Vertebral hemangiomas: their demographical characteristics, location along the spine and position within the vertebral body

Vertebral Hemangiomas: Prevalence, new classification and natural history. magnetic resonance imaging-based retrospective longitudinal study

BACKGROUND AND PURPOSE

To determine the prevalence of vertebral hemangiomas (VHs), establish a new classification of VHs based on their MRI-signal pattern, and study their natural history.

METHODS

MRI of 1000 consecutive patients who underwent at least two MRI with an interval of at least 3 years. Growth rate and change of MRI-signal pattern during the follow-up period were the parameters included in studying the natural history of VHs.

RESULTS

The prevalence of VHs was 41%. VHs were classified as type I-IV with fat-rich VHs (type I), constituted 79% of all VHs. VHs were more common among females 43% versus males 39%, p = .22. The most affected vertebra was L1. Occurrence rates for cervical (1%), thoracic (7%), and lumbar spine (10%) differed significantly (p < .001). The prevalence of VHs increased with age regardless of gender or spinal part involved (p < .001). Only 26% of VHs changed their size and 4% changed their signal during the average follow-up of 7 years. All VHs were slowly growing lesions (average expected growth of <3 mm/10 years). No significant difference between growth rate of VHs type I (0.25 mm/year) and other types of VHs. None of the VHs that were initially reported as "metastases cannot be rule out" showed alarming change in signal or size.

CONCLUSIONS

VH can be classified into four types based on their MRI-signal pattern. Regardless of their type, VHs are slowly growing lesions. The presence of typical morphological pattern should enable radiologists to confidently differentiate them from vertebral metastases.

Primary Benign Tumors of the Spinal Canal

Benign tumors that grow in the spinal canal are heterogeneous neoplasms with low incidence; from these, meningiomas and nerve sheath tumors (neurofibromas and schwannomas) account for 60%-70% of all primary spinal tumors. Benign spinal canal tumors provoke nonspecific clinical manifestations, mostly related to the affected level of the spinal cord. These tumors present a challenge for the patient and healthcare professionals, for they are often difficult to diagnose and the high frequency of posttreatment complications. In this review, we describe the epidemiology, risk factors, clinical features, diagnosis, histopathology, molecular biology, and treatment of extramedullary benign meningiomas, osteoid osteomas, osteoblastomas, aneurysmal bone cysts, osteochondromas, neurofibromas, giant cell tumors of the bone, eosinophilic granulomas, hemangiomas, lipomas, and schwannomas located in the spine, as well as possible future targets that could lead to an improvement in their management.

Clinical evaluation of preoperative embolization, vertebroplasty, and decompression in the treatment of aggressive vertebral hemangiomas

OBJECTIVE

To evaluate the efficacy and safety of preoperative embolization and vertebroplasty in the treatment of aggressive hemangioma.

METHODS

A retrospective clinical review of patients diagnosed with aggressive vertebral hemangiomas was conducted. All the patients were assigned to three groups according to the treatment strategies: patients in Group A underwent embolization and decompression with internal fixation, patients in Group B underwent vertebroplasty and decompression with internal fixation, patients in Group C received all three treatments. Clinical indexes were compared within three groups.

RESULTS

There were 16 patients received embolization and decompression (Group A), 19 patients underwent decompression with vertebroplasty (Group B) and 16 patients in Group C. The operative duration of patients in group A (198.33 ± 38.43 min) were less than another two groups (p = 0.001). The intraoperative blood loss of patients in group C was 713.33 ± 165.13 mL, which was significantly less than group A and group B (p = 0.045). Patients in group C exhibited the lowest volume of drainage on POD 1 (178.33 ± 66.76 mL), which showed significant difference compared with group A (368.33 ± 191.15 mL, p = 0.01). There was no significant difference of preoperative and postoperative VAS and JOA score among three groups, as well as drainage on POD 2, total volume and hospital duration.

