, the rest suffer only from back pain. [3] Our case also had back pain only without any neurological deficits. ...
... [3,7] Aggressive hemangiomas characteristically have reduced fat content and more vascular component causing hypointensity on T1-weighted MRI. [1,4,8] This appearance may resemble vertebral metastasis, however, metastatic foci commonly reveal hypointensity on T1-weighted images and hyperintensity on T2-weighted images. [7] In addition, the morphology, including the presence of coarsened trabeculae can be used for differentiation. ...
A case of a 42-year-old man with back pain associated with left radiculopathy and infiltrative mass involving the T12 and L5 vertebrae is described. Magnetic resonance imaging (MRI) and computed tomography indicated aggressive hemangiomas involving the T12 and L5 vertebrae. Three-year follow-up by imaging indicated minimally increased aggressiveness of the L5 lesion without any significant change in appearance of the T12 lesion thus, confirming the initial diagnosis of multiple aggressive vertebral hemangiomas.
... Symptomatic VH oc-cur in 0.9 to 1.2% of patients. 5,6 The term aggressive or active haemangioma is used for those lesions. The differentiation of aggressive VH lesions from some other tumour lesions of vertebral column could be challenging. ...
... 7 The lesions typically contain less fat and more vascular stroma thereby producing a low signal on T1 weighted magnetic resonance (MR) images. 4,5,8 Marked postcontrast enhancement is another characteristic. However, the lesion can resemble a solitary vertebral plasmacytoma on computer tomography (CT), as well as on MR images. ...
... 14 Fatty VH may represent inactive forms of this lesion, whereas low signal intensity at MR imaging (less fat content) may indicate more active lesion with the potential to compress the spinal cord. 4,5,8,13 Other radiological signs of aggressiveness are: location between Th3 and Th9, involvement of the entire vertebral body, extension to the neural arch, expanded cortex with indistinct margins, irregular honeycomb pattern, and soft-tissue mass. 7 Determination of aggressiveness is an important part of imaging evaluation, as it influences the decision about the treatment. ...
Background
Most vertebral haemangioma are asymptomatic and discovered incidentally. Sometimes the symptomatic lesions present with radiological signs of aggressiveness and their appearance resemble other aggressive lesions (e.g. solitary plasmacytoma).
Case report.
We present a patient with large symptomatic aggressive haemangioma like lesion in 12th thoracic vertebra in which a magnetic resonance spectroscopy (MRS) was used to analyse fat content within the lesion. The lesion in affected vertebrae showed low fat content with 33% of fat fraction (%FF). The fat content in non-affected (1st lumbar) vertebra was as expected for patient’s age (68%). Based on MRS data, the lesion was characterized as an aggressive haemangioma. The diagnosis was confirmed with biopsy, performed during the treatment – percutaneous vertebroplasty.
Conclusions
The presented case shows that MRS can be used as an additional tool for evaluation of aggressiveness of vertebral haemangioma like lesions.
... T2 hyperintensity is often greater than that of fat, thereby differentiating hemangiomas from focal fat deposition. Agreesive hemangiomas typically contain less fat and more vascular stroma thereby producing a low MR signal on T1 weighted images (Chen et al., 2007;Ross et al., 1987 andFox& Onofrio,1993). This appearance may resemble a metastatic lesion.However metastatic lesions usually have low signal on T1 weighted images and high signal on T2 weighted images . ...
... (Figure I,II,III & IV) Vertebral hemangiomas are one of the common benign lesions with incidence of 10-12%. Typically incidental findings, they are symptomatic in very few individuals (Chen et al., 2007 andCheung, et al., 2011). Category of symptomatic lesions are known as aggressive hemangiomas and are identified with bone expansion, extraosseous extension of tumor, disturbance of local blood flow, and rarely compression fractures and paravertebral soft tissue extension. ...
Vertebral hemangiomas are encountered commonly and most of them are benign. A rare variety of these are characterized as aggressive (incidence .03 to .1%) as they have an extra-osseous extension, ballooning of bone, compression fractures and involvement of paravertebral muscles. We present a case of young woman with progressive paraplegia and an infiltrative mass of L2 vertebrashowing rare involvement of posterior elements withMR signals and characters consistent with Hemangioma.
... In myeloma, MRI has shown greater sensitivity than 18F-FDG-PET in staging, but inferior for evaluating response to treatment that is detected earlier on 18F-FDG-PET whereas it takes approximately 9-12 months for lesions to resolve on MRI (168,169). Hemangiomas is the most frequent benign tumor lesions seen in the spine with an incidence ranging from 10% to 27% and related to increasing age (170,171). CT is more sensitive than radiography revealing a classic "corduroy cloth" on sagittal images or the polka dot sign on axial images (171,172). Typical hemangiomas are generally non-symptomatic and appear as hyperintense on T1 and T2 weighted MRI, due to the predominance of fatty tissue that is suppressed with fat suppression techniques (173). ...
... CT can show the typical osseous remodelling of hemangiomas and the typical signs described above in up to 80% of the cases (174). Aggressive vertebral hemangiomas consist of a very rare subset of vertebral hemangiomas that enlarge, disrupting the cortex and extending to the soft tissues, even resulting in neural compression (170). Due to its aggressive appearance the final diagnosis may require CT guided biopsy (175) (Figure 28). ...
Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.
... Vertebral hemangiomas are the most common benign angiomatous lesions involving the spine, with an estimated incidence of 10% -12% based on large au- topsy series and reviews of spine radiographs [1]. Histologically, these lesions are composed of fully developed adult blood vessels with slow flowing, dilated venous channels surrounded by fat, infiltrating the medullary cavity [2]. ...
... A rare subset of vertebral hemangiomas, however, is characterized by extraosseous extension, bone expansion, disturbance of blood flow, and occasionally compression fractures and thereby referred to as aggressive hemangiomas [4], and it accounts for approximately 1% of spinal hemangiomas [5]. Although vertebral hemangiomas are typically incidental findings, they are symptomatic in 0.9% to 1.2% of adults [1]. Aggressive vertebral hemangiomas are benign lesions that do not have metastatic potential and are not associated with mortality [6] and may be mistaken for metastasis resulting in unnecessary biopsies, which have a high risk of hemorrhage [7]. ...
... VHs are considered the most common benign tumours of the spine [6]. Indeed, their incidence ranges from 10% to 15% of the general population [8], according to several anatomical and imaging studies, resulting especially common among adults (40-50 y.o.) [9] and rare among elderly and children [10], with a preference for female sex (estimated male to female ratio 2:3) [11]. ...
... Aggressive VH consists in a very rare subset of vertebral haemangiomas that, despite being histologically benign, is able to progress and enlarge, causing disturbance of the blood flow and occasionally compressive fractures, even resulting in neural compression [8]. This type of haemangiomas are pathologically classified as Enneking Stage 3 lesion, by Enneking's musculoskeletal neoplasms staging system [22]. ...
Background
Vertebral Haemangiomas (VHs) are frequent and generally asymptomatic benign tumors, involving the spine, usually incidentally found on computed tomography and magnetic resonance. Despite being usually asymptomatic and quiescent lesions, VHs can occasionally manifest aggressive features, leading to clinical manifestations such as back pain and neurological deficits.
Case report.
We report a case of a 54-year-old man, presented with 5 months history of pain, associated with lower limbs paraesthesia and weakness, gait disturbance and episodes of accidental falls. Radiological evaluation by spine pre- and post-contrast MRI indicated multiple vertebral hypervascular lesions, compatible with haemangiomas, involving from T3 to T11 levels, showing several different features (typical and atypical); aggressive haemangioma radiological pattern may be valuable at T3 and T4 vertebras. A thoracic spine pre- and post-contrast computed tomography confirmed the radiological diagnosis of multiple aggressive haemangiomas.
Discussion
Aggressive VH consists in a very rare subset of vertebral haemangiomas characterized by a greater tendency in being symptomatic. They may show atypical radiological features, that make their diagnosis very complex. In the recent years, many strategies for treatment of symptomatic or aggressive VHs have been developed, but the optimal treatment strategy is still controversial.
Conclusion
Although aggressive VHs being extremely rare, recognizing radiological features of these lesions is mandatory to achieve a correct diagnosis and appropriate therapeutic targets.
... This locally aggressive subtype of vertebral hemangiomas represents 1-2% of all lesions [3]. Only one level is usually involved [2,4,5]. There is no evidence as to why some hemangiomas turn aggressive and become symptomatic while most lesions follow a benign course and remain silent. ...
... Intraosseous signal voids might be an important observation on MRI to suggest vertebral hemangioma [8,9]. Spinal angiography is both diagnostic and therapeutic in vertebral hemangioma [4,10]. It helps in determining the vascular supply of both the hemangioma and spinal cord. ...
Introduction
Asymptomatic vertebral hemangiomas are common, but extension into the spinal canal causing cord compression with neurologic symptoms is rare.
Case Reports
Case 1:A 20-year-old male patient presented with difficulty in walking for 6 months with gradually progressive weakness of both the lower limbs. On examination, upper motor neuron signs were present in both the lower limbs with a sensory level below T8 and no bladder involvement. Magnetic resonance imaging (MRI) showed a vascular tumor arising from T6 lamina and pedicle and compressing the cord. Pre-operative computerized tomogram angiography and embolization of the tumor was done, followed by decompression, stabilization of the spine, and vertebroplasty. Postoperatively, the patient received radiotherapy. Case 2: A 71-year-old male patient presented with the recurrence of vertebral hemangioma and cord compression. He had a history of hemangioma with cord compression 13 years back, which was treated by embolization, followed by decompression and fixation. The patient had gradually improved neurologically to normal activities. He was asymptomatic till 7 months back when he noticed difficulty in walking. On examination, pyramidal signs were found to be positive. MRI revealed an expansile lesion at T7 vertebra which was causing compression of the spinal cord. Pre-operative embolization, followed by decompression, stabilization, and vertebroplasty was performed. He also received radiotherapy postoperatively. The diagnosis of benign capillary hemangioma was made after histopathological examination. Neurological recovery was almost complete in both the cases. At6-month follow-up after surgery, both the patients were able to perform all the activities of daily living.
