Symptomatic Vertebral Hemangiomas Research Articles

SPIN-04 PAEDIATRIC SPINAL HEMANGIOMA PRESENTING WITH MYELOPATHY – HELPING A CHILD TO WALK AGAIN

Abstract OBJECTIVES To highlight the adaptations in management of spinal tumour patients with available resources. To emphasize on the importance of neurorehabilitation post spinal tumour surgery. INTRODUCTION Vertebral/Spinal hemangiomas are benign lesions and often asymptomatic. They are more common in the thoracic spine where they may become symptomatic with varying presentations. Only a small percentage of these tumours are symptomatic, and this can be attributed to several factors which include epidural expansion of tumour tissue, expansion of bony elements, compression by vessels feeding or draining the lesion or rarely by compression fracture of the vertebra. CASE: This is a case of an 11-year-old girl who was managed at Parirenyatwa hospital. She had presented with a 2-month history of progressive backache associated with paraparesis and numbness in the legs. Had normal bowel and bladder control. No history of trauma or other comorbidities such as Tuberculosis, HIV, or known malignancies. An MRI done revealed a contrast enhancing extradural compressive mass at the level of T5, also involving parts of T5 vertebral body. RESULTS The patient was taken to theatre for thoracic spine decompression and biopsy, without instrumentation. Histology revealed that the lesion was a hemangioma. Patient recovered well over 2months on a corset and physiotherapy, 4 months later she was able to mobilise by herself and to run around. CONCLUSION The main stay of treating symptomatic vertebral hemangiomas remains surgery, with or without instrumentation. It is often rewarding though may be challenging to both the patient and the surgeon even in the best of centers. As exemplified by this case, we have managed to yield a satisfying outcome in the face of ‘adaptive’ measures. Neurorehabilitation enhanced the chances for the child to be able to walk again.

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

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

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

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

Symptomatic and aggressive vertebral hemangiomas in children: features of modern interpretation and treatment tactics

Objective. To analyze the features of clinical-radiological manifestations of symptomatic vertebral hemangiomas in children and the possibility of algorithmizing their treatment.Material and Methods. As part of a monocenter cohort, 24 children aged 4 to 17 years received treatment for symptomatic vertebral hemangiomas. The clinical-radiological manifestations of the tumor and the effectiveness of various methods of invasive treatment were evaluated.Results. Symptomatic uncomplicated and complicated vertebral hemangiomas, corresponding to stages S2 and S3 of the Enneking classification for benign tumors, occur in children with almost equal frequency. For tumors without extravertebral spread, a closed percutaneous vertebroplasty provides stable relief of complaints. For aggressive hemangiomas with extravertebral, including epidural, spread, various treatment methods are used. An algorithm for choosing therapeutic tactics is proposed.Conclusion. Surgical treatment of symptomatic vertebral hemangiomas should be carried out using a tactical algorithm that takes into account the stage of the tumor (S2 or S3) and the possibility of performing closed or open vertebroplasty, selective arterial embolization and decompression and stabilization operations on the spine.

SURG-06. Management outcome (5years or more) of paediatric vertebral haemangiomas presenting with myelopathy

INTRODUCTION: Vertebral hemangiomas are very rare in pediatric age group. In this study we analysed the outcomes of patient treated at department of neurosurgery , All india institute of medical sciences New Delhi since may 2010 to January 2022 with at least 5 year follow up. MATERIALS AND METHOD: All patients up to 18 years age of vertebral haemangioma treated at our hospital from may 2010 to january 2022 with at least 5 year follow up. All had features of myelopathy.Patients demography, clinical details and follow up and complications were retrieved from hospital records. Functional clinical outcomes were measured using ASIA score. Mean age was 14.21 years with range of 12 years to 18 years. All patients had magnetic resonance imaging and computed tomography of spine in preoperative and postoperative period. Mean follow up was 78 months with range from 60 month to 144 months. RESULTS: There were 6 male and 8 female patients with sex ratio of 3:4. All were located in dorsal spine with single level involvement . Upper dorsal spine involvement was more common (10 cases 71.43%) than lower dorsal spine involvement (4 case 28.57%). All patients had weakness of lower limbs with features of myelopathy, urinary bladder symptoms were present in 6 patients local site pain in 1. D1 involvement was present in 1, D3 in 2, D4 in 2, D5 in 2, D6 in 3 , D8 in 1,D10 in 1,D11 in 1 and D12 in 1. All patients have improvement in power of both lower limbs after surgery. Bladder symptom and pain resolved in all patients. CONCLUSION: Good postoperative results can be achieved in pediatric symptomatic vertebral hemangioma with minimal complications. Individualization of treatment for each patient should be done with avoidance of selecting more blood loss procedures like corpectomies.

