Vertebral hemangioma: retrograde embolization-stabilization with methyl methacrylate

Lumbar vertebral haemangioma causing pathological fracture, epidural haemorrhage, and cord compression: a case report and review of literature

CONTEXT

Vertebral haemangiomas are recognized to be one of the commonest benign tumours of the vertebral column, occurring mostly in the thoracic spine. The vast majority of these are asymptomatic. Infrequently, these can turn symptomatic and cause neurological deficit (cord compression) through any of four reported mechanisms: (1) epidural extension; (2) expansion of the involved vertebra(e) causing spinal canal stenosis; (3) spontaneous epidural haemorrhage; (4) pathological burst fracture. Thoracic haemangiomas have been reported to be more likely to produce cord compression than lumbar haemangiomas.

FINDINGS

A forty-nine year old male with acute onset spinal cord compression from a pathological fracture in a first lumbar vertebral haemangioma. An MRI delineated the haemangioma and extent of bleeding that caused the cord compression. These were confirmed during surgery and the haematoma was evacuated. The spine was instrumented from T12 to L2, and a cement vertebroplasty was performed intra-operatively. Written consent for publication was obtained from the patient.

CLINICAL RELEVANCE

The junctional location of the first lumbar vertebra, and the structural weakness from normal bone being replaced by the haemangioma, probably caused it to fracture under axial loading. This pathological fracture caused bleeding from the vascularized bone, resulting in cord compression.

Safety and feasibility of percutaneous vertebroplasty with radioactive (153)Sm PMMA in an animal model

PURPOSE

We investigated the safety and feasibility of the combination of samarium-153-ethylenediamine tetramethylene phosphonate ((153)Sm-EDTMP)-incorporated bone cement (BC) with percutaneous vertebroplasty (PVP) in dogs.

METHODS AND MATERIALS

(153)Sm-EDTMP-incorporated BC was prepared by combining solid (153)Sm-EDTMP and polymethylmethacrylate (PMMA) immediately before PVP. It was then injected into the vertebrae of four healthy mongrel dogs (two males and two females) by PVP under CT guidance. Each dog was subjected to five PVP sessions at a (153)Sm-EDTMP dose of 30-70 mCi. The suppressive effect of local injection of (153)Sm-EDTMP on the hematopoietic system was evaluated through counting of peripheral blood cells. Distribution of (153)Sm-EDTMP-incorporated BC and the status of tissues adjacent to injected vertebrae were evaluated with SPECT, CT and MRI. Histopathology was carried out to assess the influence of PVP on the vertebra and adjacent tissues at the microscopic level.

RESULTS

PVP was done successfully, and all dogs exhibited normal behavior and stable physical signs after procedures. (153)Sm-EDTMP-incorporated BC was concentrated mainly in target vertebrae, and the peripheral blood cells remained within normal range. The spinal cord and tissues around BC did not exhibit signs of injury even when the dosage of (153)Sm-EDTMP increased from 30 mCi to 70 mCi.

CONCLUSION

A dose lower than 70 mCi of (153)Sm is safe when it was injected into vertebrae. (153)Sm-EDTMP-incorporated BC did not influence the effect of PVP. This means might strengthen anti-tumor activity locally for vertebra with osseous metastasis without damaging adjacent tissues.

Percutaneous vertebroplasty to treat painful myelomatous vertebral deposits-long-term efficacy outcomes

Developed for benign conditions including osteoporotic fractures and haemangiomas, vertebroplasty has since been employed in neoplastic lesions, including myeloma. Advances in myeloma treatments, yielding improved survival times, have led to an increasing need for effective therapies that improve quality of life. The first randomised trials of vertebroplasty to treat painful osteoporotic crush fractures have cast doubt of its benefit over a placebo procedure, with a proposed rationale that fracture healing over time may account for the non-superiority of the results. However, these findings cannot be extrapolated to myeloma where the pathology is one of progressive bony destruction coupled with failure of new bone formation. In this paper, we present the outcome data for myeloma patients treated at our tertiary referral centre over a 5-year period, focusing on both subjective and objective measures of efficacy and safety. Records were reviewed to extract pain score, function and analgesia pre/post-procedure. Where possible, patients were then contacted directly and asked to assess their benefit by grading change in pain score, analgesia use and mobility. Performance status was assessed using the Eastern Cooperative Oncology Group scale. Of the 26 patients treated for painful thoraco-lumbar lesions, 77% reported improved pain score (P < 0.003). Analgesia reduction, better mobility and improved performance status were also seen. Our data support the consideration of vertebroplasty as a first-line treatment for painful myelomatous vertebral disease. Prospective randomised studies are now required to further define its role.