Conclusion
Aggressive vertebral hemangiomas causing progressive neurological deficit should be treated with surgical decompression, stabilization, and vertebroplasty. Pre-operative angiography, embolization, and post-operative low-dose radiation therapy are recommended.
... Most hemangiomas are small, about a third are multiple and only 0.9-1.2% of hemangiomas cause symptoms [1,3]. Very few hemangiomas are aggressive causing bony expansion and extraosseous Case Report Journal of Orthopaedic Case Reports 2017 Mar-Apr: 7(2): [7][8][9][10] What to Learn from this Article? ...
... Treatment options for aggressive vertebral body hemangiomas include interventional radiology options like embolization or ethanol injection, radiotherapy or surgery. Literature shows all these modalities to be effective in treatment [3,4,5,9,10]. As early as 1994, intralesional ethanol injection was advocated for treatment [11]. ...
Introduction
Hemangiomas are benign tumors characterized by proliferation of blood vessels. A few hemangiomas are aggressive, characterized by bone expansion and extraosseous extension. These benign tumors may be mistaken for metatasis resulting in unnecessary biopsies, which have a high risk of hemorrhage. These hemangiomas can spread not just into the paraspinal soft tissues but also into the epidural region of the spinal canal causing cord compression and paraparesis. These clinical symptoms can be relieved by surgical decompression of the posterior elements, embolization or radiotherapy.
Case Report
In this case report the authors describe the imaging features of two aggressive vertebral body hemangiomas in two patients with back pain. One patient had isolated motor deficit while the other patient had both sensory and motor deficit. On imaging this benign tumor was seen involving both the vertebral body and its posterior elements with paraspinal and epidural extension causing compressive myelopathy.
Conclusion
Thus, these case reports help identify the characteristic imaging features of an aggressive vertebral body hemangioma, preventing unnecessary and often risky biopsy. The clinical symptoms of the patient can be relieved by surgical decompression of the posterior elements or by radiotherapy. Use of onyx for intraarterial embolization is now believed to be the safest and most efficacious method for treatment of aggressive vertebral body hemangiomas. However, in the absence of definite guidelines, a multicentric study is warranted to prove that embolization with onyx is better than surgery with post-operative radiotherapy.
... Vertebral hemangioma, common benign lesion of spine was first described by Perman, in 1926, followed by Bailey and Bucy in 1930. Although typically incidental findings in 10%-12% cases, they are symptomatic in 0.9 to 1.2% of adults [1,2]. Symptomatic or aggressive hemangiomas are characterized by bone expansion, extra osseous extension, compression fractures, soft tissue component & neurological complication [1]. ...
... Although typically incidental findings in 10%-12% cases, they are symptomatic in 0.9 to 1.2% of adults [1,2]. Symptomatic or aggressive hemangiomas are characterized by bone expansion, extra osseous extension, compression fractures, soft tissue component & neurological complication [1]. Approximately 45% of aggressive hemangiomas are associated with neurologic deficits, the others only characterized by pain [3]. ...
... 1,6,8,9,15 There are reports on the rapid onset of signs of VH in the third trimester of pregnancy, suggesting that growth of the hemangioma can be stimulated by elevated secretion of estrogen with contribution of increased intraabdominal pressure. 3,8,9,15,16 To the best of our knowledge, spontaneous malignant transformation of VHs has not been reported. 2,3,8 According to criteria highlighted by Laredo and colleagues, aggressive VHs most frequently affect vertebrae from T-3 to T-9 and involve the entire VB, pedicles, and vertebral arch. ...
... 3,8,9,15,16 To the best of our knowledge, spontaneous malignant transformation of VHs has not been reported. 2,3,8 According to criteria highlighted by Laredo and colleagues, aggressive VHs most frequently affect vertebrae from T-3 to T-9 and involve the entire VB, pedicles, and vertebral arch. Moreover, they exhibit irregular trabeculation, expanded and poorly defined cortex, disrupted cortex, and swelling of the paravertebral soft tissue. ...
The authors report on colon cancer metastasis to the L-3 vertebra, which had been previously found to be involved by an asymptomatic hemangioma. A 61-year-old female patient was admitted after onset of lumbar axial pain and weakness of the right quadriceps muscle. Her medical history included colon cancer that had been diagnosed 3 years earlier and was treated via a right hemicolectomy followed by chemotherapy. Presurgical imaging revealed an asymptomatic hemangioma in the L-3 vertebral body. Computed tomography and MRI of the spine were performed after admission and revealed a hemangioma in the L-3 vertebral body as well as a soft-tissue mass protruding from the L-3 vertebral body to the spinal canal. Treatment consisted of vertebroplasty of the hemangioma, left L-3 hemilaminectomy, and removal of the pathological mass from the spinal canal and the L-3 vertebral body. Histopathological examination revealed the presence of colon cancer metastasis and a hemangioma in the same vertebra.
... Several therapeutic strategies have been described in the literature, including embolization, sclerotherapy, surgical resection, radiotherapy, and methacrylate vertebroplasty [7,8]. Embolization and sclerotherapy may have complications such as spinal cord infarction, osteonecrosis, Brown Sequard syndrome, and infectious complications [8]. ...
... Several therapeutic strategies have been described in the literature, including embolization, sclerotherapy, surgical resection, radiotherapy, and methacrylate vertebroplasty [7,8]. Embolization and sclerotherapy may have complications such as spinal cord infarction, osteonecrosis, Brown Sequard syndrome, and infectious complications [8]. Surgery is usually * Aurélien Courvoisier aurelien.courvoisier@gmail.com ...
To describe two cases of a dorsal vertebral hemangioma diagnosed in a 12- and 14-year-old child successfully treated with vertebroplasty.
Cases reports.
Two cases of aggressive vertebral hemangiomas were diagnosed and treated in two independent institutions. Percutaneous vertebroplasty was then decided. Bipedicular vertebroplasty was performed under general anesthesia, under biplanar fluoroscopic guidance. The injection of acrylic cement filled the entire vertebral body without significant leakage. At last follow-up, the clinical and radiographic outcome was very good. In one patient, last control radiographs showed a gap between the end plates and the cement, spinal growth seemed to have resumed.
Vertebral hemangioma is rare in pediatric patients, and its diagnosis requires meticulous and regular clinical examinations and a combination of imaging studies, particularly an MRI and a CT scan, which can assess the aggressiveness of the lesion. Vertebroplasty seems to be an effective and safe treatment of this benign tumor in children with stable outcome at 2-year follow-up. Spinal growth may resume despite the aggressiveness of both the tumor and the treatment.
... Current literature reports that the coupling of partial tumor resection and decompression is also suitable for AVHs with progressive neurological deficits [5,8,10]. Previous studies have shown that surgical decompression is appropriate when there is a significant or progressive neurological deficit [6,16,19,22,[24][25][26]. Cloran et al. [40] suggested an algorithm to treat AVH in their paper. ...
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.
... Symptoms often arise from extension of the hemangioma into the epidural space, causing cord compression. [1][2][3] Surgical intervention is warranted for symptomatic hemangiomas. Treatment strategies include resection, vertebroplasty, ethanol injection, and percutaneous embolization. ...
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.
... Some case reports have shown good results. Chen et al. demonstrated that a 27-yearold woman with an L3 hemangioma presented with sudden onset of lower limb pain and incomplete paralysis below the hip flexors [21]. Ethanol sclerosis therapy was administered three days after transarterial embolization. ...
Vertebral hemangiomas of the spine are rare benign tumors. They occur primarily in the thoracic region and are often asymptomatic and found incidentally on radiological examination; however, some are symptomatic, aggressive, and gradually increase in size. Various therapeutic approaches have been proposed for their management. This study aimed to review the therapeutic management, focusing on ethanol sclerosis therapy. The PubMed database was searched from inception to January 2023 using the keywords “hemangioma”, “spine OR vertebra”, and “ethanol”. Twenty studies were retrieved, including two letters. The first report of spinal therapy was published in 1994. Ethanol sclerosis therapy is effective in treating vertebral hemangiomas. It is performed independently or in combination with other techniques, such as vertebroplasty using cement and surgery. The therapy is performed under local or general anesthesia with fluoroscopic or computed tomography guidance. A total of 10–15 mL of ethanol is slowly injected via unilateral or bilateral pedicles. Complications of the therapy include hypotension and arrhythmia during the procedure, paralysis immediately after the procedure, and delayed compression fractures. This review could enable the refinement of knowledge regarding ethanol sclerosis therapy, which is a treatment option that could be adopted.
... 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.
... [7,8] They have varied presentation depending on the location, the degree of cord, or nerve root compression. [9] Based on the lesion morphology and symptoms, VHs are classified into four types, type IV being most aggressive and symptomatic. [10] Type III and type IV belong to Enneking grade 3 [11] and are more likely to involve the entire vertebral body, have soft tissue component, and extend into the posterior elements and spinal canal. ...
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.
... VH rarely causes acute and subacute neurological deficits (in up to 45%) and/or pain. [10,11] In VH, the involved vertebra shows a trabecular pattern and that, by itself, preserves the vertebral function and resists the axial load; the compression fractures are, therefore, less common in comparison to other spinal tumors. [7,12] VH can be histologically classified into capillary, cavernous, and mixed subtypes. ...
