Diagnosis and treatment of vertebral hemangiomas with neurologic deficit: a report of 29 cases and literature review

Effective and Successful Control of Symptomatic Vertebral Hemangiomas With Epidural Extension Using Stereotactic Spine Radiosurgery

BACKGROUND AND OBJECTIVES

We present our experience in the management of symptomatic vertebral hemangiomas with epidural extension (SVHEE) using spine stereotactic radiosurgery (SSRS).

METHODS

An Institutional Review Board approved retrospective review of all SVHEE patients treated with SSRS at our institution (2007-2022) was performed. Baseline patient demographics, clinical presentation, lesion volume, and Bilsky grade (to directly evaluate the epidural component) were determined. Clinical and radiographic response and treatment outcomes were subsequently evaluated at first (∼6 months) and final follow-up.

RESULTS

Fourteen patients with SVHEE underwent SSRS (16-18 Gy/1-fraction); the mean follow-up was 24 months. The median lesion volume (cc) was 36.9 (range: 7.02-94.1), 31.5 (range: 6.53-69.7), and 25.15 (range: 6.01-52.5) at pre-SSRS, first, and final follow-up, respectively. Overall volume reduction was seen in the last follow-up in all 14 patients, median 29.01% (range: 6.58%-71.58%). Bilsky score was stable or improved in all patients at the last follow-up when compared with pre-SSRS score. Patients who underwent both surgical decompression and SSRS (n = 9): 8 had improved myelopathic symptoms and pain and 1 had stable radiculopathy postintervention. In the 5 patients treated with SSRS monotherapy, 2 had stable radicular pain and the other 3 improved pain and numbness. No patients experienced adverse outcomes.

CONCLUSION

To our knowledge, this represents the largest series of SVHEE patients treated with SSRS, either as monotherapy or part of a multimodal/separation surgery treatment approach. We demonstrate that SSRS represents a potentially safe and effective treatment option in these patients. However, larger prospective studies and longer follow-ups are necessary to further assess the role, durability, and toxicity of SSRS in the management of these patients.

Atypical Aggressive Hemangioma of Thoracic Vertebrae Associated With Thoracic Myelopathy-A Case Report and Review of the Literature

Aggressive thoracic hemangiomas are rare, benign tumors that extend into the spinal canal and cause neurological symptoms. Delayed diagnosis and treatment, due to a paucity of literature on optimal treatment strategies, can increase morbidity. This case report describes a 19-year-old male patient with aggressive thoracic hemangioma who presented with upper back pain and progressive weakness of the lower extremities. The patient underwent preoperative embolization and sclerotherapy, followed by decompression, posterior instrumentation, and stabilization. The final diagnosis was confirmed by biopsy, and there was a significant improvement in neurology after the surgical intervention. The diagnosis of rare lesions, such as aggressive hemangiomas, requires a high level of clinical suspicion and the assistance of imaging modalities in patients with features of compressive myelopathy. A combination of endovascular and surgical approaches can lead to optimal outcomes.

Compressive vertebral hemangiomas with neurological deficits: diagnosis, surgical strategies and long term outcome

PURPOSE

Compressive vertebral hemangiomas with neurological deficits (CVHND) form a rare, unique subset of lesions comprising of differing clinico-imaging findings, pathologic behavior and treatment, when compared to the commoner and usually incidental intra-osseus vertebral hemangiomas (VH). Though various surgical strategies and a broad array of adjuncts have evolved and changed over the years, there is paucity of comprehensive data from sizeable series of such patients treated surgically with long term follow up. The purpose of this study is to device an optimum management strategy in CVHND based on our surgical experience.

MATERIALS AND METHODS

The data from electronic medical records of 26 consecutive patients operated in our department from 2009 to 2019 were retrospectively analyzed.

RESULTS

There were 11 males and 15 females with a mean age of 34.7 years. Neurological examination revealed paraparesis or paraplegia with myelopathy in all patients with Frankel score of B, C and D in 1 (3.9%), 11 (42.3%) and 14 (53.8%) patients respectively. Sixteen patients (61%) underwent laminectomy and gross total excision of extradural soft tissue component, 7 (27%) laminectomy with posterolateral fusion, three (12%) underwent additional anterior interbody support. The mean follow up was 72.4 months and at last follow-up 24 patients (92%) were Frankel E. Symptomatic recurrence was seen in two patients operated early in the series, they underwent re-surgery, gross total excision with posterolateral fusion, remaining neurologically intact at last follow up.

CONCLUSIONS

Pre-operative embolization, surgical excision of extradural component and intra-operative vertebroplasty form the mainstay of treatment for CVHND. Instrumented posterolateral fusion with optional anterior interbody support accomplished through the same approach is required only in a minority of cases. The long-term outcome following timely and appropriate treatment is excellent. Anterior or anterolateral approaches for intervertebral support and radical procedures like total en-bloc spondylectomy (TES) are not usually required.

Vertebral hemangiomas: a review on diagnosis and management

BACKGROUND

Vertebral hemangiomas (VHs) are the most common benign tumors of the spinal column and are often encountered incidentally during routine spinal imaging.

METHODS

A retrospective review of the inpatient and outpatient hospital records at our institution was performed for the diagnosis of VHs from January 2005 to September 2023. Search filters included "vertebral hemangioma," "back pain," "weakness," "radiculopathy," and "focal neurological deficits." Radiographic evaluation of these patients included plain X-rays, CT, and MRI. Following confirmation of a diagnosis of VH, these images were used to generate the figures used in this manuscript. Moreover, an extensive literature search was conducted using PubMed for the literature review portion of the manuscript.

