Treatment of Typical Enneking Stage 3 Thoracic Aggressive Vertebral Hemangiomas with Pain and Neurologic Deficits: Results After at Least 36 Months of Follow-Up

Preoperative elastoplasty of aggressive vertebral hemangiomas in elderly patients: a new strategy for reducing intraoperative bleeding and complications

PURPOSE

Preoperative elastoplasty could be an alternative strategy for treating aggressive vertebral hemangiomas (VHs) in frail patients needing for spinal cord decompression, combining the advantages of embolization and vertebroplasty.

METHODS

Three elderly patients with spinal cord compression from thoracic aggressive VHs underwent XperCT-guided percutaneous injection of silicone (VK100), filling the whole affected vertebra, followed by a decompressive laminectomy. At 12-months follow-up no recurrences, vertebral collapse or segmental kyphosis were noted at the CT scans, with patients reporting an improvement of preoperative neurological deficits, VAS and Smiley-Webster pain scale (SWPS) parameters.

RESULTS

With its elastic modulus, non-exothermic hardening, and lower viscosity than PMMA, VK100 allowed a preoperative augmentation of the affected vertebral body, pedicles, and laminae without complications, with a controlled silicone delivery even in part of VH's epidural components thanks to XperCT-guidance.

CONCLUSION

When facing highly bony erosive VH encroaching the spinal canal, VK100 combines the advantages of embolization and vertebroplasty especially in elderly patients, permeating the whole VH's angioarchitecture, significantly reducing tumor.

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 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.

A less aggressive approach to the treatment of aggressive vertebral hemangioma of the thoracic spine: A case report and literature review

BACKGROUND

Different treatments are available for aggressive vertebral hemangioma [AVH], but a consensus is yet to be reached about the best therapeutic approach.

PURPOSE

To explore the possibility that selecting a less aggressive therapeutic approach for AVH decreases the intraoperative and postoperative complications while providing similar clinical, radiographic, and disease-free survival results to more aggressive therapeutic methods.

STUDY

We report the case of an AVH of the thoracic spine at the T5 level, treated via perioperative selective arterial embolization plus surgical decompression via laminectomy and reconstruction with polymethylmethacrylate (PMMA) vertebroplasty.

PATIENT

The patient was a 17-year-old male referred to our center with the chief complaint of low back pain from two months earlier, without any response to analgesics, and with neurologic manifestations as paraparesis (one month) and progressive sphincter problems (one week). Upon imaging, the impression was an aggressive spinal tumor with cord compression.

OUTCOME MEASURES

After the operation, the patient's pain immediately improved, and his neurologic manifestations progressively improved.

RESULTS

The patient started walking with help about three weeks after the operation. Roughly six months later, he achieved a complete neurological recovery. At present, about two years following the operation, he has a normal life without any neurological problems.

CONCLUSION

Based on our experience with AVH, the selection of less aggressive therapeutic approaches such as perioperative diagnostic angiography and selective embolization decrease the intraoperative and postoperative complications like intraoperative bleeding and neurological injury, while achieving similar clinical, radiographic, and disease-free survival outcomes to more aggressive therapeutic methods.

Thoracic spine hemangioma causing rapidly progressive myelopathy and mimicking a malignant tumor: A case report

Vertebral hemangiomas are common benign tumors that are mostly asymptomatic and are discovered incidentally. Only 0.9–1.2% of all vertebral hemangiomas, termed aggressive vertebral hemangiomas, expand to cause pain and neural compression. We present an extremely rare case of a 49-year-old woman who had an aggressive vertebral hemangioma of the thoracic spine that caused rapidly progressive myelopathy with remarkable irregular extraosseous bone proliferation, which mimicked a malignant vertebral tumor. In this case, despite the lesion's hostile appearance during imaging, the pathological diagnosis was benign and symptom-based surgical treatment with posterior decompression and stabilization provided good clinical outcomes during the postoperative 18 months follow-up period. In this case, despite the use of standard imaging modalities (radiograph, CT, and MRI), making a preoperative imaging diagnosis of an aggressive vertebral hemangioma was difficult, and although aggressive vertebral hemangiomas with atypical radiological features are rare, they should be considered as a differential diagnosis.