Long-Term Outcome of Surgical Management in Symptomatic Pediatric Vertebral Hemangiomas Presenting With Myelopathy

Singh, Pankaj K MCh; Chandra, Sarat P MCh; Agrawal, Mohit MCh; Sawarkar, Dattaraj MCh; Kumar, Rajender MCh; Kumar, Amandeep MCh; Verma, Satish MCh; Kale, Shashank S MCh

Utility of spinal angiography and arterial embolization in patients undergoing CT guided alcohol injection of aggressive vertebral hemangiomas.

The purpose of this study is to evaluate the role of spinal angiography and arterial embolization in avoiding spinal cord ischemia in patients undergoing CT-guided alcohol injection of aggressive vertebral hemangiomas. In this retrospective study, patients with vertebral hemangioma who underwent CT-guided direct alcohol injection between January 2007 and October 2018 were identified. Of 28 such patients, 26 had neurological deficits, and 2 had only back pain or radiculopathy. Direct alcohol injection without prior arterial embolization was done in 17 patients. Direct alcohol injection with prior arterial embolization was done in 11 patients. Clinical outcome was assessed immediately after the intervention and at follow-up. Three patients, who underwent alcohol injection without trans-arterial embolization, had worsening of neurological deficits in the post procedure period due to spinal cord ischemia. No complications related to spinal cord ischemia were noted in the embolization group. There was no significant difference in the outcomes between the two groups if the three patients with complications are excluded (p = 0.34). While CT-guided direct alcohol injection is effective in the management of symptomatic and aggressive vertebral hemangiomas, spinal angiography and trans-arterial embolization of the blood supply to the vertebral body hemangioma, prior to the direct transpedicular alcohol embolization of the lesion, improves the safety of the procedure.

Early response assessment after CyberKnife stereotactic radiosurgery for symptomatic vertebral hemangioma by quantitative parameters from dynamic contrast-enhanced MRI.

The present study aimed to explore the value of DCE-MRI to evaluate the early efficacy of CyberKnife stereotactic radiosurgery in patients with symptomatic vertebral hemangioma (SVH). A retrospective analysis of patients with spinal SVH who underwent CyberKnife stereotactic radiosurgery from January 2017 to August 2019 was performed. All patients underwent DCE-MRI before treatment and three months after treatment. The parameters included volume transfer constant (Ktrans), transfer rate constant (Kep), and extravascular extracellular space volume fraction (Ve). A total of 11 patients (11 lesions) were included. After treatment, six patients (54.5%) had a partial response, five patients (45.4%) had stable disease, and three patients (27.3%) presented with reossification. Ktrans and Kep decreased significantly in the third month after treatment (p = 0.003 and p = 0.026, respectively). ΔKtrans was -46.23% (range, -87.37 to -23.78%), and ΔKep was -36.18% (range, -85.62 to 94.40%). The change in Ve was not statistically significant (p = 0.213), and ΔVe was -28.01% (range, -58.24 to 54.76%). DCE-MRI parameters Ktrans and Kep change significantly after CyberKnife stereotactic radiosurgery for SVH. Thus, DCE-MRI may be of value in determining the early efficacy of CyberKnife stereotactic radiosurgery.

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

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. We retrospectively analysed CT and MRI characteristics of 118 patients with clinically and pathologically confirmed SVH. 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. 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. The imaging features of SVHs are not fully understood. We examined the largest series of SVH cases reported to date.

Surgical management of symptomatic vertebral hemangiomas: A case report and literature review.

Background: Vertebral hemangiomas (VHs) are common benign tumors that only rarely become symptomatic. There is a paucity of data regarding their surgical management and outcomes. Here, we reported a case involving an aggressive cervical VH, discussed its surgical management and outcomes, and reviewed the literature.Methods: We assessed the clinical, radiological, and surgical outcomes for a patient with an aggressive cervical VH. We also performed a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to describe surgical outcomes for symptomatic VH.Results: A total of 154 studies including 535 patients with VH were included in the study. The majority of patients were female (62.8%), the average age was 43 years, and the thoracic spine was most commonly involved (80.6%). Utilizing Odom’s criteria, outcomes were excellent in 81.7% (95% CI 73.2–90.2) of cases. For those presenting with myelopathy (P = 0.045) or focal neurological deficits (P = 0.018), outcomes were less likely to be excellent. Preoperative embolization was not associated with excellent outcome (P = 0.328).Conclusion: Surgical outcomes for VH are predominantly favorable, but aggressive VHs have the potential to cause significant residual postoperative neurological morbidity.