RESULT

VHs are benign vascular proliferations that cause remodeling of bony trabeculae in the vertebral body of the spinal column. Horizontal trabeculae deteriorate leading to thickening of vertical trabeculae which causes a striated appearance on sagittal magnetic resonance imaging (MRI) and computed tomography (CT), "Corduroy sign," and a punctuated appearance on axial imaging, "Polka dot sign." These findings are seen in "typical vertebral hemangiomas" due to a low vascular-to-fat ratio of the lesion. Contrarily, atypical vertebral hemangiomas may or may not demonstrate the "Corduroy" or "Polka-dot" signs due to lower amounts of fat and a higher vascular component. Atypical vertebral hemangiomas often mimic other neoplastic pathologies, making diagnosis challenging. Although most VHs are asymptomatic, aggressive vertebral hemangiomas can present with neurologic sequelae such as myelopathy and radiculopathy due to nerve root and/or spinal cord compression. Asymptomatic vertebral hemangiomas do not require therapy, and there are many treatment options for vertebral hemangiomas causing pain, radiculopathy, and/or myelopathy. Surgery (corpectomy, laminectomy), percutaneous techniques (vertebroplasty, sclerotherapy, embolization), and radiotherapy can be used in combination or isolation as appropriate. Specific treatment options depend on the lesion's size/location and the extent of neural element compression. There is no consensus on the optimal treatment plan for symptomatic vertebral hemangioma patients, although management algorithms have been proposed.

CONCLUSION

While typical vertebral hemangioma diagnosis is relatively straightforward, the differential diagnosis is broad for atypical and aggressive lesions. There is an ongoing debate as to the best approach for managing symptomatic cases, however, surgical resection is often considered first line treatment for patients with neurologic deficit.

Electrochemotherapy in Aggressive Hemangioma of the Spine: A Case Series and Narrative Literature Review

(1) Background: this case series and literature review aims to evaluate the efficacy and safety of electrochemotherapy in the management of aggressive spinal hemangiomas, presenting two distinct cases. (2) Methods: we present two cases of spinal aggressive hemangioma which were refractory to conventional treatments and underwent electrochemotherapy. Case 1 involves a 50-year-old female who presented with an aggressive spinal hemangioma of L1, who previously underwent various treatments including surgery, radio-chemotherapy, and arterial embolization. Case 2 describes a 16-year-old female with a T12 vertebral hemangioma, previously treated with surgery and stabilization, who faced limitations in treatment options due to her young age and the location of the hemangioma. (3) Results: in Case 1, electrochemotherapy with bleomycin was administered following the failure of previous treatments and resulted in the reduction of the lesion size and improvement in clinical symptoms. In Case 2, electrochemotherapy was chosen due to the risks associated with other treatments and was completed without any adverse events. Both cases demonstrated the potential of electrochemotherapy as a viable treatment option for spinal hemangiomas, especially in complex or recurrent cases. (4) Conclusions: electrochemotherapy with bleomycin is a promising treatment for aggressive spinal hemangiomas when conventional therapies are not feasible or have failed. Further research is needed to establish definitive protocols and long-term outcomes of electrochemotherapy in spinal hemangioma management.

Vertebral Angiomatosis in a Dog

A 3 yr old spayed female Cavalier King Charles spaniel was referred for insidious ataxia and paraparesis. A thoracolumbar lesion was suspected. Computed tomography showed focal osteolysis of the vertebral body and pedicles of T5. In addition, a hyperdense, extradural material within the vertebral canal, causing spinal cord compression on the right side, was present. The lesion was confirmed with magnetic resonance imaging. A T4-T5 hemi-dorsal laminectomy was performed to decompress the spinal cord. Histopathological examination was consistent with vertebral angiomatosis. After the surgery, the dog rapidly improved; however, 5 mo later the clinical signs relapsed. Vertebral angiomatosis is a vasoproliferative disorder, rarely reported as a cause of myelopathy in cats. This condition has not previously been reported in dogs. This case report describes the clinical features, the diagnostic findings, and the follow-up of a young dog with vertebral angiomatosis.

Surgical strategies in the management of aggressive spinal haemangiomas: Retrospective case series with literature review and a practical treatment algorithm

Purpose

We studied the clinico-radiological features and treatment outcomes of patients with aggressive spinal haemangiomas.

Methods

We undertook a retrospective review of 24 patients with aggressive spinal haemangiomas managed at our centre from 2004 to 2016. The cohort was divided into two groups. Group1 included patients managed from 2004 to 2009 while Group 2 was those treated between 2010 and 2016. Clinicoradiological features and treatment outcomes were studied.

Results

Back pain (24/24) and myelopathy (18/24) were the most common presenting complaints. Over 80% (20/24) of patients, had involvement of the thoracic spine and more than 50% (13/24) had severe spasticity, being Nurick grade 4&5 at presentation. The various treatment modalities used were laminectomy with or without instrumented posterior fusion (10/24), corpectomy with instrumented fusion (10/24) and alcohol injection alone (4/24). Patients who were treated with surgery had significant clinical improvement at follow-up in both groups. Patients who underwent alcohol injection did not have any improvement in symptoms at follow-up. There was a change in our strategy in the later part of the series from a two staged anterior and posterior approach to a single staged posterior-only approach to address vertebral body disease with preoperative angioembolization.

Conclusion

Haemangiomas are benign lesions with locally aggressive behavior in some cases. Results of conservative approaches such as alcohol injection in management of these lesions are discouraging. Aggressive surgical decompression combined with preoperative adjuncts such as angioembolization with or without stabilization reduces intra operative blood loss and results in good neurological recovery even in patients with severe myelopathy.

Aggressive Diffuse Intraosseous Hemangioma: Case Report

Vertebral hemangioma is a benign vascular tumor that is usually asymptomatic and is discovered incidentally on imaging. When symptomatic, the most frequent presentation occurs in the form of vague back pain of insidious onset and, in rare cases, may be associated with root or spinal compression, causing sensory and motor deficits. The authors report the case of a 33-year-old man, previously healthy, with a diagnosis of thoracic spine hemangioma at multiple levels, in the sternum, in the scapula and in the costal arches; all lesions were symptomatic, and surgical intervention was required; one of the lesions at the thoracic spine level evolved with spinal compression and acute neurological deficit, requiring urgent surgical intervention. Intraosseous hemangiomas represent < 1% of all bone tumors, having few reports of multifocal presentation in the axial and appendicular skeleton. In the literature review, no other case of aggressive multifocal intraosseous hemangioma with this presentation was found, including associated neurological symptoms in the same case.