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.
... Contudo, em raros casos, heman-giomas podem se apresentar agressivos, com déficit neurológico decorrente de compressão medular. 1,2,[5][6][7][8] A forma evolutiva do presente caso demonstra lesões difusas, em paciente masculino, sintomáticas, agressivas e não concomitantes, com surgimento de novos hemangiomas durante o seguimento, não passíveis de tratamento conservador. ...
Resumo
O hemangioma vertebral, um tumor vascular benigno, geralmente é assintomático e descoberto incidentalmente em exames de imagem. Quando sintomático, a apresentação mais frequente ocorre sob a forma de dorsalgia vaga de início insidioso e, em raros casos, pode estar associado a compressão radicular ou medular, causando déficit sensitivo e motor. Os autores relatam o caso de um homem de 33 anos, previamente hígido, com diagnósticos de hemangioma na coluna torácica em múltiplos níveis, no esterno, na escápula e nos arcos costais; todas as lesões eram sintomáticas e houve necessidade de intervenção cirúrgica, sendo que uma das lesões ao nível da coluna torácica evoluiu com compressão medular e déficit neurológico agudo, com necessidade de intervenção cirúrgica de urgência. Os hemangiomas intraósseos representam < 1% de todos os tumores ósseos, e a apresentação multifocal no esqueleto axial e apendicular apresenta poucos relatos. Na revisão bibliográfica, não foi encontrado outro caso de hemangioma intraósseo multifocal agressivo com tal apresentação, inclusive com sintomas neurológicos associados em um mesmo caso.
... [9][10][11][12] The presenting symptoms depend on the tumor location and the extent of spinal cord or nerve root compression. [13] Even in aggressive hemangiomas, the lesion keeps its benign nature with no malignant transformation. [1] Intervention is considered only in symptomatic lesions. ...
Background:
There are different surgical modalities designed to manage aggressive vertebral hemangioma (VH) that causes neurological symptoms. The selection of the best approach is still controversial. It is crucial to safely achieve neurological recovery with the elimination of the risk of recurrence. The combined use of surgical decompression and vertebroplasty is one of the surgical modalities that are used to manage these cases.
Patients and methods:
From January 2012 to January 2019, nine patients with aggressive VH were retrospectively included in the study. All of them were operated upon using combined surgical decompression and vertebroplasty. We evaluated all the patients preoperatively, immediate postoperative, 1 month, and 12 months later. Clinical and radiological outcomes were assessed.
Results:
Affected spinal levels were dorsal in six cases and lumbar in three cases. There was no postoperative worsening of the preoperative neurological status. For the cases presented with sciatica, the mean VAS score has dropped from 8.33 preoperatively to 2.67 postoperatively. One month later, all of them are free from the radicular pain. For the cases presented with myelopathy, they regain their motor power in both lower limbs over a period of 4 weeks with a mean Nurick grade of 1.17. The postoperative radiological studies revealed near total occlusion of the VH with the maintenance of the vertebral body height. No clinical or radiological signs of spinal instability or recurrence are observed over the period of follow-up.
Conclusions:
The combined use of surgical decompression and vertebroplasty is considered a safe and effective modality in the management of aggressive VHs.
... Because of the small number of cases, no consensus exists concerning the gold standard to treat S3 hemangiomas. Currently, the reported treatments for vertebral hemangiomas include radiotherapy [17], interventional embolization [18], alcohol ablation [19,20], vertebroplasty [21], and surgery [2,3,8]. Cloran et al. [4] believed that physicians should attend to symptomatic hemangiomas and that multimodal treatments should be used for patients with S3 hemangiomas, which includes preoperative interventional embolization, spinal canal decompression or en bloc. ...
Background:
Elderly patients with vertebral hemangiomas are rare and might require surgery. Thus, the choice of surgery for these lesions remains controversial because of the rarity of these lesions. This study aimed to analyze the clinical efficacy of the intraoperative injection of absorbable gelatin sponge mixed with cement followed by spinal decompression to treat the elderly with typical vertebral hemangiomas. The risk factors for hemangioma recurrence were investigated through a literature review.
Methods:
We retrospectively analyzed 13 patients with typical aggressive hemangiomas between January 2009 and January 2016. Of these patients, 7 were treated with spinal decompression combined with intraoperative vertebroplasty (Group A), and 6 patients were treated with decompression with intraoperative vertebroplasty and absorbable gelatin sponge (Group B). The general data and perioperative data of the patients were compared. Patients were followed up for at least 3 years, and postoperative complications and recurrence rates were recorded and compared.
Results:
All patients had typical aggressive hemangiomas. The average age of all patients was 64.4 ± 3.3 years. The preoperative data did not differ significantly between the two groups (P > 0.05). The blood loss of groups A and B was 707.1 ± 109.7 ml and 416.7 ± 103.3 ml, respectively (P = 0.003) (P = 0.003), and the average surgery durations were 222 ± 47.8 min and 162 ± 30.2 min, respectively (P = 0.022). The average follow-up duration was 62 ± 19 months, and no cases of recurrence were found at the final follow-up assessment.
Conclusions:
Multimodal treatment significantly alleviated the clinical symptoms of elderly patients with typical aggressive vertebral hemangiomas. Intraoperative absorbable gelatin sponge injection is a safe and effective way to reduce blood loss and surgery duration.
... Its incidence increases gradually with age [8]. It is usually found in middle-aged adults between the fourth and fifth decade; about one-third of the lesions are revealed in the fifth decade [9]. In our case, the site of the lesion was rather lumbar (L3) unlike the one whose dorsal location is most frequent from T3 to T9 [5]. ...
... [1][2][3][4] Though these benign tumors are prevalent in the general population, only 0.9% to 1.2% become symptomatic requiring intervention. [5][6][7] Exceedingly rare are symptomatic vertebral hemangiomas in the pediatric population. Fewer than 20 pediatric cases of vertebral hemangiomas have been published to date, [8][9][10][11][12][13][14][15] with lesions noted in children as young as 8 yr of age. ...
... [1][2][3][4] Though these benign tumors are prevalent in the general population, only 0.9% to 1.2% become symptomatic requiring intervention. [5][6][7] Exceedingly rare are symptomatic vertebral hemangiomas in the pediatric population. Fewer than 20 pediatric cases of vertebral hemangiomas have been published to date, [8][9][10][11][12][13][14][15] with lesions noted in children as young as 8 yr of age. ...
... Compression of the anterior radiculomedullary artery by tumor causes circulatory disturbances of the spinal cord resulting in myelopathy [31,32]. Expansive growth of the tumor with resorption of the adjacent bone and formation of an extra-vertebral soft tissue component in the anterolateral direction or into the vertebral canal associated with a risk of spinal cord compression, compressive fracture and vertebral body collapse have been observed [5,6,20,35,42]. Spinal hemangiomas with an intracanal component occur rarely in the lumbar spine. Lumbar vertebral hemangioma can cause cauda equina syndrome [14]. ...
Objective. To evaluate the outcomes of the differentiated surgical treatment in patients with aggressive vertebral hemangiomas.
Material and Methods. The study included 127 patients with aggressive vertebral hemangiomas operated on in 2013–2016. The tumor lo-
calization was cervical in 9.5% of cases, thoracic in 59.8 % and lumbar in 30.7 %. Patients were divided into two groups: Group I (n = 110)
with type IIIA aggressive hemangiomas, and Group II (n = 17) with type IIIB aggressive hemangiomas. Preoperative assessment included
clinical and neurological examination, VAS, ODI, JOA, Weinstein-Boriani-Biagini classification, and radiography; MSCT and MRI studies
of the spine were performed before treatment and in 12 months after surgery.
Results. Patients in Group I underwent puncture vertebroplasty. Back pain was 6 VAS, after 12 months – 2 VAS. The average preop-
erative ODI score was 32 and decreased to 9 in 12 months after surgery. In Group II, patients underwent decompression and stabiliza-
tion with intraoperative open vertebroplasty of the affected vertebra. Preoperative embolization of tumor vessels was performed in two
of 17 patients to reduce intraoperative blood loss. Preoperative back pain was 6 VAS, in 12 months after surgery – 2 VAS. The ODI score
showed the improvement in all patients as compared to preoperative values.
Conclusion. Puncture vertebroplasty ensures the achievement of good functional result in 95.4 % of cases of type IIIA aggressive hemangioma.
Decompression and stabilization surgery with intraoperative open vertebroplasty provides good functional result in 93.4 % of cases of type IIIB
aggressive hemangioma. The use of vertebroplasty in type IIIB aggressive hemangiomas allows for vertebral segment stabilization with a low
risk of the tumor recurrence.
... Generally, the diagnosis is easily made, but in some cases the hypothesis of malignant lesions, such as vertebral metastasis, myeloma or lymphoma or vertebral infection, should be taken into account [9][10][11][12]. Vertebral hemangiomas is generally an asymptomatic incidental finding, but clinical presentation may vary from pain to radicular symptoms and thoracic myelopathy [13][14][15][16][17]. Pain is most often due to the fracture of the involved vertebra or canal stenosis caused by bone expansion, while myelopathy is observed in association with the epidural extension of the lesion. ...
Vertebral hemangioma is a benign vascular lesion that may onset with neurologic symptoms due to spinal cord compression by epidural extension. Surgical procedure, embolization and radiotherapy are the gold standard for the treatment of this disease. We present a case of a 84 years old woman admitted at our department with worsening paraparesis and urinary retention. Her magnetic resonance images (MRI) showed a lesion involving both anterior and posterior vertebral element of D5, with extension into epidural space and spinal cord compression. The patient was operated for laminectomy and epidural lesion removal. Histological examination confirmed the diagnosis of cavernous hemangioma.