CONCLUSION

Both embolization and vertebroplasty are efficient and safe measures to reduce blood loss in the surgical treatment of aggressive vertebral hemangiomas, combination of all three methods is also competent.

Accuracy of diffusion-weighted imaging in discriminating atypical vertebral haemangiomas from malignant masses in patients with vertebral lesions: a cross-sectional study

Purpose

Vertebral haemangiomas are incidental findings in imaging modalities. Atypical haemangiomas are haeman-giomas rich in vascular tissue, and they are found to be hypointense in T1 sequences and hyperintense in T2 sequences, mimicking the findings of metastatic lesions. In the present study we aim to evaluate the ability of diffusion- weighted imaging to differentiate these two groups of vertebral lesions.

Material and methods

In the present cross-sectional study, a total of 23 lesions were included, including 10 haemangiomas and 13 malignant lesions. Diffusion-weighted imaging was used to compare atypical haemangiomas and metastatic lesions. The apparent diffusion co-efficient was determined for each lesion, and then the mean of each group was calculated. The means were then compared. Receiver operating characteristic analysis was used to determine a cut-off ADC value to differentiate these lesions.

Results

The difference between the mean age of the two groups was not significant. The mean ADC value for atypical haemangiomas was 1884 ± 74 × 10^-6 mm²/s and 1008 ± 81 × 10^-6 mm²/s for the malignant lesions. The difference between the two groups was statistically significant (p < 10^-3). ROC curve analysis determined an ADC value of 958 × 10^-6 mm²/s to be able to differentiate between atypical haemangiomas and malignant lesions.

Conclusions

Diffusion-weighted MRI could be used to differentiate between atypical haemangiomas and malignant metastatic lesions.

Natural History, Clinical, and Surgical Management of Cavernous Malformations

We describe Natural history, clinical and surgical management of cavernous malformation of the brain and spinal cord. Decision-making for treatment of cavernous malformations cannot ignore their natural history and risk of bleeding, which is different depending on the location. Surgical morbidity also depends on the position of the lesion. We performed a review of hemorrhage risk and clinical assessment of superficial and deep supratentorial, brainstem and intramedullary cavernous malformations.

Palaeopathological analysis of a Chilean gomphothere (Proboscidea: Gomphotheriidae)

OBJECTIVE

Re-evaluate the pathological lesions found on a gomphothere recovered from Quebrada Quereo (Late Pleistocene), Coquimbo region, Chile (31º55'41" S, 71º34'43" W, 20 masl).

MATERIALS

227 axial and appendicular specimens from a young adult male individual (SGO.PV.267).

METHODS

Macroscopic and radiographic analysis.

RESULTS

Pathological conditions identified included asymmetries of a cervical vertebra and of thoracic vertebra 16, degenerative joint disease in thoracic and lumbar vertebrae, possible evidence of neoplastic lesions within the bodies of three thoracic vertebrae (possibly hemangiomas), and fusion at thoracic vertebrae 15 and 16, suggesting the presence of spondyloarthropathy.

CONCLUSIONS

The original diagnosis of traumatic lesions on this specimen is unsupported. The re-evaluation identified the presence of developmental defects, degenerative joint disease, possible neoplastic lesions, and spondyloartropathy.

SIGNIFICANCE

The present analysis adds data to the sparse paleopathological record of South American gomphotheres.

LIMITATIONS

Taphonomic alteration of some skeletal elements, as well as the presence of an incomplete individual, limits the ability to determine the etiology of some of the lesions identified.

SUGGESTIONS FOR FURTHER RESEARCH

Researchers are encouraged to re-examine specimens curated in museums in order to identify pathological conditions that might have been overlooked or might benefit from re-evaluation.

Atypical Radiographic Features of Aggressive Vertebral Hemangiomas

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.