Surgical Options for Aggressive Vertebral Hemangiomas：A case series, literature review and treatment recommendations

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.

Surgical management of symptomatic vertebral hemangiomas: a single institution experience and literature review

Vertebral hemangiomas (VHs), formed from a vascular proliferation in bone marrow spaces limited by bone trabeculae, are the most common benign tumors of the spine. While most VHs remain clinically quiescent and often only require surveillance, rarely they may cause symptoms. They may exhibit active behaviors, including rapid proliferation, extending beyond the vertebral body, and invading the paravertebral and/or epidural space with possible compression of the spinal cord and/or nerve roots ("aggressive" VHs). An extensive list of treatment modalities is currently available, but the role of techniques such as embolization, radiotherapy, and vertebroplasty as adjuvants to surgery has not yet been elucidated. There exists a need to succinctly summarize the treatments and associated outcomes to guide VH treatment plans. In this review article, a single institution's experience in the management of symptomatic VHs is summarized along with a review of the available literature on their clinical presentation and management options, followed by a proposal of a management algorithm.

Aggressive thoracic vertebral hemangioma: case report and literature review

INTRODUCTION

Vertebral hemangiomas are common and typically benign vascular lesions, with a prevalence of 10-12% in the general population and 2-3% in all spine tumors. A small subset of vertebral hemangiomas can be categorized as "aggressive" if they exhibit extraosseous expansion that compress the spinal cord, causing pain and various neurologic symptoms. This report details a case of aggressive thoracic hemangioma resulting in worsening pain and paraplegia to draw attention to this rare condition, including identification and treatment.

CASE PRESENTATION

In this case, we present a 39 year-old female with a history of progressively worsening pain and paraplegia caused by compression of the spinal cord from an aggressive thoracic vertebral hemangioma. Clinical presentation, imaging, and biopsies, confirmed the diagnosis. A combined surgical and endovascular treatment strategy was implemented, and the patient's symptoms improved.

DISCUSSION

Aggressive vertebral hemangioma is a rare condition that may cause symptoms that diminishes the quality of life, including pain and various neurological symptoms. Given the low number of such cases, and significant impact on lifestyle, it is beneficial to identify cases of aggressive thoracic hemangiomas to ensure timely and accurate diagnosis and help development of treatment guidelines. This case highlights the importance of identifying and diagnosing this rare but serious disease.

Aggressive vertebral hemangiomas in children

BACKGROUND

Aggressive vertebral hemangiomas are rare tumors in children, usually occurring in the thoracic spine that can cause significant neurological morbidity. They are technically difficult to treat with significant risk of blood loss during surgery.

METHODS

We describe a case of aggressive vertebral hemangioma managed in our institution. We performed a literature review of reported cases of aggressive vertebral hemangiomas in pediatric age group. We discuss the clinical presentation, diagnosis, and management of these lesions.

RESULTS

We identified 23 cases of aggressive vertebral reported in children. Neurodeficit was the most common presentation, and the most common location was the thoracic spine. Surgery was the most common modality of treatment. All the patients reported in literature had improvement in their symptoms after treatment.

CONCLUSION

Although technically challenging, aggressive vertebral hemangiomas have a good outcome after treatment. Treatment should be tailored to the individual patient. Further studies are needed to determine the optimum treatment strategy.

In Vertebral Hemangiomas with Neurological Deficit, Is a Less Extensive Approach Adequate

STUDY DESIGN

This was a retrospective study.

PURPOSE

To analyze the surgical and neurological outcomes following surgical decompression in patients with aggressive vertebral hemangioma (AVH) presenting with neurological deficit and to determine whether a less extensive approach is appropriate.

OVERVIEW OF LITERATURE

AVHs are a rare subset of benign vascular tumors frequently presenting with neurological deficit because of spinal cord compression. Though the results of surgical management have improved over time, there is a lack of consensus on the ideal management in this group of patients.

METHODS

Twenty-one patients who underwent surgery for AVH between 2009 and 2018 were analyzed. Demographic and clinical details of patients were retrieved from hospital information system. Imaging information (i.e., radiography, computed tomography, magnetic resonance imaging) of all patients was accessed and analyzed in picture archiving and communication system. Tumor staging was performed using Enneking and Weinstein-Boriani-Biagini classifications and Spinal Instability Neoplastic Score. At followup, neurological and radiological evaluations were performed.

RESULTS

Twenty-one patients (13 [61.9%] females and 8 [38.1%] males) were included with a mean age of 44.29 years (range, 14-72 years). All patients in the study had neurological deficit. Back pain was present in 80.9% of patients. Mean duration of symptoms was 4.6 months (range, 1 day to 10 months). Most common lesion location was thoracic spine (n=12), followed by thoracolumbar (D11- L2; n=7) and lumbar (n=2) regions. Ten patients had multiple level lesions. All patients underwent preoperative embolization. Nine patients underwent intralesional spondylectomy with reconstruction; another nine patients underwent stabilization, decompression, and vertebroplasty; three patients underwent decompression and stabilization. Neurology improved in all patients, and only one case of recurrence was noted in a mean follow-up of 55.78±25 months (range, 24-96 months).

CONCLUSIONS

In AVH, good clinical and neurological outcomes with low recurrence rates can be achieved using less extensive procedures, such as posterior instrumented decompression with vertebroplasty and intralesional tumor resection.

Radiotherapy for vertebral hemangioma: the single-center experience of 80 patients

PURPOSE

This study aimed to evaluate the therapeutic effect of radiotherapy and to determine possible prognostic factors in patients with painful vertebral hemangioma.