... 17,32,38,55,63,69 To avoid the risk of vertebral collapse, some surgeons may inject lower doses of ethanol or combine ethanol injection with percutaneous vertebroplasty. 13,17 A case report by Chen et al. 10 also describes the successful treatment of an aggressive vertebral hemangioma using ethanol injection in combination with en-dovascular embolization with no clinical or radiographic recurrence at 21-month follow-up. Nevertheless, because there are other treatment options with comparable clinical outcomes and fewer complications, alcohol ablation has fallen out of favor. ...
OBJECTIVE
Vertebral hemangiomas are common tumors that are benign and generally asymptomatic. Occasionally these lesions can exhibit aggressive features such as bony expansion and erosion into the epidural space resulting in neurological symptoms. Surgery is often recommended in these cases, especially if symptoms are severe or rapidly progressive. Some surgeons perform decompression alone, others perform gross-total resection, while others perform en bloc resection. Radiation, embolization, vertebroplasty, and ethanol injection have also been used in combination with surgery. Despite the variety of available treatment options, the optimal management strategy is unclear because aggressive vertebral hemangiomas are uncommon lesions, making it difficult to perform large trials. For this reason, the authors chose instead to report their institutional experience along with a comprehensive review of the literature.
METHODS
A departmental database was searched for patients with a pathological diagnosis of “hemangioma” between 2008 and 2015. Medical records were reviewed to identify patients with aggressive vertebral hemangiomas, and these cases were reviewed in detail.
RESULTS
Five patients were identified who underwent surgery for treatment of aggressive vertebral hemangiomas during the specified time period. There were 2 lumbar and 3 thoracic lesions. One patient underwent en bloc spondylectomy, 2 patients had piecemeal gross-total resection, and the remaining 2 had subtotal tumor resection. Intraoperative vertebroplasty was used in 3 cases to augment the anterior column or to obliterate residual tumor. Adjuvant radiation was used in 1 case where there was residual tumor as well. The patient who underwent en bloc spondylectomy experienced several postoperative complications requiring additional medical care and reoperation. At an average follow-up of 31 months (range 3–65 months), no patient had any recurrence of disease and all were clinically asymptomatic, except the patient who underwent en bloc resection who continued to have back pain.
CONCLUSIONS
Gross-total resection or subtotal resection in combination with vertebroplasty or adjuvant radiation therapy to treat residual tumor seems sufficient in the treatment of aggressive vertebral hemangiomas. En bloc resection appears to provide a similar oncological benefit, but it carries higher morbidity to the patient.
... On MRI, benign incidental haemangioma usually appear as hyperintense on both T1-and T2-weighted images due to high fat component and less vascular stroma. On the other hand, aggressive haemangioma are usually hypointense to isointense on T1-weighted images and hyperintense on T 2 -weighted images due to prominent hypervascular stroma and less amount of fat [1,3,4] . MRI is also helpful in showing paravertebral and epidural extension of the lesion. ...
... The prognosis of VH lesions remains unclear. The presence of low signals on T1 weighted MRI and high signals on T2 images, the presence of soft tissue stroma between the osseous trabeculae on CT images, the presence of epidural tissue and evidence of cortical erosion are all radiological features of aggressiveness [6]. In our case, symptomatic lesion showed sign of aggressiveness on MRI examination. ...
Vertebral hemangiomas (VHs) are benign tumours with rich vasculature. They are the most common tumours of the spine with an estimated incidence of 10% - 12% of the population. Despite its high incidence, they are often asymptomatic and only 0.9% - 1.2% are symptomatic. They may also be aggressive and are characterised by bone expansion, extra osseous extension of the tumour, disturbance of local blood flow and, in rare cases, compression fractures. We report a 59-year-old woman, presented with back pain after falling from standing height. Magnetic resonance imaging revealed lumbar spine vertebral fractures and T12 osteolytic lesion with spinal canal extension, concurring to VH type IV, according to Tomita’s surgical classification of spinal. Embolization, posterior decompression and fixation were performed followed by postoperative radiotherapy. Her symptoms were resolved immediately without recurrence after 6 mouths.
... The most common is enlargement of the vertebral body, which leads to narrowing and distortion of the spinal canal. The other mechanisms are extraosseous extension of the tumor into the epidural space, compression fracture, and bleeding from the tumor into the epidural space (2,3). In this case we aim to present preoperative and postoperative Computed Tomography (CT) fi ndings of a cavernous hemangioma that caused sudden motor defi cit and was localised to the thoracic vertebra corpus and posterior elements. ...
Vertebral body hemangiomas are benign lesions and account for 4% of all spinal tumors. The most common histological type is cavernous hemangioma. These tumors generally locate in the vertebral body as a solitary lesion. Multiple lesions are seen in approximately 25-30% of vertebral hemangiomas. Mostly they are asymptomatic and incidentally found with radiological studies. Symptomatic vertebral hemangiomas are rare and represent < 1% of all hemangiomas; however, if untreated, they may cause local or radicular pain and neurological deficits ranging from myeloradiculopathy to paralysis. In this case we aim to present preoperative and postoperative Computed Tomography findings of a cavernous hemangioma that caused sudden motor deficit and was localised to the thoracic vertebra corpus and posterior elements.
Background:
Vertebral hemangioma (VH) is one of the most common benign spinal tumors and can be aggressive in some cases. While most aggressive VHs have typical radiographic features, including vertical striations, a honeycomb appearance, and/or a "polka-dot sign" in computed tomography (CT) scans, cases with atypical features might complicate diagnosis. This study aimed to determine the range and frequency of these atypical features.
Methods:
In this retrospective study, to identify the typical and atypical features of aggressive VH, pretreatment CT and magnetic resonance imaging (MRI) were reviewed retrospectively by 1 radiologist and 1 orthopaedic surgeon. Percutaneous biopsies were performed to confirm the VH in atypical cases.
Results:
A total of 95 patients with aggressive VHs were treated in our hospital from January 2005 to December 2017. Thirty-four (36%) of the lesions showed at least 1 atypical radiographic feature: 16 patients (17%) had a vertebral compression fracture, 11 patients (12%) had expansive and/or osteolytic bone destruction without a honeycomb appearance and/or "polka-dot sign", 11 patients (12%) had obvious epidural osseous compression of the spinal cord, 12 patients (13%) had involvement of >1 segment, 9 patients (10%) had a VH centered in the pedicle and/or lamina, and 8 patients (8%) had atypical MRI signals. Forty-three patients underwent percutaneous biopsies, which had an accuracy of 86%.
Conclusions:
Based on radiographic analysis, aggressive VH can be classified as typical or atypical. More than one-third of aggressive VH lesions may have at least 1 atypical feature. CT-guided biopsies are indicated for these atypical cases.
Chordomas and chondrosarcomas are distinct pathological entities that share many clinical-radiological similarities. Furthermore, a variety of different tumors may also be a part of their differential diagnosis. These include other primary osseous tumors, cartilaginous, soft tissue, and central nervous system neoplasms as well as congenital, nonneoplastic, and metastatic secondary lesions. Proper management of cranial base and spinal tumors depends, among other factors, on accurate diagnosis. A multidisciplinary team of physicians with significant experience with complex skull base and spinal pathologies should, ideally, evaluate these patients so as to decrease the likelihood of diagnostic errors and treatment delays. This chapter discusses the clinical, radiological, and histological characteristics of cranial base and spinal tumors by which they can be distinguished from chordomas and chondrosarcomas.
Vertebral hemangiomas are benign lesions and are often asymptomatic. Most vertebral hemangiomas that cause cord compression and neurological symptoms are located in the thoracic spine and involve a single vertebra. The authors report the rare case of lumbar hemangiomas in a 60-year-old woman presenting with severe back pain and rapidly progressive neurological signs attributable to 2 noncontiguous lesions. After embolization of the feeding arteries, no improvement was noted. Thus, the authors performed open surgery using a combination of posterior decompression, intraoperative kyphoplasty, and segmental fixation. The patient experienced relief from back and leg pain immediately after surgery. At 3 months postoperatively, her symptoms and neurological deficits had improved completely. To the authors' knowledge, this is the first description of 2 noncontiguous extensive lumbar hemangiomas presenting with neurological symptoms managed by such combined treatment. The combined management seems to be an effective method for treating symptomatic vertebral hemangiomas.
Quel que soit l’âge du patient, mais peut-être plus encore en pédiatrie, les douleurs rachidiennes persistantes, invalidantes, d’horaire mixte doivent toujours faire évoquer et rechercher une étiologie. Nous rapportons le cas d’un hémangiome vertébral thoracique diagnostiqué chez un enfant de 12 ans. Cette lésion osseuse non compliquée mais considérée comme agressive a été traitée par cimentoplastie. À 18 mois de recul, le résultat est satisfaisant. Le patient est asymptomatique et la croissance de la vertèbre semble se poursuivre. À la revue de la littérature, peu de cas d’hémangiomes vertébraux ont été décrits en pédiatrie. À notre connaissance, il n’a pas été décrit de traitement par cimentoplastie. Après avoir discuté des critères cliniques et radiologiques permettant de différencier un hémangiome agressif d’un hémangiome non agressif, les auteurs discutent des différentes possibilités thérapeutiques, ainsi que de leurs complications.
Objective:
To evaluate the effectiveness of vertebroplasty in symptomatic vertebral haemangiomas (VHs) with no neurological deficit, with or without features of aggressiveness in imaging studies.