Integrated treatment of a lumbar vertebral hemangioma with spinal stenosis and radiculopathy: A case report and a review of the literature

We describe a comprehensive, multidisciplinary treatment approach for lumbar vertebral hemangiomas (VHs) with spinal stenosis and radiculopathy. A 59-year-old female presented with 1 year of pain predominantly in the lower back, with pain in the left buttock and proximal left anterior thigh as well and magnetic resonance imaging of the lumbar spine demonstrated lumbar scoliosis and an L3 vertebral lesion suspicious for hemangioma. A computed tomography guided biopsy was done, which supported the diagnosis. Definitive treatment entailed preoperative angiography and embolization, followed by L3 laminectomy, right L3 pedicle resection, partial L3 corpectomy, L3 vertebral cement augmentation, and L1 to L5 instrumented fusion. By 1-year postoperatively, the patient reported no radicular pain and only mild groin pain attributed to left hip degenerative joint disease. Radiographs 1-year postoperatively confirmed the stability of the instrumented posterior fusion and a magnetic resonance imaging with and without contrast confirmed no VH recurrence. A comprehensive and multidisciplinary approach for the treatment of VHs with neurological symptoms or signs is presented. This approach is recommended to maximize lesion removal, ensure biomechanical stability, and minimize recurrence.

Progression of aggressive vertebral hemangiomas during pregnancy: Three case reports and literature review

RATIONALE

Vertebral hemangiomas (VHs), one of the most common benign tumors of the spine, can be aggressive, which is a rare condition and causes neurological deficits. Pregnancy is related to the worsening of aggressive VHs. The diagnosis and treatment of aggressive VHs remain challenging, especially for pregnant cases.

PATIENT CONCERNS

We report 3 cases of aggressive VH in women who developed progressive neurological deficits during pregnancy among 95 patients treated for aggressive VH in our hospital in the past 15 years.

DIAGNOSES AND INTERVENTIONS

All 3 patients experienced progressive deterioration of neurological function and pain at 13, 28, and 41 weeks' gestation. On radiological examination, VHs were the suspected radiological diagnoses in 2 patients; 1 patient was preoperatively misdiagnosed with a spinal metastatic tumor. All 3 patients underwent decompression surgery with intraoperative vertebroplasty and/or postoperative radiotherapy. The pathological diagnosis after surgery was all hemangiomas.

OUTCOMES

In all 3 patients, there were no tumor recurrences, and neurological functions remained normal at the last follow-up of 75, 38, and 15 months after the treatment, respectively.

LESSONS

Pregnancy might lead to the onset of aggressive VHs. The diagnosis and treatment of VHs during pregnancy remain controversial due to concern for both maternal and fetal safety. Timely surgery could preserve neurological function. Decompression surgery by laminectomy followed by adjuvant therapies require less skill and have a shorter surgery time, and can be considered more appropriate for aggressive VHs with pregnancy.

The Role of Radiotherapy and Surgery in the Management of Aggressive Vertebral Hemangioma: A Retrospective Study of 20 Patients

Background

Vertebral hemangioma is usually a benign and asymptomatic tumor of blood vessels, but can be aggressive (symptomatic) with expansion, pain, and spinal cord compression. The aim of this study was to review the effects of radiotherapy, surgery, and other treatment approaches in patients with aggressive vertebral hemangioma.

Material/Methods

Retrospective clinical review included 20 patients who underwent radiotherapy as their first-line treatment for aggressive vertebral hemangioma with mild or slowly developing neurological deficit. External radiation was divided into 20–25 fractions with a total dose of 40–50 Gy. Minimum clinical follow-up after treatment was 20 months.

Results

The 20 patients included eight men and 12 women (mean age, 46.6 years), with aggressive vertebral hemangioma located in the cervical, thoracic, and lumbar vertebrae in four, 14, and two patients, respectively. Following radiotherapy treatment, 65.0% of patients (13/20) were symptom-free, without recurrence or malignant transformation at the time of last clinical follow-up (average, 75.2 months). Due to minor post-radiation vertebral re-ossification, two of the 13 patients who were initially symptom-free after radiotherapy requested percutaneous vertebroplasty. A further seven patients required surgery after radiotherapy, due to increasing neurological deficit in three patients, and persistent neurological deficit in four patients. At the last follow-up (average, 63.6 months), six patients were symptom-free, and one patient still had slight residual symptoms.