METHODS

In the last two decades, 80 patients with vertebral hemangioma who received radiotherapy in our institute were evaluated in terms of pain response, treatment-related side effects, and prognostic factors. All patients were questioned 3 months after radiotherapy for the evaluation of pain response and were divided into three groups (complete response, partial response, and no change). Moreover, the visual analog scale (VAS) was used for pain response assessment in 46 patients. Pain status was assessed to detect recurrence at each clinical examination during the follow-up period. Possible prognostic factors such as gender, size of the hemangioma, location, multilevel involvement and additional musculoskeletal disease on pain response were analyzed.

RESULTS

In this study, 45 individuals had lesions in the lumbar spine, 28 in the thoracic, and 7 in the cervical region. Furthermore, 51 patients had additional musculoskeletal conditions such as disc herniation, degenerative diseases, spondylolisthesis, and compression fracture. Radiotherapy was performed with a median daily dose of 2 Gy and a median total dose of 40 Gy. Complete pain response occurred in 58.8% of patients, 26.2% of patients had partial pain response, and 15% of patients had no pain response. The overall response rate was 85%, and 7 patients showed recurrent pain symptoms in the overall response group at routine follow-up. Additional musculoskeletal disorders were found to be the only prognostic factor associated with pain response. The median follow-up time was 60 months. Secondary malignancy was not found in any of the patients in this short follow-up time. No acute or late radiation-associated side effects greater than grade II were observed.

CONCLUSION

To our best knowledge, this study is one of the largest single-institution radiotherapy series on vertebral hemangiomas reported to date. The obtained data support the efficacy and safety of radiotherapy in the treatment of painful vertebral hemangioma. Our study showed that additional musculoskeletal disease plays an important role in pain response. Other prognostic factors and treatment of vertebral hemangioma with stereotactic radiosurgery should be investigated in future studies.

Single-center outcomes of image-guided radiotherapy in the management of vertebral hemangioma with daily kilovoltage cone-beam computerized tomography

Background

Vertebral hemangiomas are defined as benign proliferation of blood vessels. Vertebral hemangiomas are generally found incidentally by computerized tomography or magnetic resonance imaging; however, they may also cause pain and quality-of-life impairment in some circumstances with reference to their location and association with the spinal cord. In this study, we assessed the utility of image-guided radiation therapy (IGRT) in the management of patients with painful vertebral hemangioma.

Materials and Methods

Patients receiving IGRT for the management of painful vertebral hemangioma were evaluated. The total dose was 24 Gy delivered in 12 daily fractions. The verbal numeric scale (VNS) was used for the assessment of pain relief. The median follow-up duration was 13 months (range: 6-24 months).

Results

Median preradiotherapy VNS score was 8 (range: 6-10) and median postradiotherapy VNS score was 1 (range: 0-2) for the total 135 patients treated with IGRT at our department for painful vertebral hemangioma. Reduction in VNS scores after IGRT was statistically significant (P < 0.05).

Conclusion

Our single-center study revealed that IGRT resulted in substantial relief of pain from vertebral hemangioma. Randomized prospective multicenter trials are needed to shed light on the optimal management of patients suffering from pain due to vertebral hemangioma.

Role of Combined Vertebroplasty and Spinal Decompression in the Management of Aggressive Vertebral Hemangiomas

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.

Aggressive L3 vertebral hemangioma coexisting with adult thoracolumbar scoliosis: Case report

Vertebral hemangiomas are benign vascular tumors that are commonly asymptomatic. A low percentage might become aggressive; however, they are not known to be associated with scoliosis. We present a case of a third lumbar vertebral lesion coexisting with a moderate thoracolumbar scoliosis. The patient's initial presentation was back pain with bilateral lower limb radiculopathy and neurogenic claudication. Diagnosis was established using CT and MRI, which showed classical findings of an aggressive vertebral hemangioma. The patient underwent Partial hemangioma excision and scoliosis correction, with satisfactory outcome at 1 year follow up.

Imaging features and atypical signs of symptomatic vertebral haemangioma: a retrospective single-centre analysis of 118 patients

OBJECTIVES

Symptomatic vertebral haemangioma (SVH) can present with atypical imaging features. Thus, this study analysed the imaging features of SVH using CT and MRI to improve SVH awareness.

METHODS

We retrospectively analysed CT and MRI characteristics of 118 patients with clinically and pathologically confirmed SVH.

RESULTS

Overall, 118 patients were diagnosed with SVH, including 79 females and 39 males (mean age, 45.76 ± 16.36 years). The thoracic spine (n = 86) was the most common location of SVH, followed by the lumbar spine (n = 17). Involvement of multiple spinal segments was observed in 15 patients (12.71%). A total of 101 lesions (85.59%) were centred in the vertebral body, 15 lesions (12.71%) were centred in the posterior attachment, and two lesions (2%) were centred in the paraspinal region. CT showed 39 lesions (33.05%) without a typical honeycomb or polka-dot pattern. Compression fracture was observed in 23 patients (19.49%). Extraosseous extension was present in 111 patients (94.1%), and 17 lesions (14.41%) presented with foraminal extension. Epidural bony compression was observed in 46 patients (38.98%). 20 lesions (16.95%) had atypical T₂ weighted MRI signals, and 8 lesions (10.26%) showed atypical enhancement.

CONCLUSION

SVH was predominantly located in the thoracic spine. Involvement of multiple segments, posterior attachment localisation, absence of honeycomb or polka-dot signs, compression fracture, and atypical T₂ weighted imaging signals and enhancement were uncommon. Epidural bony compression was not uncommon and has important clinical significance.

ADVANCES IN KNOWLEDGE

The imaging features of SVHs are not fully understood. We examined the largest series of SVH cases reported to date.

Doughnut vertebroplasty for circumferential aggressive vertebral hemangiomas

BACKGROUND

To assess the feasibility, safety and efficacy of a percutaneous doughnut vertebroplasty of circumferential aggressive vertebral hemangiomas (VHs).

METHODS

We retrospectively reviewed our prospectively collected database of patients with VHs treated with vertebroplasty between January 2009 and January 2018. Patient demographics, clinical presentations and procedural details were recorded. All patients underwent preoperative computed tomography (CT) and magnetic resonance imaging (MRI). All vertebroplasties were performed under conscious sedation in the prone position, predominantly using biplane fluoroscopic guidance. A clinical and imaging evaluation (early CT scan and MRI) as well as a final follow-up clinical assessment was performed.