Balloon kyphoplasty combined with posterior instrumentation for the treatment of burst fractures of the spine--1-year results

OBJECTIVE

Clinical and radiologic follow-up of patients with osteoporosis with painful, traumatic A3-type vertebral compression fractures in the thoracic and lumbar spine.

DESIGN

Prospective study over the period of 1 year.

SETTING

Level I Trauma Center.

PATIENTS AND INTERVENTION

Twenty-five patients with osteoporosis (14 women and 11 men) and painful, traumatic A3-type fractures were treated with Balloon Kyphoplasty in combination with a short-segment posterior fixation (using the Universal Spine System). Twenty-one patients returned for their 1-year follow-up visit. X-rays were taken preoperatively, postoperatively, and at 3, 6, and 12 months' follow-up to evaluate vertebral height and local Cobb angle. Pain was measured using the self-reporting Visual Analogue pain Scale (VAS). Disability was measured using the Oswestry Disability questionnaire (ODI).

RESULTS

The mean pain score (VAS) improved significantly from pretreatment to posttreatment from 7.8 +/- 2.2 (5.6-10) to 4.9 +/- 2.1 (2.8-8.0) (P < 0.001). It improved further to 2.9 +/- 1.4 (2.1-4.3) at 3 months and increased slightly after 1 year (3.8 +/- 1.9) (1.9-4.7). Limitation of daily activities (ODI) improved significantly from 88% (78-100) to 35% (15-48) at 3 months (P < 0.05). Improvement was maintained at 1 year at 36.5% (10-42). At 1-year follow-up, maintenance of the height restoration and kyphotic deformity correction was found.

CONCLUSIONS

Balloon Kyphoplasty in combination with short-segment posterior instrumentation in traumatic A3 vertebral fractures led to a significant reduction in pain and disability. The combination of both surgical techniques was able to restore and maintain vertebral body height and correction of angular deformity. This technique might offer important safety advantages over an invasive anterior-posterior approach.

Percutaneous balloon kyphoplasty in the treatment of pathological vertebral body fracture and deformity in multiple myeloma: a one-year follow-up

PURPOSE

To evaluate the clinical and radiographic outcomes of balloon kyphoplasty in patients with fractures of the thoracic and lumbar spine caused by multiple myeloma.

MATERIAL AND METHODS

Vertebral fractures due to multiple myeloma were treated by balloon kyphoplasty (20 patients, 48 vertebral bodies). Symptomatic levels were identified by clinical presentation, magnetic resonance imaging (MRI), radiographs, and computed tomography (CT). During the following year, visual analog scale (VAS) and Oswestry disability score were documented. Radiographs were taken pre- and postoperatively at 3, 6, and 12 months. Vertebral height and kyphotic deformity were measured to assess restoration of the sagittal alignment.

RESULTS

The median pain scores (VAS) decreased significantly from pre- to posttreatment, as did the Oswestry disability score (p < 0.05). Clinically asymptomatic cement leakage occurred at 5 fracture levels (10.4%). During 1-year follow-up, this surgical technique demonstrated restoration and stabilization of the height of the vertebral body.

CONCLUSION

Balloon kyphoplasty is an effective minimally invasive procedure for stabilizing pathological vertebral fractures caused by multiple myeloma and leading to a statistically significant reduction of pain status. Balloon kyphoplasty stabilizes the vertebral body height, but is only partially able to prevent further kyphotic deformities.

Clinical results of an open prospective study of a bis-GMA composite in percutaneous vertebral augmentation