Conclusions

Radiotherapy was a safe and effective treatment choice for aggressive vertebral hemangioma, but in case with severe spinal cord compression and neurological deficit, surgical intervention was required.

Intraoperative vertebroplasty during surgical decompression and instrumentation for aggressive vertebral hemangiomas: a retrospective study of 39 patients and review of the literature

BACKGROUND CONTEXT

Aggressive (Enneking stage 3, S3) vertebral hemangiomas (VHs) are rare, which might require surgery. However, the choice of surgery for S3 VHs remains controversial because of the rarity of these lesions.

PURPOSE

We reported our experience of treating S3 VHs, and evaluated the effectiveness and safety of intraoperative vertebroplasty during decompression surgery for S3 VHs.

STUDY DESIGN

This is a retrospective study.

PATIENT SAMPLE

Thirty-nine patients with a definitive pathologic diagnosis of aggressive VHs who underwent primary decompression surgery in our department were included in this study.

OUTCOME MEASURES

Basic data such as surgical procedure, surgical duration, estimated blood loss during surgery, and pathology were collected. The modified Frankel grade was used to evaluate neurologic function. Enneking staging was based on radiological findings.

METHODS

We retrospectively examined aggressive VHs with neurologic deficits. Surgery was indicated if the neurologic deficit was severe or developed quickly or if radiotherapy was ineffective. Decompression surgery was performed. Intraoperative vertebroplasty during posterior decompression has been used since 2009. If contrast-enhanced computed tomography (CT) revealed a residual lesion, we recommended adjuvant radiotherapy with 40-50 Gy to prevent recurrence. Patients' basic and surgical information was collected. The minimum follow-up duration was 18 months. This study was partially funded by Peking University Third Hospital, Grant no. Y71508-01.

RESULTS

Average age of the 39 patients with S3 VHs who underwent primary decompression surgery was 46.2 (range, 10-69) years. All patients had neurologic deficits caused by aggressive VHs. Aggressive VH lesions were located in the cervical, thoracic, and lumbar spine in 2, 32, and 5 patients, respectively. The decompression-alone group had 17 patients, and the decompression plus intraoperative vertebroplasty group had 22. There were no statistically significant intergroup differences in preoperative information (p>.05). The average estimated blood losses were 1,764.7 mL (range, 500-4,000 mL) and 1,068.2 mL (range, 300-3,000 mL) in the decompression-alone group and decompression plus vertebroplasty group, respectively (p=.017). One patient who underwent primary decompression alone without adjuvant radiotherapy experienced recurrence after the first decompression. The average follow-up was 50.2 (range, 18-134) months, and no cases of recurrence were observed at the last follow-up.

CONCLUSIONS

Our results suggest that posterior decompression effectively provides symptom relief in patients with aggressive (S3) VHs with severe spinal cord compression. Intraoperative vertebroplasty is a safe and effective method for minimizing blood loss during surgery, whereas adjuvant radiotherapy or vertebroplasty helps in minimizing recurrence after decompression.

Apparent diffusion coefficient of vertebral haemangiomas allows differentiation from malignant focal deposits in whole-body diffusion-weighted MRI

OBJECTIVES

The aim of this study was to identify apparent diffusion coefficient (ADC) values for typical haemangiomas in the spine and to compare them with active malignant focal deposits.

METHODS

This was a retrospective single-institution study. Whole-body magnetic resonance imaging (MRI) scans of 106 successive patients with active multiple myeloma, metastatic prostate or breast cancer were analysed. ADC values of typical vertebral haemangiomas and malignant focal deposits were recorded.