RESULTS

Twenty-two patients with aggressive VHs who underwent circumferential vertebroplasty with cementation of the entire vertebral body and at least one posterior hemi-arch were included (six males, mean age 53 years). At 3 months follow-up, nine patients (41%) had complete, 11 (50%) had partial and two (9%) had no resolution of pain. Nine of 14 patients had a decrease in venous swelling on MRI. No complications were observed. Five patients (23%) underwent adjunctive surgery within 1 year for persistence or worsening of neurological symptoms. Clinical and radiographic improvements were maintained to final follow-up.

CONCLUSIONS

Doughnut vertebroplasty offers a mini-invasive, safe and effective treatment of aggressive circumferential VHs. This technique improves pain in over 90% of patients as well as a reduction in radicular and neurological symptoms associated with a tendency to regression of the compressive epidural venous component of these lesions.

Full-Endoscopic Resection of Osteoid Osteoma in the Thoracic Spine: A Case Report

Common symptoms such as axial pain or nocturnal pain, associated with warning signs that are often worrisome in addition to nonspecific radiological findings, can characterize benign lesions in the spine, and osteoid osteoma is among them. We describe here a clinical case of a pediatric patient with an expansive bone lesion in the thoracic spine discovered after investigation for thoracic pain, mainly at night, which, despite a good response to simple analgesics, evolved in the short term with global spinal deformity. After a multidisciplinary evaluation, she underwent surgical resection using a pioneering endoscopic technique that allowed the definitive anatomopathological diagnosis of osteoid osteoma and guaranteeing very satisfactory treatment and evolution. Although there are already several therapeutic techniques described and with good results in specific cases of osteoid osteomas and other benign neoplastic lesions of the spine, full-endoscopic resection appears as an innovative and potentially promising option for diagnosis and treatment, especially since it is a safe, effective, and not too morbid intervention.

Rapidly Progressive Atypical Vertebral Hemangioma: A Case Report

Vertebral hemangiomas are common, benign, and asymptomatic tumors that rarely extend into the epidural space or involve the posterior elements. Surgery is recommended for aggressive vertebral hemangiomas if symptoms are severe or evolve rapidly. A 57-year-old male patient was admitted to our department for several months of back pain. A computed tomography (CT) scan and magnetic resonance imaging (MRI) were suggestive of T12 hemangioma without the involvement of the spinal canal or posterior elements. Despite aggressive conservative treatments, such as medications or nerve blocks, the back pain worsened. The CT and MRI 2 months later revealed a lesion involving the vertebral body and posterior elements with extension into the epidural space and with spinal cord compression. The patient underwent surgery for bone cement-augmented percutaneous screw fixation followed by low-dose radiotherapy. Histological examination confirmed the diagnosis of atypical hemangioma, specifically an epithelioid hemangioendothelioma.

Long-Term Outcomes of Excision Surgery for Aggressive Vertebral Hemangiomas

OBJECTIVE

We describe the clinical outcomes in patients with aggressive vertebral hemangiomas (AVHs) after total tumor excision and discuss the treatment options for AVHs.

METHODS

A retrospective data review of 15 patients (6 men, 9 women) with AVHs who underwent total excision between 1996 and 2018 was performed.

RESULTS

In total, 13 thoracic and 2 lumbar lesions were involved with 8 type A-D tumors and 7 type B-D tumors based on the Weinstein-Boriani-Biagini classification. All tumors showed low or low-iso signal intensity by T1-weighted magnetic resonance imaging. All patients received a combination of preoperative transarterial embolization and total tumor excision including the tumor margins. Eleven patients underwent total tumor excision as the initial surgery (total en bloc spondylectomy = 10 patients, piecemeal total tumor excision = 1 patient), and 4 underwent it as either a revision procedure 2 weeks after ineffective laminectomy or in the long-term follow-up (4-14 years) as a piecemeal total tumor excision. Intraoperative blood loss ranged from 150 to 3400 mL (mean, 1314 mL). None of the cases had a recurrence during the mean follow-up period of 128.4 ± 88.6 months.

CONCLUSIONS

Low signal intensity on T1-weighted magnetic resonance imaging was observed in all the patients with AVHs. The long-term clinical results of the preoperative transarterial embolization and total tumor excision were satisfactory. The effect of decompressive incomplete tumor excision is temporary for AVHs, and repeated tumor excision may be necessary because of tumor recurrence in the long term. Reliable total tumor excision during the initial surgery is desirable.

Bone up on spinal osseous lesions: a case review series

Spinal osseous neoplasms are frequently encountered and can be challenging when present as solitary lesions. Familiarity with the range of benign and malignant spinal pathology can help the radiologist formulate a comprehensive differential diagnosis. This article focuses on the spectrum of extradural spinal tumors, accounting for the majority of primary spinal tumors, by comparing the epidemiology, pathophysiology, clinical presentation, and characteristic imaging appearance of these lesions. The discussion includes the commonly encountered benign lesions, such as vertebral venous vascular malformation and enostosis, as well as malignant lesions including metastases and lymphoma. The article also includes other less-encountered primary spinal tumors such as plasmacytoma, osteoid osteoma, osteoblastoma, giant cell tumor, eosinophilic granuloma, chordoma, chondrosarcoma, osteosarcoma, Ewing’s sarcoma, and angiosarcoma. Familiarity with the characteristic imaging features can help the radiologist reach an accurate diagnosis and obviate the need for unnecessary invasive procedures such as biopsy and surgery.

F18-fluorodeoxyglucose positron emission tomography/computed tomography in the evaluation of vertebral vascular tumors

PURPOSE

F-FDG PET/CT in vertebral vascular tumors.

MATERIALS AND METHODS

We retrospectively collected PET/CT and clinical data of patients with vertebral vascular tumors and analyzed the location, number, and bone destruction and FDG uptake features of the lesion. We measured SUVmax and maximum diameter and analyzed the correlations between SUVmax and the pathological results, size, and CT features.