In this open prospective trial, 53 patients with acute pain from osteoporotic vertebral fracture related to osteoporosis or malignancy underwent vertebral augmentation with a new bisphenol-a-glycidyl dimethacrylate (bis-GMA) resin (Cortoss, Orthovita, Malvern, Pa, USA). Treatment consisted of up to 8 ml of Cortoss injected into a given vertebra. The procedure encompassed single and multiple injections (including the contralateral hemivertebra, to a maximum of 3 vertebral levels). Follow-up was at 4 and 8 days and at 1, 3, and 6 months. The primary efficacy end point was patient-rated pain using a 100-point visual analog scale (VAS, with 100 as severest pain) on day 4 following treatment; secondary end points were analgesic use and quality-of-life and disability scores from the Oswestry Disability Index (ODI) and a short-form 12-item questionnaire (SF-12). The present report contains interim results collected up to the 1-month post-treatment time point. At baseline, the group's mean VAS score was 69, indicating moderate to severe pain; at day 4, 32 of 53 patients (60.4%) reported a 30% or greater reduction in baseline pain accompanied by a VAS pain score less than 50 (mean 38.1). Pain reduction was maintained at 1 month (mean VAS 31.3). The average ODI score at baseline was 55, suggesting significant disability among participants prior to Cortoss treatment. Following treatment, the ODI scores were significantly reduced from these baseline levels (day 8, 47.4; 1 month, 33.6). Further, SF-12 physical and mental component scores at 1 month after treatment increased from baseline by 26% and 11%, respectively; while analgesic use decreased concomitantly, primarily among patients with underlying osteoporosis. A total of 20 adverse events were deemed to be device-related. The most frequent clinically significant adverse events attributed to Cortoss were leakage of Cortoss from within the vertebral body at placement (12%), back pain (7%), and unspecified pain (7%). These results indicate that vertebral augmentation with Cortoss rapidly reduces pain, decreases disability, and improves physical functioning in patients with painful vertebral compression fractures.

Percutaneous Vertebroplasty for Malignant Compression Fractures with Epidural Involvement

PURPOSE

To evaluate safety and effectiveness of performance of percutaneous vertebroplasty (PVP) in patients with malignant compression fractures and involvement of the epidural space.

MATERIALS AND METHODS

PVP was performed in 50 patients with metastatic disease or multiple myeloma between June 1998 and April 2002. Twenty-five women (mean age, 62.3 years; range, 38-85 years) and 25 men (mean age, 63.1 years; range, 37-92 years) were included. Cases were retrospectively reviewed. Patients who had undergone cross-sectional imaging were classified into three groups. First group had no epidural involvement; second group, mild epidural involvement without contact with spinal cord or nerve roots; third group, moderate involvement and contact with spinal cord or nerve roots. Procedural safety was evaluated with review of all post-PVP complications and their treatment. Effectiveness was evaluated with follow-up phone calls for assessment of change in pain level and activity after PVP. Follow-up calls were performed at 1 day; 2 weeks; 1, 3, and 6 months; and 1 and 2 years. Differences between groups were assessed with singly ordered Kruskal-Wallis test.

RESULTS

Fourteen patients were classified in the first group, 18 in the second, and 18 in the third. There were no significant differences in pain or mobility outcomes among groups. At the last follow-up call, 41 (82%) of 50 patients reported improvement in pre-PVP pain. Six (12%) reported no change, and three (6%) reported increased pain. After PVP in 26 (52%) patients, there was a period of increased mobility; in 19 (38%), no improvement in mobility occurred; and in five (10%), decreased mobility was reported. Complications included acute increased pain or new areas of pain in seven (14%) patients. None of these required surgery; four were treated with nerve root block; two, with central epidural injection; and one, with overnight intravenous steroids.

CONCLUSION

PVP can be performed safely and effectively with conscious sedation in patients with malignant compression fractures and epidural involvement.

Percutaneous vertebroplasty: rationale, clinical outcomes, and future directions

Percutaneous transpediculate vertebroplasty is an innovative and successful treatment of painful osteoporotic and pathologic compression fractures that are refractory to medical therapy. Large-scale clinical series have shown that vertebroplasty can provide significant pain relief with very low complication rates. Expectations of positive results of the ongoing randomized trials are high. With the accumulation of scientific data, technological advancements, and acceptance by the general community, vertebroplasty may be become the standard of care for treatment of painful vertebral body compression fractures.

Is there a dose-effect relationship for the treatment of symptomatic vertebral hemangioma?

PURPOSE

Symptomatic vertebral hemangiomas are rare vascular lesions. Radiotherapy is the most common treatment. Because of a lack of information in the literature, uncertainty exists about the total radiation dose to be applied.

METHODS AND MATERIALS

Individual data from our own and published patients with symptomatic vertebral hemangioma treated with radiotherapy alone were obtained. The data were pooled, and the impact of the total dose on complete pain relief was evaluated using the chi-square test. Because different single-fraction doses were used, the equivalent dose in 2-Gy fractions (EQD(2)) was used for the analysis.

