Epithelioid hemangioma of the spine: an uncommon cause of spinal cord compression

Abstract

A 65-year-old female presents to the emergency room with worsening mid-back pain, rapidly progressive numbness starting from below the breasts (T5 sensory level), and bilateral lower extremity weakness. She reported increasing difficulty ambulating and was unsteady on her feet. She had radiating pain into her anterior thighs, occasionally extending into her calves, right greater than left and had new-onset loss of sphincter, bowel and bladder control. Her focused neurologic exam showed quadriceps strength of 4?/5 on the left and 4-/5 on the right. Ankle dorsiflexion was 4-/5 bilaterally. She had a known history of midthoracic back pain for the preceding 4 months. She denied any history of remote or recent spinal trauma. Spinal cord compression was suspected and the initial CT imaging revealed a large lytic lesion at the T7–8 level with involvement of the corresponding ribs. Coronal imaging revealed destruction, expansion and trabeculation of the vertebral bodies of T7–9 and loss of vertebral body height. On axial imaging, there was paravertebral soft tissue extension with central canal narrowing (Figs. 1, 2, 3). An initial differential diagnosis of vascular tumor versus malignancy was considered and a CT-guided biopsy with angiographic embolization of feeding vessels was planned urgently, followed by definitive surgical intervention. She underwent an uneventful biopsy and successful Onyx-18 (eV3, Irvine, California, USA) embolization of feeding vessels (Fig. 3). The post-embolization surgical procedure involved laminectomies from T6 to T9, T7–8 vertebroplasty and partial transpedicular vertebrectomies followed by tumor resection with T4–T11 arthrodesis and posterior spinal fusion (Figs. 4, 5). She regained motor strength within 48 h and near complete resolution of numbness postoperatively. Final pathology was consistent with epithelioid hemangioma (EH).