RESULTS

Twenty-one pathology-proven vertebral vascular tumors were included: 2 angiosarcomas (SUVmax, 11.6 and 32.3), 1 epithelioid hemangioendothelioma (SUVmax, 5.7), 1 epithelioid hemangioma (SUVmax, 8.5), and 17 aggressive hemangiomas. Twelve cases of typical hemangiomas were included as controls. The SUVmax and diameter of the aggressive hemangiomas were higher than those of the typical hemangiomas. The mean SUVmax of aggressive hemangiomas with cortical destruction was higher than that of those without cortical destruction (t = -2.566, P = 0.022). Radioactive distribution in aggressive hemangiomas was homogeneous and heterogeneous in nine and eight cases, respectively. In six aggressive hemangiomas, the FDG uptake of residual and marginal sclerosing bone was higher than that of the osteolytic destruction area and/or paravertebral soft tissue. Six aggressive hemangiomas involved the spinal canal, without clear visualization on PET/CT.

CONCLUSION

F-FDG PET/CT shows limitations in evaluating the spinal canal involvement of aggressive hemangioma.

Thoracic aggressive vertebral hemangiomas: multidisciplinary management in a hybrid room

PURPOSE

Vertebral hemangiomas (VH) account for 2-3% of all spinal tumors. The majority is incidentally found on radiographic studies: 1% present with pain and/or neurologic deficits. We report our experience with the multidisciplinary management of aggressive symptomatic thoracic VH by concomitant intraoperative sclerotization with sodium tetradecyl sulfate (STS), vertebroplasty, posterior decompression (with/without fusion) and surgical resection in a hybrid operating room (HR) equipped with a rotational scanner and a radiolucent operating table.

METHODS

Patients admitted with aggressive spinal VH between 2007 and 2018 were included. Data regarding demographics, presenting symptoms, location of the lesion, preoperative embolization, length of the surgery, estimated blood loss (EBL) as well as follow-up (FU) were retrieved.

RESULTS

Five patients were included (three females, mean age 65 years; range 59-75). Three patients presented with a myelopathy and two mechanical thoracic pain. All patients underwent a single-stage percutaneous sclerotization and vertebroplasty followed by a surgical decompression associated with epidural intralesional injection of STS and subtotal resection of the epidural lesion. Two patients had preoperative embolization. Mean procedural duration was 338 min (range 210-480 min). Four patients had marginal EBL, one patient had 500 ml EBL. Patients had no evidence of lesion recurrence or progression at the end of the follow-up.

CONCLUSIONS

The single-stage multimodal management of aggressive symptomatic VH is safe and effective. It allows for a direct intraoperative sclerotherapy combined with maximal tumor resection, resulting in reduced blood loss. The use of STS as a direct intraoperative sclerotizing agent is safe and reliable.

Intraoperative injection of absorbable gelatin sponge (AGS) mixed with cement followed by spinal decompression to treat elderly with vertebral hemangiomas

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.

Preoperative Endovascular Embolisation of the Symptomatic Hemangioma in 7th Thoracic Vertebrae: Case Report

Although, as asymptomatic, they appear in about 10-12% of the worldwide population, vertebrae hemangiomas are symptomatic in about 0.9-1.2% of all the cases.

We showed the case of the symptomatic hemangioma in the 7th thoracic vertebrae in 67 year old patient, that was successfully preoperative embolised. Magnetic resonance imaging (MRI) detected the tumor in the body of 7th vertebrae with mass effect on the anterior aspect of the spinal cord. Multidetector computed tomography (MDCT) imaging describes this tumor as hemangioma that is in the body of the Th7 vertebrae and in the both pedicules. We performed selective and supraselective spinal angiography which showed pathological vascularisation of the tumor, and then the tumor was embolised. The control angiography detected the reduction of the tumor blood vessels, as a sign of the successful embolisation. Ten days after embolisation, the patient went through corporectomia of the Th7 and the stabilization of the thoracic spine was performed. Intraoperative blood transfusion in our patient was 930 mL, while expected blood transfusion during the surgical intervention without preoperative embolisation is about 1600 mL.

Method of choice in conditions with neurological compressive symptoms caused by vertebral hemangioma is surgery for the decompression of the nerve structures. Embolisation of aggressive vertebral hemangioma is recommended and preoperatively performed for the intraoperative hemorrhage reduction and decreasing of intraoperative complications.

Surgical Management and Adjuvant Therapy for Patients With Neurological Deficits From Vertebral Hemangiomas: A Meta-Analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVE

To understand the benefits and limitations of surgical management and adjuvant therapies for patients presenting with neurological deficits from vertebral hemangiomas (VH).

SUMMARY OF BACKGROUND DATA

VH is the most common benign spine tumor but rarely causes symptoms. Patients with back pain alone are treated with conservative management (kyphoplasty and radiation therapy), while those with neurological deficits require complex multi-modal treatment plans.

METHODS

A PubMed literature search for "symptomatic vertebral hemangioma with spinal cord compression" identified 47 articles. From these articles and their references, 19 observational studies on patients who underwent surgery for VH met inclusion criteria. Meta-analyses were performed comparing outcomes of the surgical and adjuvant therapies using Stata13 software. For those with insufficient data for meta-analyses, descriptive analyses of variables were completed.

RESULTS

One hundred ninety seven surgical cases of VH with neurologic deficits were identified. Surgery provided a complete remission of symptoms in 84% of patients, however 18% of patients had recurrence of hemangioma. Adjuvant interventions included radiation, embolization, and kyphoplasty. Radiation therapy (XRT) was associated with a lower recurrence rate and an increase in minor transient adverse effects. Preoperative embolization performed in 98 patients was associated with improved symptoms, reduced complications, lower recurrence rate, less blood loss, and higher incidence of pathologic vertebral fractures. Meta-analyses did not yield statistically significant results, likely due to the heterogeneity amongst the studies and small sample sizes, but the results compiled together provide insight on potential benefits of preoperative embolization for symptomatic relief and reduced risk of recurrence with XRT that deserves further study.