RESULTS

Complete data could be obtained from 117 patients. Patients were categorized according to total dose (EQD(2)) into two groups of similar size (Group A: 20-34 Gy, n = 62; and Group B: 36-44 Gy, n = 55). Radiation-induced complete pain relief was achieved in 39% (24/62) of the patients in Group A and in 82% (45/55) of the patients in Group B. The difference was statistically significant (p = 0.003).

CONCLUSIONS

The data suggest a dose-effect relationship in the radiotherapy of symptomatic vertebral hemangiomas. We recommend a total radiation dose 36-40 Gy with a dose per fraction of 2.0 Gy.

Treatment of lower lumbar radiculopathy caused by osteoporotic compression fracture: the role of vertebroplasty

The authors used vertebroplasty for the treatment of severe lower lumbar radicular pain caused by osteoporotic compression fracture. Patients presented with severe radiating leg pain rather than lower back pain from recent osteoporotic compression fracture of lower lumbar vertebra. Radiologic findings showed osteoporotic compression fracture combined with preexisting stenosis of the intervertebral foramen resulting in root compression. After injection of polymethylmethacrylate into the compressed vertebral body through the pedicle of the symptomatic side, all seven patients experienced dramatic pain relief that lasted throughout the mean follow-up duration of 9.1 months. They conclude that vertebroplasty may be an effective way of relieving radicular pain caused by osteoporotic compression fracture combined with foraminal stenosis.

Prospective evaluation of pain relief in 100 patients undergoing percutaneous vertebroplasty: results and follow-up

PURPOSE

To determine the efficacy and durability of percutaneous vertebroplasty for the treatment of back pain associated with vertebral body compression fractures.

MATERIALS AND METHODS

One hundred patients (79 women, 21 men; mean age, 73.7 y) underwent 156 percutaneous injections of polymethylmethacrylate (PMMA) into a vertebra (68 thoracic and 88 lumbar) under fluoroscopic guidance over a 35-month period. Before the procedure and at follow-up, patients were asked to quantify their pain on a visual analog scale (VAS) and complete a follow-up questionnaire of our own design.

RESULTS

The procedure was technically successful in all patients. There were two complications. One patient sustained a sternal fracture and one experienced a transient radiculopathy. Ninety-seven patients (97%) reported significant pain relief 24 hours after treatment. Mean follow-up duration was 21.5 months (6-44 mo) in 99 patients. Ninety-two patients (93%) reported significant improvement in back pain previously associated with their compression fractures as well as improved ambulatory ability. Before vertebroplasty, the VAS score for the 99 patients was 8.91 +/- 1.12 compared to a score of 2.02 +/- 1.95 at follow-up. The mean difference in VAS scores was significant (P <.0001).

CONCLUSION

Percutaneous vertebroplasty of symptomatic vertebral body compression fractures is a minimally invasive procedure that provides immediate and sustained pain relief in patients with refractory pain.

The role of vertebroplasty in metastatic spinal disease

Many advances have been made in the treatment of metastatic spinal disease over the last few decades. Radiotherapy offers benefit and pain relief to many patients; however, this modality provides minimal vertebral stabilization. Surgical management consists of decompression and complex fusions. Vertebroplasty offers an adjuvant therapy to both radiotherapy and surgery by providing additional stabilization and pain relief. The results of case studies suggest that including vertebroplasty in the management of these patients is beneficial. In this article the authors review the role of vertebroplasty in metastatic spinal disease.

Interstitial quinacrine for elimination of abnormal tissue; therapy of experimental glioma

BACKGROUND

When quinacrine is injected interstitially, an intense migration of leukocytes and accumulation of various lymphokines is obtained locally, and the reaction is followed by cicatricial fibrosis. This property has been used in humans to induce tubal fibrosis in women and pleurodesis in patients with pleural effusion.

METHODS

In a controlled study, a single dose of 150 mg of quinacrine was injected interstitially into a C6 glioma implanted in the subcutaneous tissue of Wistar rats. Changes in size, histologic variations, and microscopic characteristics of leukocyte subpopulations infiltrating the tumor were studied by immunohistochemistry. Tumor necrosis factor and interleukin-1 beta were measured at different times in tumor homogenates.

RESULTS

The day after the injection of quinacrine, infiltration of leukocytes and macrophages was observed, accompanied by an accumulation of proinflammatory endogenous cytokines. Tumoral necrosis soon ensued; complete tumor disappearance was obtained in 72% of the animals. Cicatrization proceeded without injury of perilesional structures. In all controls injected with the vehicle, a large tumor developed (P <.0001).