Methods:
A retrospective study was conducted to review 31 consecutive patients with symptomatic VHs that underwent vertebroplasty procedures (13 males, 18 females; mean age, 57.5 years), for a total of 33 affected vertebral levels (range, T4-L5 levels). Pre procedure radiological examinations were reviewed. The presence of predominant soft tissue stroma on CT, low signals on T1W of MRI, epidural tissue, and cortical erosion are considered features of aggressiveness. The clinical effects were evaluated using the visual analogue scale (VAS) and modified Roland-Morris Disability Questionnaire (RDQ) at the pre and each postoperative follow-up time point (mean follow-up of 15.8 months).
Results:
Symptomatic VHs with no signs of aggressiveness were observed in 26 lesions and those with signs of aggressiveness in 7 lesions. Vertebroplasty was successfully performed under fluoroscopic guidance with a unipedicular approach in 16 levels, a bipedicular approach in 17 levels. VAS scores and RDQ scores were significantly improved after vertebroplasty (P < 0.001). Extraosseous cement leakage was observed in 4 patients without clinical complications.
Conclusions:
Vertebroplasty is an optional treatment for symptomatic VHs with no neurological deficit.
Key points:
• Vertebral haemangiomas with or without aggressive signs may cause pain. • Radiological signs of aggressiveness include evidence of lesions that contain less fat predominance, evidence of epidural soft tissue and evidence of cortical erosion. • Vertebroplasty provides effective treatment for symptomatic vertebral haemangiomas causing no neurological deficit.
An F-FDG-PET with CT scan was performed to stage a tongue cancer, revealing the hypermetabolic region in the thoracic vertebra. This corresponded to a benign lesion seen on MRIs and CT.Although these findings suggested a vertebral hemangioma, "hot" vertebra in FDG-PET was atypical. The final diagnosis was confirmed capillary hemangioma by the scopic biopsy and this lesion was no change at 1 year later.Careful interpretation of metabolic (FDG-PET) and anatomic (CT and MRI) images should be performed to accurately characterize the foci of increased FDG uptake.
We retrospectively studied 31 patients with painful bone (15 patients) and soft-tissue (16 patients) hemangiomas treated with 39 embolizations using N-2-butyl cyanoacrylate from 2003 to 2010. The mean tumor size before embolization was 6 cm for bone and 7 cm for soft-tissue hemangiomas. The technique of embolization was the same for bone and soft-tissue lesions. Preoperative embolization was done in six patients, while the remaining patients had embolization as only treatment. The mean follow-up was 47 months (11-89 months). The clinical and imaging effect of treatment was evaluated at follow-up with a pain score scale, tumor size, and ossification. In four patients, embolization was not feasible because of the inability to catheterize and low blood flow of the feeding vessels. Nine patients with bone and 10 with soft-tissue hemangiomas experienced complete pain relief. Four patients with bone and four with soft-tissue hemangiomas experienced recurrence of pain and were treated with repeat embolization. Re-recurrences were not observed in any of the patients with soft-tissue hemangiomas until the period of this study. Ossification and tumor size reduction were higher for bone hemangiomas. Embolization-related complications were more common for soft-tissue hemangiomas.
Vertebral hemangiomas are common lesions and usually considered benign. A rare subset of them, however, are characterized by extra-osseous extension, bone expansion, disturbance of blood flow, and occasionally compression fractures and thereby referred to as aggressive hemangiomas. We present a case of a 67-year-old woman with progressive paraplegia and an infiltrative mass of T4 vertebra causing mass effect on the spinal cord. Multiple conventional imaging modalities were utilized to suggest the diagnosis of aggressive hemangioma. Final pathologic diagnosis after decompressive surgery confirmed the diagnosis of an osseous hemangioma.
Back pain prevalence in the pediatric age group is less compared with adults. There is a wide range of possible etiologies, and tumors such as primary spinal hemangiomas are uncommon. Most are incidental findings and asymptomatic; however, painful lesions can be presented in up to 0.9% to 1.2% of cases. These lesions can produce neurologic involvement either spinal cord compression or cauda equina syndrome as in our case. The aim of this study is to describe a case of low back pain in a child due to a vertebral hemangioma complicated with acute cauda equina syndrome, and performed a literature review that will help us to recognize this aggressive variance making an early treatment feasible.
A 13-year-old female, follow-up in an outer health care center due to a L1 vertebral hemangioma, characterized by 3 years of low back pain without neurologic symptoms presented to our emergency department with an acute cauda equina syndrome.
An outside magnetic resonance imaging showed complete obliteration of the spinal canal at the level of the conus medullaris related to retropulsion of bone at L1. She underwent 2-stage surgical treatment: complete posterior L1 laminectomy and partial T12-L2 laminectomies, with partial L1 vertebrectomy and posterior fusion with instrumention from T11 to L3. Three weeks later, embolization before anterior fusion with inner body cage was performed. Forty months after surgery, she is doing well with no neurologic deficits.
Even though hemangiomas are not a common cause of back pain, they should be taken into account. It is important to recognize the aggressive variance so an early treatment could be performed. There is no enough clinical data to establish guidelines of management in children, therefore, the treatment should be individualized.
The authors present a rare case of lumbar vertebral hemangioma extending to the epidural space with a bisected appearance and impinging on thecal sac. This 52-year-old lady presented with one year history of low back pain and bilateral leg radiation. Plain radiography showed vertical linear streaks at L2 vertebral body and axial computed tomography (CT) scan revealed small "polka dot" appearance within the vertebral body. Magnetic resonance imaging (MRI) showed low signal intensity on T1-weighted images in L2 vertebral body which was not characteristic for hemangioma. The patient underwent an L2 laminectomy, spinal canal decompression and posterior spinal instrumentation. This study indicates that lumbar vertebral hemangioma can extend to the epidural space and cause neurologic symptoms. Magnetic resonance imaging may not show diagnostic features, especially in active lesions and plain radiography and CT scan may be helpful.
Context:
Vertebral haemangiomas are recognized to be one of the commonest benign tumours of the vertebral column, occurring mostly in the thoracic spine. The vast majority of these are asymptomatic. Infrequently, these can turn symptomatic and cause neurological deficit (cord compression) through any of four reported mechanisms: (1) epidural extension; (2) expansion of the involved vertebra(e) causing spinal canal stenosis; (3) spontaneous epidural haemorrhage; (4) pathological burst fracture. Thoracic haemangiomas have been reported to be more likely to produce cord compression than lumbar haemangiomas.
Findings:
A forty-nine year old male with acute onset spinal cord compression from a pathological fracture in a first lumbar vertebral haemangioma. An MRI delineated the haemangioma and extent of bleeding that caused the cord compression. These were confirmed during surgery and the haematoma was evacuated. The spine was instrumented from T12 to L2, and a cement vertebroplasty was performed intra-operatively. Written consent for publication was obtained from the patient.
Clinical relevance:
The junctional location of the first lumbar vertebra, and the structural weakness from normal bone being replaced by the haemangioma, probably caused it to fracture under axial loading. This pathological fracture caused bleeding from the vascularized bone, resulting in cord compression.
A case report and a discussion of recent published data.
To highlight the importance of vertebral hemangioma (VH) as a differential diagnosis in the evaluation of locally aggressive spinal lesions.
VH commonly occur as incidental findings, however, locally aggressive VH have been described. Difficulties in diagnosing these lesions are well reported and relate to changes in fat content causing uncharacteristic appearances on imaging. The management options for these lesions include a combination of observation, embolization, sclerotherapy, surgical decompression, or stabilization and radiotherapy.
A 45-year-old patient who was previously well presented with back pain and rapidly progressive paraparesis. Imaging confirmed the presence of an extensive lesion centered within the right T3 vertebral pedicle with intrusion into the spinal canal. Urgent surgical decompression was undertaken and was complicated by extensive intraoperative hemorrhage requiring massive transfusion.
Histologically, the lesion was shown to be a cavernous VH with no evidence of malignancy. Following radiation oncology review, he was offered adjuvant radiotherapy to minimize the risks of recurrence. He achieved a near full neurologic recovery within 2 weeks and had a full recovery by 12 months.
VH should be considered in the evaluation of locally aggressive spinal lesions. Angiography is a useful adjunct in the evaluation of these lesions, both as a diagnostic and therapeutic tool. After diagnosed correctly a wide range of treatment options exist that may prevent the patient from undergoing major surgical resection and reconstruction procedures, which may be associated with high rates of morbidity.
Vertebral haemangiomas are generally benign asymptomatic vascular tumours seen commonly in the adult population. Presentations in paediatric populations are extremely rare, which can result in rapid onset of neurological symptoms. We present a highly unusual case of an aggressive paediatric vertebral haemangioma causing significant cord compression.
A 13-year-old boy presented with only 2 weeks duration of progressive gait disturbance, truncal ataxia and loss of bladder control. Magnetic resonance imaging (MRI) of the spine revealed a large vascular epidural mass extending between T6 and T8 vertebral bodies. Associated displacement and compression of the spinal cord was present. A highly vascular bony lesion was found during surgery. Histopathology identified this tumour to be a vertebral haemangioma.
We present an extremely unusual acute presentation of a paediatric vertebral haemangioma. This study highlights the need for early diagnosis, MRI for investigation and urgent surgical management.