CONCLUSION

For patients with neurologic deficits from spinal cord or nerve root compression, surgery provides improvement in symptoms. Recurrence of VH and symptoms refractory to surgery can be further reduced by adjuvant therapies such as embolization, kyphoplasty, and radiation with some unique risks to each therapy.

LEVEL OF EVIDENCE

2.

Surgical Management of Enneking Stage 3 Aggressive Vertebral Hemangiomas With Neurological Deficit by One-stage Posterior Total En Bloc Spondylectomy: A Review of 23 Cases

STUDY DESIGN

Clinical case series.

OBJECTIVE

The aim of this study was to describe the treatment of aggressive vertebral hemangiomas (VHs) with neurological deficit treated with total en bloc spondylectomy (TES) in a single institute.

SUMMARY OF BACKGROUND DATA

Despite increasing utilization of surgery to treat aggressive VHs, owing to the rarity, the diagnosis and treatment protocols of aggressive VHs are still questionable and disputable.

METHODS

All patients with Enneking stage 3 aggressive thoracic or lumbar VHs with neurological deficit and treated with TES from January 2005 to January 2013 were included. Clinical characteristics and surgery outcomes of patients, including Tomita classification, operation time, blood loss, pre- and postoperative American Spinal Injury Association (ASIA) impairment scale, visual analogue score (VAS), and Spinal Instability Neoplastic Score (SINS), were retrospectively reviewed.

RESULTS

A total of 23 VHs patients were enrolled in this study, including 17 in the thoracic spine and six in the lumbar spine. All patients suffered neurological deficits caused by direct spinal cord compression with or without associated mechanical instability. The average SINS score was 9.78 ± 1.51. The mean operation time of patients with preoperative embolization was 426.6 ± 104.3 minutes and the mean blood loss was 1883.3 ± 932.1 mL. There were no technical difficulties or serious complications. After surgery, all patients recovered to ASIA-E levels. The VAS pain score decreased from 8.0 ± 0.9 to 2.8 ± 0.8 (P < .05).

CONCLUSION

TES is a good treatment option for patients with aggressive VHs with bony destruction and neurological deficit.

LEVEL OF EVIDENCE

4.

The lipid-poor hemangioma: an investigation into the behavior of the "atypical" hemangioma

OBJECTIVE

Most vertebral hemangiomas contain high signal intensity on T1-weighted MRI images. Atypical vertebral hemangiomas, which are defined as showing low-signal intensity on T1-weighted images, have been described as lesions which are prone to aggressive behavior. This study was performed to assess behavior of atypical hemangiomas.

MATERIALS AND METHODS

Thoracic and lumbar spine MRI reports for the year 2012 were reviewed for diagnosis of atypical hemangioma. Images were reviewed by two independent observers, and cases which showed atypical vertebral hemangioma, and had imaging or clinical follow-up, were included in our study.

RESULTS

Thirty atypical hemangiomas which had follow-up data were identified out of 2784 thoracic and lumbar MR examinations performed during 2012 at a single institution. Imaging follow-up was available for 23 lesions (mean follow-up 32 months), while there was clinical follow-up for the remaining seven lesions (mean 43.6 months). Twenty-two lesions were stable on imaging, while one demonstrated significant growth over approximately 6 years, developing MRI signal characteristics of a typical hemangioma. Eleven lesions had CT scans showing typical features of hemangioma. Two of the index lesions could not be identified on follow-up CT examinations, which showed normal-appearing spines. The remaining seven lesions were followed clinically; none of the patients reported symptoms in the region of the index lesions.

CONCLUSIONS

Atypical hemangiomas are uncommon lesions. The cases in our population did not show aggressive behavior. A more appropriate designation for these lesions may be lipid-poor hemangioma, to distinguish them from aggressive hemangiomas.

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.

[Effect of preoperative feeding artery occlusion on invasive vertebral hemangioma resection]

OBJECTIVE

To evaluate the effectiveness and safety of preoperative feeding artery occlusion on vertebral resection of invasive vertebral hemangioma.

METHODS

The clinical data of 20 patients with invasive vertebral hemangioma who received posterior lumbar vertebral body resection, bone grafting, fusion and internal fixation between March 2010 and March 2017 were retrospectively analyzed. According to whether feeding artery occlusion was performed before operation, the patients were divided into group A (11 cases, tumor feeding artery occlusion before operation) and group B (9 cases, no tumor feeding artery occlusion before operation). There was no significant difference in gender, age, lesion segment, and disease duration between the two groups ( P>0.05). The operation time, intraoperative blood loss, postoperative drainage volume, blood transfusion volume, and ambulant time after surgery, hospitalization time, and deep venous thrombosis of lower extremities were recorded and compared between the two groups. Pain improvement was evaluated by visual analogue scale (VAS) score.

RESULTS

The operation time, intraoperative blood loss, blood transfusion volume, and ambulant time after surgery were significantly less in group A than those in group B ( P<0.05). There was no significant difference in postoperative drainage volume and hospitalization time between the two groups ( P>0.05). Five patients (3 in group A and 2 in group B) suffered from pleural tear due to intraoperative pleural adhesions. Closed thoracic drainage tubes were placed immediately after suture and extubated on 3-5 days. Both groups were followed up 1-1.5 years, with an average of 1.35 years. In group B, 1 patient died of pulmonary embolism at 7 days after operation; and 2 patients developed deep venous thrombosis of lower extremity after operation, who were treated with inferior vena cava filter and thrombolytic therapy, and recovered well after operation. The local pain of the other patients was significantly relieved after operation, and the pain disappeared at 1 month after operation. The VAS scores of the two groups at 3 days after operation were significantly improved when compared with those before operation ( P<0.05). There was no significant difference in VAS scores between the two groups before operation and at 3 days after operation ( P>0.05). Three patients (2 in group A and 1 in group B) who had neurological symptoms were significantly relieved after surgery. Bone healing was achieved in both groups at 1 year after operation. No fracture or loosening of internal fixator occurred during follow-up.