RESULTS

The ADC of haemangiomas (72 ROIs, median ADC 1,085×10-6mm2s-1, interquartile range 927-1,295×10-6mm2s-1) was significantly higher than the ADC of malignant focal deposits (97 ROIs, median ADC 682×10-6mm2s-1, interquartile range 583-781×10-6mm2s-1) with a p-value < 10-6. Receiver operating characteristic (ROC) analysis produced an area under the curve of 0.93. An ADC threshold of 872×10-6mm2s-1 separated haemangiomas from malignant focal deposits with a sensitivity of 84.7 % and specificity of 91.8 %.

CONCLUSIONS

ADC values of classical vertebral haemangiomas are significantly higher than malignant focal deposits. The high ADC of vertebral haemangiomas allows them to be distinguished visually and quantitatively from active sites of disease, which show restricted diffusion.

KEY POINTS

• Whole-body diffusion-weighted MRI is becoming widely used in myeloma and bone metastases. • ADC values of vertebral haemangiomas are significantly higher than malignant focal deposits. • High ADCs of haemangiomas allows them to be distinguished from active disease.

Vertebral metastases from neuroendocrine tumours: How to avoid false positives on 68Ga-DOTA-TOC PET using CT pattern analysis?

OBJECTIVES

To develop criteria to improve discrimination between vertebral metastases from neuroendocrine tumours (NETs) and benign bone lesions on PET combined with CT using DOTA-D-Phe¹-Tyr³-octreotide labelled with gallium-68 (⁶⁸Ga-DOTA-TOC).

METHODS

In 535 NET patients, ⁶⁸Ga-DOTA-TOC PET/CT examinations were reviewed retrospectively for vertebral CT lesions and/or PET foci. For each vertebral PET abnormality, appearance on CT, biological volume (BV), standardized uptake value (SUV_max) and ratios to those of reference organs were determined. All vertebral abnormalities were characterized as a metastasis, a typical vertebral haemangioma (VH) or other benign lesion.

RESULTS

In 79 patients (14.8 %), we found 107 metastases, 34 VHs and 31 other benign lesions in the spine. The optimal cut-off values to differentiate metastases from benign lesions were BV ≥0.72 cm³, SUVmax ≥2, SUVmax ratio to a reference vertebra ≥2.1, to liver ≥0.28 and to spleen ≥0.14. They corresponded to lesion-based ⁶⁸Ga-DOTA-TOC PET/CT sensitivity of 87 %, 98 %, 97 %, 99 % and 94 %, and specificity of 55 %, 100 %, 90 %, 97 %, 100 %, respectively.

CONCLUSIONS

The high sensitivity of ⁶⁸Ga-DOTA-TOC-PET/CT in detecting NET vertebral metastases was confirmed; this study showed that specificity could be improved by combining CT features and quantifying ⁶⁸Ga-DOTA-TOC uptake.

KEY POINTS

• Bone metastases in neuroendocrine tumours correlate with prognosis. • Benign bone lesions may mimic metastases on ⁶⁸ Ga-DOTA-TOC PET/CT imaging. • The specific polka-dot CT pattern may be missing in some vertebral haemangiomas. • Lesion atypical for haemangiomas can be better characterized by quantifying ⁶⁸ Ga-DOTA-TOC uptake.

Imaging of Benign Tumors of the Osseous Spine

The purpose of this paper is to present an overview of the imaging features of the most prevalent benign bone tumors involving the spine. Benign tumors of the osseous spine account approximately for 1% of all primary skeletal tumors. Many lesions exhibit characteristic radiologic features. In addition to age and location of the lesion, radiographs are an essential step in the initial detection and characterization but are limited to complex anatomy and superposition. CT and MR imaging are often mandatory for further characterization, assessment of local extension and guiding biopsy.