Vertebral hemangiomas (VHs) are frequently asymptomatic lesions found incidentally during investigations for other spinal problems. Symptomatic VHs are less common, and there are few reports of compressive VHs in the literature. VHs with aggressive behavior present with low signal intensity on T1-weighted and high signal intensity on T2-weighted MRI. We present a case series of four patients with compressive VH, all of whom were neurologically compromised. Each of the four patients underwent preoperative arterial embolization followed by surgical treatment of their VHs. All patients recovered normal motor function after surgery. At follow-up (average 53 months), one patient had a recurrent tumor requiring reoperation and radiotherapy. Although it is rare, aggressive VH can be a devastating condition. Total surgical resection or subtotal resection with radiotherapy may be warranted.
A retrospective review of consecutive series of Enneking stage 3 vertebral hemangiomas surgically treated at a major tertiary spine tumor center.
To determine the short-term recurrence rates, pain improvement, and operative morbidity of intralesional spondylectomy combined with preoperative embolization for Enneking stage 3 vertebral hemangiomas.
Aggressive vertebral hemangiomas (Enneking stage 3) often involve both the anterior and posterior columns with spinal canal and local soft tissue extension and may present with dramatic bony destruction, spinal instability, and pain accompanied with neurologic compromise. Although the current treatment paradigm for most vertebral hemangiomas is conservative management directed toward symptomatic relief, the subset of patients presenting with this rare variant requires more extensive surgical treatment.
A retrospective clinical review of patients diagnosed with Enneking stage 3 vertebral hemangiomas was conducted at the University of California at San Francisco.
We identified 10 consecutive cases of Enneking stage 3 hemangiomas. Average follow-up was 2.42 years. The most common presentation was pain with or without myelopathy. Three of the 10 cases were recurrences after prior partial resection and reconstruction or cement augmentation. All patients underwent preoperative embolization. Average blood loss despite embolization was 2.1 L (range: 0.8 to 5 L). Average preoperative back pain visual analog scale was 7.2 and postoperative visual analog scale was 3.1 at 6 months. On postoperative imaging, all patients had gross total resection. Six patients had staged posterior/anterior transcavitary approach and 4 patients underwent single stage posterior transpedicular spondylectomy. To date, no patient has required adjuvant radiation therapy for tumor recurrence.
Our results suggest that complete wide resection of aggressive Enneking stage 3 lesions can be safely accomplished with acceptable morbidity and blood loss and significant improvement in pain and neurological status. Partial resection of stage 3 lesions, even with stabilization or vertebroplasty, may lead to early recurrence.
Because of advances in the treatment of cancer, the average rate of patient survival is increasing. As patients with cancer live longer, the incidence of spinal metastasis also likely will increase. To help control pain and maintain function, some of these metastases will require surgical intervention. Because >60% of spinal metastases are hypervascular, preoperative embolization may be considered in order to decrease hemorrhage risk and improve outcomes. Embolization for spinal metastasis can be performed through the angiogram catheter. When such embolization is performed carefully, the complication rate is low.
Vertebral hemangiomas are relatively common abnormalities. They have been found in 10.7 percent of spines at autopsy and in 14.2 percent of people over the age of 60 years1. However, neurologic symptoms, which result from epidural compression of the spinal cord by the hemangioma, hypertrophied bone, epidural hemorrhage, or compression fracture, are uncommon2,3. Current treatments for symptomatic vertebral hemangioma include surgery, radiotherapy, and transarterial embolization4. Surgical treatment is often associated with profuse hemorrhage, incomplete resection, and lengthy convalescence5–7. Although radiotherapy is moderately effective, its effects on the hemangioma are delayed, and there is a . . .
To describe the technique and results of injecting ethanol directly into symptomatic vertebral hemangiomas.
Eleven patients with paraplegia (n = 6) or radiculopathy (n = 5) due to vertebral hemangioma were treated by means of injecting ethanol (5-50 mL) directly into the lesion with computed tomographic (CT) guidance. CT angiograms were essential prior to treatment to identify functional vascular spaces of the hemangioma and direct needle placement.
All hemangiomas were obliterated completely at follow-up angiography and gadolinium-enhanced magnetic resonance imaging. Five of six patients with paraplegia recovered completely: One who was treated recently was walking with assistance. Four of five patients with radiculopathy improved. No immediate complications were associated with ethanol injection. The two patients who received the largest volumes of ethanol, 42 and 50 mL, developed pathologic fractures of the involved vertebrae 4 and 16 weeks after treatment.
Direct injection of ethanol into symptomatic vertebral hemangioma is an effective and safe treatment, provided the dose is less than 15 mL.
The clinical records and radiographs of 18 patients with vertebral hemangiomas treated with ethanol vertebroplasty were reviewed to evaluate the usefulness of this method.
To assess, after a mean 2-year follow-up, the complication rate, results, and patient satisfaction with ethanol injection into vertebral hemangioma.
There is controversy about the safety of ethanol injections in the treatment of vertebral hemangiomas.
Twenty-four patients with vertebral hemangiomas were prepared for ethanol vertebroplasty. Eighteen patients were treated with ethanol vertebroplasty (average age, 49 years; range, 18-77 years) with a mean follow-up of 2 years (range, 1-4 years). The rest of the patients were not treated with ethanol vertebroplasty because in a pretreatment test injection the contrast medium was not retained by the hemangioma.
Intralesional injections of alcohol did not cause clinical complications in any of the cases.
This study shows that intralesional alcohol injections can be considered a safe technique for vertebral hemangiomas. However, a careful technique is required.
We analyzed the outcome of patients with symptomatic vertebral hemangiomas treated at University of California, San Francisco, over a 20 year period. Treatment included transarterial embolization, embolization followed by surgical decompression or vertebral reconstruction with arthrodesis, and percutaneous vertebroplasty alone.
All medical, surgical, and radiological records were reviewed retrospectively. All patients underwent follow-up neurological examination and evaluation of back pain.
Sixteen patients diagnosed with symptomatic vertebral hemangiomas causing pain or neurological deficit were treated at University of California, San Francisco, between 1984 and 2004. Mean follow-up was 81 months. Seven of nine patients undergoing surgical decompression and tumor resection reported pain relief and demonstrated improvement in neurological deficit when present. Two patients had recurrent myelopathy: one was successfully treated with a second decompressive surgery, whereas the second underwent a staged vertebrectomy. All three patients undergoing vertebrectomy had cord compression from extraosseous tumor growth. Preoperative embolization reduced expected intraoperative blood loss in four patients. Three of four patients who underwent transarterial embolization alone experienced resolution of back pain. Two of four patients treated with vertebroplasty had long-term pain relief.
Transarterial embolization followed by laminectomy is a safe and effective procedure for the treatment of cord compression by vertebral hemangioma causing stenosis without instability or deformity. Vertebrectomy preceded by embolization and followed by reconstruction can be used to treat cord compression from extraosseous tumor extension. Transarterial embolization without decompression is an effective treatment for painful intraosseous hemangiomas. Vertebroplasty is useful for improving pain symptoms, especially when vertebral body compression fracture has occurred in patients without neurological deficit, but is less effective in providing long-term pain relief.
Vertebral haemangiomas are relatively common, but those extending into the epidural space are rare. A 59-year-old man with severe lower back and right leg pain that did not resolve with conservative treatment was seen in an outpatient clinic. Magnetic resonance imaging of the lumbar spine identified an L3 vertebral corpus lesion with epidural extension. The diagnosis was unclear, so the patient underwent surgery. The pathologic diagnosis was capillary haemangioma, so angiography-guided embolization was performed postoperatively. Vertebral haemangioma must be considered when there is evidence of a vertebral corpus lesion with epidural extension on magnetic resonance imaging.
In this paper, we report a case of vertebral hemangioma during pregnancy in a 21-year-old woman presenting with paraparesis of rapid onset. An emergency MRI scan of the dorsal spine showed a lesion of the ninth thoracic vertebra with extradural extension and marked spinal cord compression. A cesarean section was done, and this was followed by emergent laminectomy. Her symptoms and neurologic deficits quickly improved. The etiopathogenesis, clinical, radiological features, and treatment modalities are discussed in the light of the literature.
OBJECTIVE AND IMPORTANCE
Pregnancy-related vertebral hemangioma compressive myelopathy is a rare occurrence that tends to arise in the upper thoracic and lower cervical spine, peaks during the third trimester, and remits after parturition. Whether corticosteroid receptors play a role in the pathogenesis of these lesions is unknown. Most of these lesions have been managed with posterior decompression.
CLINICAL PRESENTATION
A 29-year-old woman presented with acute-onset lower-extremity weakness and sensory loss immediately after parturition.
INTERVENTION
We used a retropleural approach for anterior decompression and fusion, followed by radiation therapy. Immunohistochemical analysis of estrogen and progesterone receptor expression was performed.
CONCLUSION
We report an unusual case of lower thoracic postpartum vertebral hemangioma compressive myelopathy caused by a parturition-related compression fracture. Results of tests for corticosteroid receptors were negative, which implicated a hemodynamic rather than hormonal cause for disease progression.
Pregnancy is a recognized risk factor for quiescent vertebral hemangiomas becoming symptomatic; this usually occurs during the 3rd month of gestation. The natural history of these lesions is poorly understood, and treatment practices must consider the overall safety of the mother and fetus. The authors report a case of cervical vertebral hemangioma presenting during the 24th week of pregnancy and review the current literature.
A 26-year-old woman in her 24th week of pregnancy presented with upper-back pain and progressive spastic paresis in the legs. Neuroimaging studies revealed a diffuse C-7 vertebral body lesion with extradural extension and compression of the spinal cord consistent with a vertebral hemangioma. Successful decompression was accomplished, and the fetus experienced no adverse effects from the surgery.