CONCLUSION

Nutritional artery occlusion before vertebrectomy for invasive vertebral hemangioma can effectively reduce intraoperative blood loss, operation time, perioperative blood transfusion, and other perioperative complications.

Per-operative glue embolization with surgical decompression: A multimodality treatment for aggressive vertebral haemangioma

OBJECTIVE

The aim of this study is to share our experience in per-operative embolization of aggressive vertebral haemangioma and to compare the surgical outcome with existing modalities of management.

BACKGROUND

Vertebral haemangioma accounts for 12% of benign lesions of the vertebral column detected incidentally. Rarely they may enlarge, cause pain and neurological deficit because of spinal cord compression, vertebral body or arch expansion, or pathological fracture. Treatment options for symptomatic vertebral haemangioma include pre-operative transarterial embolization, surgical excision, radiotherapy, and percutaneous injection of alcohol or methyl methacrylate. We present our experience of per-operative glue embolization for aggressive (Enneking stage 3) vertebral haemangiomas.

MATERIALS AND METHODS

We describe five patients with symptomatic vertebral haemangioma at the dorsal level who underwent per-operative glue embolization. After initial laminectomy, a tumorogram was obtained under fluoroscopic guidance through direct contrast injection via spinal needle inserted through the pedicles of vertebra at the involved level. Varied concentration of glue was injected via the same spinal needle. All patients underwent surgical decompression of the intraspinal epidural component in the same sitting along with posterior spinal stabilization of the adjacent levels in two patients.

RESULTS

In all five patients, complete embolization of the tumour was possible per-operatively through the transpedicular approach along with adjunctive surgical decompression, and the blood loss was significantly less. Clinical follow-up of these patients at 12-48 months showed reduction in size of the epidural component, relief of cord compression, and significant improvement in their neurological deficits with no recurrence.

CONCLUSION

We conclude that per-operative embolization is a safe and efficacious adjunctive procedure with surgical decompression with or without spinal stabilization for the treatment of symptomatic vertebral haemangiomas.

Atypical Vertebral Hemangiomas Are Frequently Associated with Radiculomedullary Arteries

BACKGROUND

Preoperative endovascular embolization of atypical hemangiomas of the spine can reduce intraoperative blood loss. One frequent concern raised about embolizing these tumors is a possible association with arteries feeding the spinal cord, such as the artery of Adamkiewicz. This study aimed to elucidate a relationship between spinal levels affected by atypical spinal hemangiomas and radiculomedullary arteries.

METHODS

This was a retrospective review of 8 patients undergoing preoperative embolization of atypical spinal hemangiomas. We evaluated 54 spinal levels by angiography during embolization procedures. Each spinal level was categorized on the basis of the presence or absence of tumor and radiculomedullary artery.

RESULTS

Six of 15 (40%) affected levels had an associated radiculomedullary artery. Four of 39 (10.2%) unaffected levels had an associated cord feeding artery. The relative risk of affected spinal levels having an associated radiculomedullary artery was 3.9 (95% confidence interval 1.28-11.91). The attributable risk was 0.40 (95% CI 0.12-0.76). The chi-squared statistic was 6.35, with a P value of 0.01. Six of 8 patients (75%) had a radiculomedullary artery at a level of disease and embolization.

CONCLUSIONS

In this study, spinal levels affected by atypical hemangiomas requiring surgery were associated with radiculomedullary arteries. When performing preoperative embolization, great care must be taken to identify and preserve arteries supplying the spinal cord.

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.

Percutaneous Treatments of Benign Bone Tumors

Benign bone tumors consist of a wide variety of neoplasms that do not metastasize but can still cause local complications. Historical management of these tumors has included surgical treatment for lesion resection and possible mechanical stabilization. Initial percutaneous ablation techniques were described for osteoid osteoma management. The successful experience from these resulted in further percutaneous image-guided techniques being attempted, and in other benign bone tumor types. In this article, we present the most common benign bone tumors and describe the available results for the percutaneous treatment of these lesions.

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.

Differential diagnosis of hemangiomas from spinal osteolytic metastases using 3.0 T MRI: comparison of T1-weighted imaging, chemical-shift imaging, diffusion-weighted and contrast-enhanced imaging

The retrospective study investigated accuracy of quantitative evaluation of T1-weighted imaging (T1WI) with and without fat suppression (FS), chemical-shift, diffusion-weighted imaging (DWI) and enhanced imaging at 3.0 T MRI for distinguishing spinal hemangiomas from metastases. 27 patients with 33 spinal hemangiomas (15 atypical hemangiomas) and 26 patients with 71 metastases were recruited. T1WI, FS T1WI, in- and out-phase, DWI and enhanced T1WI were acquired. Signal intensities (SIs) of lesions were obtained. Signal intensity ratios (SIRs) and enhancement ratios of lesions in enhanced imaging were assessed. Ratio of SI loss of hemangiomas or atypical hemangiomas between T1WI and FS T1WI was higher than those of metastases (p < 0.001). The accuracies of ratio of SI loss between T1WI and FS T1WI for differentiating hemangiomas and atypical hemangiomas from metastases were 96.15% and 91.86%. Ratio of SI loss between in- and out- phase could differentiate hemangiomas and atypical hemangiomas from metastases with accuracies of 74.04% and 84.88%. Cutoff values for hemangiomas in SIRs of ≤ 1.52 (early phase) and ≤ 1.38 (middle phase) yielded accuracies of 92.31% and 82.69%. Enhancement ratios of atypical hemangiomas in middle and delayed phases were higher than that of metastases. Accuracies of apparent diffusion coefficient for differentiating hemangiomas and atypical hemangiomas from metastases were 70.19% and 89.53%. T1WI with and without fat suppression could distinguish spinal hemangiomas from metastases. Quantitative assessment of chemical-shift, DWI and enhanced imaging were helpful to identification of spinal hemangiomas and metastases.