Spinal tumors in children

Summary Introduction: Spinal tumors are rare in the pediatric population, presenting many specific peculiarities when compared to adults. We have performed a broad narrative review to describe the most common spinal tumors in children, discussing their main characteristics and management options. Method: The authors have performed an extensive review of the peer-reviewed literature addressing the aforementioned objectives. Results: Multimodality radiological studies (plain films, 3D computed tomography scan and magnetic resonance imaging) are necessary for proper evaluation and differential diagnosis of spinal tumors in children. In selected cases nuclear medicine imaging is used to improve the chances of a more accurate diagnosis. As a general rule, a fine needle biopsy is recommended after radiological evaluation to confirm the tumor's histology. Primary bone tumors can be divided into benign bone tumors, mostly represented by vertebral hemangiomas, osteoid osteomas, osteoblastomas, aneurismal bone cysts, and eosinophilic granulomas, and malign or aggressive tumors, such as Ewing's or osteogenic sarcomas. Secondary bone tumors (spinal metastases) comprise different tumor histologies, and treatment is mainly based on tumor's radiosensitivity. The characteristics and treatment options of the main spinal tumors are discussed in details. Conclusion: Spinal tumors in children are rare lesions that demand a thorough understanding of their main characteristics for their proper management. Understanding the nuances of spinal tumors in children is of paramount importance for improving outcomes and chances of cure.

Pathologic fracture of the thoracic spine in a male master ultra-marathoner due to the combination of a vertebral hemangioma and osteopenia

Vertebral hemangiomas are the most common benign vertebral neoplasms and are generally asymptomatic. In the present study, we report the case of a 52-year-old male master ultra-marathoner suffering from a pathologic fracture of the thoracic spine due to a vertebral hemangioma. A further examination in the athlete revealed an accompanying osteopenia, which was most likely due to a deficiency in both vitamin D and testosterone. The treatment of the fracture consisted of percutaneous vertebroplasty. Shortly after the operation the athlete was able to continue running. The most likely reason for the pathologic fracture of the vertebral body was the combination of the vertebral hemangioma and osteopenia. The further treatment consisted of supplementation of both vitamin D and testosterone. Athletes and physicians should be aware that male master ultra-marathoners older than 50 years might suffer from osteopenia, where a deficiency in vitamin D and testosterone could be contributing factors for osteopenia development in general.

A case report of spondylectomy with circumference reconstruction for aggressive vertebral hemangioma covering the whole cervical spine (C4) with progressive spinal disorder

PURPOSE

To describe the surgical experience of spondylectomy and spinal reconstruction for aggressive vertebral hemangioma (VH) induced at the C4 vertebra. No reports have described surgical strategy in cases covering an entire cervical vertebra presenting with progressive myelopathy.

METHODS

A 28-year-old man presented with rapidly progressing skilled motor dysfunction and gait disorder. The Japanese Orthopedic Association (JOA) score was 6. Radiography showed a honeycomb appearance for the entire circumference of the C4 vertebra. Spinal computed tomography and magnetic resonance imaging showed vertebral tumor with extraosseous extension causing spinal cord compression. Results of diagnostic imaging were strongly suggestive of VH. Transarterial embolization of the spinal body branch was performed first to decrease intraoperative bleeding, followed by cervical posterior fixation to stabilize the unstable segment and excision biopsy to obtain a definitive diagnosis. After definitive diagnosis of cavernous hemangioma, two-stage surgery (anterior and posterior) was performed to complete total spondylectomy and 360° spinal reconstruction.

RESULTS

Despite multiple operations, JOA scores were 8.5 after posterior fixation, 10.5 after anterior surgery, 11 after final surgery and 16 on postoperative day 90. The patient acquired excellent clinical results without complications and returned to society.

CONCLUSIONS

The present three-stage surgery comprising fixation, biopsy, and final spondylectomy with circumferential fusion from anterior and posterior approaches may offer a useful choice for aggressive VH covering the entire cervical spine with rapidly progressive myelopathy.