In a review of the literature, 23 cases of pregnancy-related vertebral hemangioma dating back to 1927 were identified. Prepartum surgical decompression was performed in eight patients, postpartum surgery was performed in 12, and surgery was not performed in four. Overall, patients experienced excellent neurological recovery, regardless of the severity and duration of spastic paresis.
Observation should be considered for symptomatic patients at greater than 32 weeks gestation. Surgery should be considered for patients with severe neurological deficits at less than 32 weeks of gestation.
Percutaneous vertebroplasty with acrylic cement (usually polymethylmethacrylate) consists of injecting cement into vertebral bodies weakened by osseous lesions. The objective of this procedure is to obtain an analgesic effect by mechanical stabilization in destructive lesions of the spine. The three major indications are aggressive vertebral hemangiomas, severe or refractory pain related to osteoporotic vertebral fractures, and malignant vertebral tumors. Complications are infrequent, but occur essentially in patients with vertebral malignant tumors. We present our experience with 148 patients that underwent 192 percutaneous PMMA vertebroplasties for the treatment of painful osteoporotic compression fractures (76 patients, 105 vertebral levels), hemangiomas (31 patients, 43 vertebral levels) and neoplasms (31 patients, 43 vertebral levels). In a vast majority of appropriately selected cases and especially in osteoporotic cases, vertebroplasty constitutes a relatively simple procedure with a very high rate of success.
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.
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.
We have described a case in which a vertebral hemangioma caused spinal cord compression in a 14-year-old girl. The diagnosis was originally missed for several reasons, one of which was the failure to obtain a plain film of the spine before ordering both CT and MR studies. This case illustrates the importance of basic diagnostic procedures.
An 11-year-old boy with pain in the right sacroiliac region was treated conservatively for six months. During this time, decreased pinprick sensation in the right thigh, shortening of the right leg, and scoliosis developed. Multiple plain films of the spine had shown no abnormality. A bone scan revealed an abnormality in the lumbar spine, and CT showed a destructive lesion. An osteoblastoma was completely resected and the child has remained well for four years.
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.
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.
Three new cases of spinal cord compression due to vertebral hemangioma are reported. The clinical presentation, with spinal pain, radicular radiation, and paraparesis, is similar to that of primary lymphoma, metastatic tumor, and disc disease. If the characteristic plain film changes of vertical trabeculations and striations are present, the preoperative diagnosis is facilitated, but in the majority of cases these are not seen. In some instances, vertebral body or pedicle erosion is present. A myelographic epidural block will be seen on further study. Spinal arteriography can prove helpful. Surgical decompression results in marked neurological improvement if intervention takes place before the onset of complete paralysis. The authors recommend that the diagnosis of vertebral hemangioma be considered in the differential diagnosis of epidural spinal cord compression whenever considered in the differential diagnosis of epidural spinal cord compression whenever a primary malignant neoplasm cannot be identified.
We describe the technique of percutaneous vertebroplasty using methyl methacrylate. We injected under the guidance of CT and fluoroscopy a group of 10 patients with back pain caused by a variety of vertebral lesions including severe osteoporosis (n = 4), hemangiomas (n = 5) and metastasis (n = 1). Over varying periods of follow-up (ranging from 4 to 17 months) none of the injected vertebral bodies demonstrated compression. All patients had relief of back pain; none had complications related to the technique. We emphasize that the efficacy of this technique in preventing vertebral collapse could not be evaluated in this small sample; a well-controlled study would be required to determine the proper indications and efficacy of this treatment.
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.
A spinal tumor complicating pregnancy is a rare condition. A 25-year-old woman who became paraplegic during the 35th week of her second pregnancy presented during the postpartum period. She underwent two surgical interventions, and the cord compression caused by a T5 vertebral body hemangioma with laminar involvement and extradural extension was relieved. The occurrence of vertebral hemangiomas during pregnancy is discussed; the radiological features with special reference to magnetic resonance imaging are outlined; and cases from the literature are reviewed.
To investigate the usefulness of preoperative percutaneous injections in vertebral hemangiomas.
Four patients presented with complicated vertebral hemangioma (spinal cord compression in three cases, intermittent spinal claudiction in one case). A three-part treatment was performed: initially, arterial embolization in three cases; 1 day later, percutaneous injections of methyl methacrylate into the vertebral body to strengthen it and of N-butyl cyanoacrylate into the posterior arch to optimize hemostasis during surgery; finally, the day after percutaneous injections, decompressive laminectomy and epidural hemangioma excision (when present).
Laminectomy was performed with minimal blood loss. The epidural component present in three cases was excised without any difficulty. The follow-up (average, 20 months) showed no evidence of vertebral collapse.
Percutaneous injections of methyl methacrylate and N-butyl cyanoacrylate might be useful before surgery for vertebral hemangiomas.
We report on cervical and two thoracic vertebral haemangiomas with neurological disturbance successfully treated by percutaneous vertebroplasty followed by decompression surgery. Vertebroplasty consolidates the vertebral body and reduces the risk of haemorrhage. Subsequent surgery may be limited to decompressive laminectomy and resection of the epidural extension of the haemangioma. embolisation was also carried out in one case. Complete neuroimaging workup, including CT, myelo-CT and MRI, is necessary prior to treatment.
Percutaneous vertebroplasty with acrylic cement consists of injecting polymethylmethacrylate into vertebral bodies destabilized by osseous lesions. The aim is to obtain an analgesic effect by reinforcing lesions of the spine. The major indications are vertebral angiomas, osteoporotic vertebral crush syndromes, and malignant spinal tumors. The clinically significant complications occur predominantly in patients with spinal metastatics, but in the great majority of cases they resolve with medical treatment.
Vertebral hemangiomas are characterized by diverse clinical histories, radiological features, and results of surgical treatment. It still remains unclear how these differences in clinical behavior relate to pathological type.
A retrospective diagnostic, surgical, and histopathological study of 86 consecutive patients with various pathological types of vertebral hemangioma was performed to establish clinicopathological correlates.
The study confirmed that differences exist in clinical course, appearance on imaging, and outcomes in pathological types of hemangiomas. Based on these findings the authors attempted to identify signs characterizing each group.
Differences in clinical history and radiological features exist among pathological types of vertebral hemangiomas. These differences cannot precisely predict the type pathology before histologic examination, but do help us to understand the natural history of such lesions more fully.
Many therapeutic techniques have been used for the treatment of symptomatic vertebral hemangiomas (SVH), and each has its own limitations. Our objective was to evaluate the therapeutic efficacy of alcohol ablation for treating these lesions.
Fourteen patients with SVH were treated by injection of absolute alcohol into the lesion via the percutaneous transpedicular route under CT guidance. Symptoms before treatment included neurologic deficit in 13 patients and debilitating pain in one. All patients underwent preprocedural MR imaging. All patients had clinical and MR imaging follow-up (14 patients at 48-96 hours and 2 months; six at 9-15 months). Results were divided into excellent (resumption of work, alleviation of pain), good (significant improvement), and failure of treatment categories on the basis of subjective assessment of clinical improvement. Clinical improvement/deterioration was correlated with MR-revealed changes.
All patients showed transient deterioration of neurologic status after alcohol ablation. Subsequently, excellent results were seen in five patients and eight were in the good category. One patient in whom treatment failed also developed a complication (paravertebral abscess). Four of the eight patients with good results had preprocedural cord changes. Total follow-up ranged from 5 to 31 months, with 11 patients showing stable improvement. One patient developed recurrent hemangioma within a month. Another patient became symptomatic after initial good response, secondary to the collapse of the involved vertebral body. Good correlation was found between clinical improvement and reduction of epidural soft-tissue masses on MR images. Cord signal alteration seen on MR images in four treated patients, however, did not show any change after treatment.
Alcohol ablation is an effective management option for symptomatic vertebral hemangiomas. Although encouraging results were seen in almost 86% of our patients, a longer follow-up period still is needed to assess the stability of improvement. Potential complications include vertebral collapse and infection.
This report describes Brown-Sequard syndrome after intralesional injection of absolute alcohol into vertebral hemangioma.
To discuss whether the described technique is safe in the management of vertebral hemangiomas.
The management of vertebral hemangiomas remains controversial. There have been reports of successful management using intralesional absolute alcohol.
The clinical and radiologic features of the reported complication are detailed.
Intralesional injection of absolute alcohol caused Brown-Sequard syndrome.
This case shows that intralesional alcohol injection cannot be considered a safe technique for management of vertebral hemangiomas with spinal cord compression.
Case report.
To illustrate a rare cause of thoracic spinal cord compression, its diagnosis, and its management.
Asymptomatic vertebral hemangiomas are common, but extraosseous extension causing spinal cord compression with neurologic symptoms is rare, and few cases appear in the English-language literature.
A previously asymptomatic 63-year-old man sought medical attention for acute back pain and thoracic myelopathy of 6 week's duration. Magnetic resonance imaging confirmed the presence of a mass in the T10 vertebral body with paravertebral and intracanalicular extension contributing to cord compression. Decompression and reconstructive surgery were performed and radiotherapy administered after surgery. Preoperative angiography was not performed because of the patient's rapidly progressive neurologic deterioration and the consideration that the differential diagnosis of vertebral hemangioma was less likely.
The diagnosis of benign capillary hemangioma was made histologically. Neurologic recovery was complete except for minor residual sensory changes in the legs. At follow-up 10 months after surgery the patient had returned to his usual active life and motor mower repairing business.
Extraosseous extension of vertebral hemangiomas is a rare cause of thoracic spinal cord compression. As such, the available data are derived from reports based on series involving only a small number of cases, rather than on results of randomized controlled trials. Those causing progressive neurologic symptoms should be surgically decompressed, with the specific procedure determined by the extent and site of the lesion. Preoperative angiography is recommended, but embolization is not always necessary or even possible. Postoperative radiotherapy is recommended when tumor removal is subtotal.