Surgery for Vertebral Hemangioma in Resource-Constrained Environment

Background: Vertebral hemangiomas are benign, highly vascular lesions of the vertebra. Asymptomatic hemangiomas are common, but they rarely enlarge in size and present with myelopathy. The aim of this study was to analyze the long-term outcome of patients of vertebral hemangioma presenting with myelopathy who were managed in a resource-constrained environment, the majority of whom were treated by our novel three-pronged strategy of alcohol injection, posterior decompression, and short segment fixation. Methods: All patients of symptomatic vertebral hemangioma with myelopathy treated at our hospital from 2001 to 2015 with follow up till January 2018, with at least 2 year follow up were included. The operative procedure, blood loss and complications were recorded. Clinical outcomes were measured using ASIA score. Results: Out of 60 patients operated, 44 (26 males, 18 females) fulfilled the inclusion criteria. 41 hemangiomas were located in the thoracic spine two in lumbar spine and one in cervical spine. Upper thoracic spine involvement was more common than lower thoracic spine involvement. Mean age was 29.34 years (range 10 - 68 years). Mean follow up was 74.63 months (range 24 - 180 months). All patients had improvement in motor strength postoperatively. Local pain, which was present in two patients resolved, bladder symptoms present in 13 patients also resolved. Conclusions: Our experience in treating symptomatic vertebral hemangiomas, along with the long term follow up data suggests that good postoperative results can be achieved with minimal complications, in carefully selected patients. Funding Statement: None. Declaration of Interests: None. Ethics Approval Statement: Approval for the study was taken from the institutional ethical board.

Long-Term Outcome of Surgical Management in Symptomatic Pediatric Vertebral Hemangiomas Presenting With Myelopathy.

Vertebral hemangiomas are benign, highly vascular lesions of the vertebra, rarely seen in the pediatric age group. To analyze the long-term (>3 yr) outcome of patients of pediatric vertebral hemangioma presenting with myelopathy and to describe our surgical strategy to treat such cases. All patients up to 18 yr of age with a symptomatic vertebral hemangioma treated at our hospital from May 2003 to August 2016, with at least 3-yr follow-up were included. Functional clinical outcomes were measured using American Spinal Injury Association (ASIA) score. There were 7 male and 7 female patients. All hemangiomas were located in the thoracic spine with single-level involvement. Upper thoracic spine involvement was more common (12 cases: 85.71%) than lower thoracic spine involvement (2 cases: 14.29%). All patients had features of myelopathy. The mean age was 14.57 yr, ranging from 10 to 18 yr. The mean follow-up was 62.21 mo, ranging from 36 to 90 mo. All patients had improvement in motor strength of both lower limbs postoperatively. Local pain, which was present in 1 patient, resolved, and the bladder symptoms present in 5 patients also resolved. Our experience in treating symptomatic pediatric vertebral hemangiomas, along with the long-term follow-up data, suggests that good postoperative results can be achieved with minimal complications in carefully selected patients.

Percutaneous vertebroplasty for the treatment of symptomatic vertebral hemangioma with long-term follow-up

There is a paucity of literature on vertebroplasty in hemangioma. The effectiveness with short-term and long-term follow-up is an important insight for research. This study aims to evaluate the effectiveness and the long-term efficacy of vertebroplasty in the treatment of the patient with symptomatic vertebral hemangioma. Materials and methodsThis is a retrospective cohort study. The outcome was evaluated by immediate post-procedure and 3 months, 1 year, and 5 years of follow-up clinical status of the patients. The significance was determined by using a paired t-test between the pre-procedure and post-procedure severity of pain, activity score, and analgesic. The P-value < 0.05 indicated statistical significance. ResultsA total of 38 vertebroplasties were performed in 34 patients. Additionally, the embolization of residual soft tissue was performed in 4 patient and Percutaneous alcohol injection for posterior elements involvement was performed in 9 patients. Immediate after the procedure, 44.12% of patients became asymptomatic, 38.23% of patients showed significant improvement, 11.77% of patients remained static and 2.94% of patients deteriorated and needed laminectomy. The complication rate was 29.4%, but only 2 patients were symptomatic and needed surgical decompression. There was significant relief of pain (P < 0.05), reduced analgesic intake (P < 0.05), and increased activity (P < 0.05) immediately after the procedure, 3 months, 1 year, and 5 years follow-up. ConclusionPVP is an effective therapeutic option for the treatment of VH with fewer complications. The additional procedures like preprocedural embolization and percutaneous alcohol injection enhance the outcome and avoid complicated surgical interventions.