Pregnancy-related vertebral hemangioma compressive myelopathy is a rare occurrence that tends to arise in the upper thoracic and lower cervical spine, peaks during the third trimester, and remits after parturition. Whether corticosteroid receptors play a role in the pathogenesis of these lesions is unknown. Most of these lesions have been managed with posterior decompression.
A 29-year-old woman presented with acute-onset lower-extremity weakness and sensory loss immediately after parturition.
We used a retropleural approach for anterior decompression and fusion, followed by radiation therapy. Immunohistochemical analysis of estrogen and progesterone receptor expression was performed.
We report an unusual case of lower thoracic postpartum vertebral hemangioma compressive myelopathy caused by a parturition-related compression fracture. Results of tests for corticosteroid receptors were negative, which implicated a hemodynamic rather than hormonal cause for disease progression.
We report a rare case of thoracic vertebral hemangioma which developed into angiosarcoma during the course of repetitive operations and irradiation. A 44 year old female was operated on for hemangioma of the first thoracic vertebra. The diagnosis of hemangioma was confirmed histopathologically with the specimen from the first operation. The tumor developed multiple lesions later in the clinical course after the first operation, these lesions were removed in four consecutive operations and each histological diagnosis was that of hemangioma. Throughout the period of these operations, the patient was treated with steroid, and with radiotherapy simultaneously. The patient underwent the fifth operation for the recurrence of the tumor on 26 March 1990, and the histopathological diagnosis was not hemangioma but hemangiosarcoma which was considered a malignant transformation. The tumor cells immunohistochemically revealed positive staining with UEA-I, Factor-VIII, as the tumor immunohistochemically showed a vascular endothelioid nature.
Thirteen consecutive cases with symptomatic vertebral hemangiomas, managed during a five year period from January 1995 at the Christian Medical College and Hospital, Vellore, were analysed. Twelve patients had lesions in the thoracic and 1 in the sacral region. Eight patients had multiple level involvement. Seven patients had laminectomy and soft tissue component excision, of which one had intraoperative injection of absolute alcohol and one had postoperative radiotherapy. One patient had vertebrectomy and stabilization with preoperative embolization. One patient underwent only endovascular embolization. However, the focus of this communication is on 4 patients who underwent a CT guided percutaneous transpedicular injection of absolute alcohol into the affected vertebral body. In the surgical group, 6 patients had cavernous type and 2 patients had mixed type of hemangiomas. Ten patients improved on the Ranawat grade by the time of discharge. On the MRC grade, 11 patients had improved, one was grade 5 pre and postoperative, while one did not improve. Several options are available for the management of symptomatic vertebral hemangiomas and multiple modalities may have to be used for a single patient. CT guided percutaneous transpedicular injection of absolute alcohol shows promising results. However, long term follow up is mandatory.
Percutaneous vertebroplasty is an emerging interventional technique in which surgical polymethylmethacrylate is injected via a large bore needle into a vertebral body under imaging guidance. This technique provides increased strength and pain relief in vertebrae weakened by a variety of bone diseases. The current indication for vertebroplasty is intractable non-radicular pain caused by compression fractures due to osteoporosis, myeloma, metastases and aggressive vertebral haemangioma. Contraindications include bleeding disorder, unstable fracture and lack of definable vertebral collapse. Our technique of percutaneous vertebroplasty is illustrated in this pictorial review.
Vertebral hemangiomas are relatively common, but those causing spinal cord compression are rare. A man in his early sixties with back pain that had not resolved with conservative treatment was seen in an outpatient physiatrist office. Subsequent workup with computed tomography scan showed a large hemangioma in the T5 vertebra extending to the posterior elements where his pain was located. Three weeks later, the patient had progressive weakness and numbness in his lower extremity. He subsequently underwent a T3-5 laminectomy, with a subtotal resection of the mass. He reported improvement in lower-extremity strength and sensation and completed a course of inpatient rehabilitation. Recognizing when to expect neurologic symptoms and the proper time to intervene can be very critical. From this case study and other similar instances, one can conclude that vertebral hemangiomas are not always benign and are capable of causing cord compression. Proper diagnosis and treatment may prevent the development of neurologic symptoms.
To present a case of symptomatic, expansile L1 vertebral hemangioma.
A 46-year-old man presented with progressive neurologic changes and insidious onset of low back pain.
After a trial of 3 visits of conservative chiropractic care, no improvement was noted. Magnetic resonance imaging was obtained, revealing an expansile hemangioma with extra-osseous component compromising the conus medullaris at the level of the L1 lumbar vertebra. Neurosurgical intervention resulted in clinical improvement.
Primary care physicians treating patients with low back pain should be aware of neurologic red flags requiring prompt attention. Magnetic resonance imaging is the imaging modality of choice when evaluating a neurologic abnormality presumably related to a space-occupying lesion. Although a disk herniation is the most common cause of these symptoms, clues in the history and examination must prompt physicians to expand their differential diagnosis to include a variety of other extradural masses.
Pregnancy is a recognized risk factor for quiescent vertebral hemangiomas becoming symptomatic; this usually occurs during the 3rd month of gestation. The natural history of these lesions is poorly understood, and treatment practices must consider the overall safety of the mother and fetus. The authors report a case of cervical vertebral hemangioma presenting during the 24th week of pregnancy and review the current literature. A 26-year-old woman in her 24th week of pregnancy presented with upper-back pain and progressive spastic paresis in the legs. Neuroimaging studies revealed a diffuse C-7 vertebral body lesion with extradural extension and compression of the spinal cord consistent with a vertebral hemangioma. Successful decompression was accomplished, and the fetus experienced no adverse effects from the surgery. In a review of the literature, 23 cases of pregnancy-related vertebral hemangioma dating back to 1927 were identified. Prepartum surgical decompression was performed in eight patients, postpartum surgery was performed in 12, and surgery was not performed in four. Overall, patients experienced excellent neurological recovery, regardless of the severity and duration of spastic paresis. Observation should be considered for symptomatic patients at greater than 32 weeks gestation. Surgery should be considered for patients with severe neurological deficits at less than 32 weeks of gestation.
Case report.
To report a case of lumbar hemangioma causing neurogenic claudication and early cauda equina, managed with hemostatic vertebroplasty and posterior decompression.
This is the first report to our knowledge of a lumbar hemangioma causing neurogenic claudication and early cauda equina syndrome. Most hemangiomas causing neurologic symptoms occur in thoracic spine and cause spinal cord compression. Vertebroplasty as a method of hemostasis and for providing mechanical stability in this situation has not been discussed previously in the literature.
L4 hemangioma was diagnosed in a 64-year-old woman with severe neurogenic claudication and early cauda equina syndrome. Preoperative angiograms showed no embolizable vessels. Posterior decompression was performed followed by bilateral transpedicular vertebroplasty. The patient received postoperative radiation to prevent recurrence.
Complete relief of neurogenic claudication and cauda equina with less than 100 mL of blood loss.
A lumbar hemangioma of the vertebral body, although rare, can cause neurogenic claudication and cauda equina syndrome. Intraoperative vertebroplasty can be an effective method of hemostasis and provide stability of the vertebra following posterior decompression.
Hemangioma is one of the most common benign tumors of the spine, and it remains silent in the vast majority of the subjects afflicted. Pregnancy is a known risk factor for symptomatic conversion of the previously dormant vertebral hemangiomas. However, the occurrence is rare with only 24 cases reported in the literature. The authors present a case of vertebral hemangioma symptomatic during the third trimester of pregnancy. The patient, a 20-year-old woman in her 33rd week of pregnancy, initially presented with acute back and bilateral leg pain, and developed the cauda equina syndrome within a week of its onset. Imaging studies revealed an L2 vertebral hemangioma, and the thecal sac was severely compressed by the epidural portion of the tumor. Emergency decompression and reconstruction surgery was undertaken 3 days after an uneventful cesarean section. The combined surgical management, consisting of laminectomy, intraoperative vertebroplasty, and segmental fixation, afforded adequate decompression, instant mechanical stability of the spine, and prompt pain elimination. The long-term efficacy of this combined treatment is unclear and needs to be followed cautiously.
Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results
- H Deramond
- C Depriester
- P Galibert
- Le Gars
Deramond H, Depriester C, Galibert P, Le Gars D: Percutaneous
vertebroplasty with polymethylmethacrylate. Technique, indications, and results. Radiol Clin North Am 36:533-546, 1998
Radiotherapy in the treatment of vertebral hemangiomas
- S L Faria
- W R Schlupp
- H Chiminazzo
Faria SL, Schlupp WR, Chiminazzo H Jr: Radiotherapy in the
treatment of vertebral hemangiomas. Int J Radiat Oncol Biol
Phys 11:387-390, 1985
Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy
- A Gangi
- B A Kastler
- J L Dietemann
Gangi A, Kastler BA, Dietemann JL: Percutaneous vertebroplasty
guided by a combination of CT and fluoroscopy. AJNR Am J
Neuroradiol 15:83-86, 1994
- M Healy
- D A Herz
- L Pearl
Healy M, Herz DA, Pearl L: Spinal hemangiomas. Neurosurgery
13:689-691, 1983
Percutaneous vertebroplasty: indications, contraindications, and technique
- Peh
Peh WC, Gilula LA: Percutaneous vertebroplasty: indications,
contraindications, and technique. Br J Radiol 76:69-75, 2003
Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results
- Deramond
Radiotherapy in the treatment of vertebral hemangiomas
- Faria
Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy
- Gangi