The priority of vertebroplasty for treatment of symptomatic vertebral hemangiomas

The priority of vertebroplasty for treatment of symptomatic vertebral hemangiomas

Linear accelerator-based single-fraction stereotactic body radiotherapy for symptomatic vertebral body hemangiomas: The Mayo Clinic experience

Symptomatic vertebral hemangiomas (SVHs) are rare benign tumors that when symptomatic require procedural intervention or radiotherapy (RT). Although conventionally-fractionated RT has been an alternative to surgical resection, there is very little data on stereotactic body radiotherapy (SBRT) for SVHs. Six consecutively treated patients with SVHs underwent definitive single-fraction SBRT from 2010 to 2018 at our institution. The RT planning parameters, treatment, outcome, and toxicities are reported for 6 patients with 6 total SVHs treated with single-fraction SBRT. Each patient presented with back pain and received single-fraction SBRT to a thoracic vertebral body hemangioma. One patient had received radiofrequency ablation prior to SBRT. The median SBRT dose was 18 Gy (range, 13–20). Following SBRT, 4 (67%) patients reported improvement in presenting symptoms and 2 patients (33%) were refractory. There were no acute or chronic toxicities associated with SBRT including esophagitis, vertebral compression fractures, or myelopathy. To date, this is the largest series of single-fraction SBRT for SVHs. Single fraction SBRT appears to be a feasible option for SVHs. Further studies are needed to confirm our preliminary findings and optimize dose fractionation.

Symptomatic vertebral hemangioma during pregnancy period: A case series and systematic literature review.

Vertebral Hemangioma (VH) is a benign tumor usually symptomless and discovered incidentally. Pregnancy, because of several hormonal and physiologic changes, is a recognized risk factor coinciding with the development of a rapid onset of neurological symptoms in patients affected by VH. In the Literature, sporadic cases of neurological symptoms have been described, which occurred during pregnancy, but only rarely the onset of symptoms was reported after pregnancy and childbirth. Usually surgical treatment is reserved for severe cases with rapid onset of neurological symptoms. However, the use of conservative treatments is still a topic of debate In the present study, we report a series of patients affected by VH become symptomatic during or after pregnancy along with a systematic review of the Literature.

Thoracic aggressive vertebral hemangiomas: multidisciplinary management in a hybrid room.

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. 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. Five patients were included (three females, mean age 65years; 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 338min (range 210-480min). Four patients had marginal EBL, one patient had 500ml EBL. Patients had no evidence of lesion recurrence or progression at the end of the follow-up. 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.

Symptomatic Vertebral Hemangioma of the Posterior Elements Sharing Blood Supply with a Radiculomedullary Artery.

Vertebral hemangiomas are common lesions usually restricted to the vertebral body. They are characterized by proliferation of endothelial cells and subsequent expansion of vascular spaces within the bone. These lesions are usually clinically silent and are discovered incidentally. Only rarely are vertebral hemangiomas symptomatic. Here, we present the case of a 68-year-old female with an aggressive hemangioma causing neurologic deficit. The lesion was localized within the posterior spinal elements, with no involvement of the vertebral body. Transarterial embolization was deemed unsafe due to the close proximity of a prominent radiculomedullary artery. The patient was treated with posterior decompression at T4-T6.

Long-term outcome of treatment of vertebral body hemangiomas with direct ethanol injection and short-segment stabilization

BackgroundVertebral body hemangiomas with myelopathy are difficult to manage. ObjectiveThe objective of this study was to evaluate the role of intraoperative ethanol embolization, surgical decompression, and instrumented short-segment fusion in vertebral hemangioma (VH) with myelopathy and long-term outcome (>24 months). Clinical Materials and MethodsThis prospective study included symptomatic VH with cord compression with myelopathy. Pathologic fractures and deformity or multilevel pathologies were excluded from the study. Surgery consisted of intraoperative bilateral pedicular absolute alcohol (<1% hydrated ethyl alcohol) injection, laminectomy, and cord decompression at the level of pathology followed by a short-segment instrumented fusion using pedicle screws. ResultsThe study included 33 patients (mean 26.9±13.2, range: 10–68 years, 18 females). The clinical features of the study were myelopathy in all patients (5 paraplegic), sphincter involvement (13), and mid back or lower back pain (7). The preoperative American Spinal Injury Association (ASIA) scores were A (7), B (11), C (6), D (8), and E (1). Majority of the patients had single vertebral involvement (30) and three patients had multiple-level involvement. Six patients underwent surgery earlier (one underwent alcohol embolization). The mean surgical time was 124±39 minutes, and the average blood loss was 274±80 cc. The mean amount of absolute alcohol injected was 14.6±5.7 cc (two patients required 20 and 25 cc). Immediate embolization was achieved in all patients, allowing laminectomy and easy removal of soft-tissue hemangioma. Post surgery, one patient had transient deterioration, and the condition of the rest of the patients improved (sphincters improved in nine patients) at a follow-up ranging 28–103 months (mean 47.6±22.3). Follow-up ASIA scores were E (26), D (4), B (2), and C (1). All patients showed evidence of bone sclerosis and relief of cord compression on follow-up imaging. ConclusionsThis is the largest study in literature showing excellent improvement, low reoperation rates after ethanol embolization, and short-segment fixation.

Percutaneous vertebroplasty as Treatment of Symptomatic Vertebral Hemangioma

Percutaneous vertebroplasty as Treatment of Symptomatic Vertebral Hemangioma