CONCLUSIONS

Quinacrine, when administered interstitially in a single dose, elicits an intense local recruitment and proliferation of activated immune cells that, at the dose used in this study, induces tissue necrosis within a radius of 1 cm around the site of quinacrine injection, leaving the surrounding tissue unharmed.

Magnetic resonance imaging in the evaluation of patients for percutaneous vertebroplasty

Osteoporosis and osteoporotic compression fractures of the vertebral bodies are major health problems facing women and older people of both sexes. In the last several years, percutaneous vertebroplasty has been developed as a treatment for pain caused by vertebral body compression fractures and primary or metastatic neoplasms. A large part of the success of this procedure depends on correct patient selection. As such, magnetic resonance imaging (MRI) plays a vital role in this process. In this review, the clinical evaluation of patients considered for vertebroplasty, the role of MRI in the pretreatment process, the postvertebroplasty appearance of the spine on MRI, and the future applications, such as real-time guidance with MR imaging, will be discussed.

Vertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients

BACKGROUND

Vertebral hemangiomas are characterized by diverse clinical histories, radiological features, and results of surgical treatment. It still remains unclear how these differences in clinical behavior relate to pathological type.

METHODS

A retrospective diagnostic, surgical, and histopathological study of 86 consecutive patients with various pathological types of vertebral hemangioma was performed to establish clinicopathological correlates.

RESULTS

The study confirmed that differences exist in clinical course, appearance on imaging, and outcomes in pathological types of hemangiomas. Based on these findings the authors attempted to identify signs characterizing each group.

CONCLUSIONS

Differences in clinical history and radiological features exist among pathological types of vertebral hemangiomas. These differences cannot precisely predict the type pathology before histologic examination, but do help us to understand the natural history of such lesions more fully.

Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results

Percutaneous vertebroplasty with acrylic cement consists of injecting polymethylmethacrylate into vertebral bodies destabilized by osseous lesions. The aim is to obtain an analgesic effect by reinforcing lesions of the spine. The major indications are vertebral angiomas, osteoporotic vertebral crush syndromes, and malignant spinal tumors. The clinically significant complications occur predominantly in patients with spinal metastatics, but in the great majority of cases they resolve with medical treatment.

Thoracic vertebral hemangioma with extradural extension and spinal cord compression. Case report

A 45-year-old man presented with progressive numbness of lower extremities and unsteady gait. Magnetic resonance imaging of the dorsal spine demonstrated multiple hyperintense inactive vertebral hemangiomas on T-1 weighted images. There was an active hemangioma involving D7 vertebral body and neural arch with epidural extension and spinal cord compression. He underwent embolization of the main feeders of the lesion and subsequent surgery. The patient's symptoms resolved after treatment. The clinical, magnetic resonance imaging findings, and treatment of this condition are discussed.

Percutaneous vertebroplasty treatment of steroid-induced osteoporotic compression fractures

This report describes the case of a woman in whom multiple compression fractures of the lower thoracic and lumbar spine occurred in association with long-term corticosteroid therapy for systemic lupus erythematosus. Pain markedly limited the patient's mobility and daily activities, and conservative therapy with bracing and narcotic analgesics gave little improvement. Affected vertebrae were treated with polymethylmethacrylate, introduced percutaneously under fluoroscopic guidance. The resulting reinforcement of the fractured vertebral bodies eliminated the pain and the need for narcotic analgesics. The utilization of percutaneous verterbroplasty as a therapeutic alternative for the treatment of pain resulting from osteoporotic compression fractures is described.

Vertebral hemangioma presenting with intermittent claudication

The case of a patient with vertebral hemangioma and unusual clinical presentation is reported, with an attempt to explain these unusual clinical complaints. Vertebral hemangioma is a common and often asymptomatic tumor. Neurologic symptoms may appear due to pressure on the neural tissue caused by extraosseous extension. The patient reported here presented with intermittent claudication. Conventional radiography CT, and MRI revealed vertebral hemangioma at T5 and extraosseous extension compressing the spinal cord. Gravity-related vascular dilatation may induce further compression of the spinal cord and, thus, is thought to be the underlying event in the induction of the intermittent clinical symptoms. The lesion was treated with subtotal corpectomy after embolization and fusion with a strut iliac crest graft. At the 9-month follow-up, the patient was without complaints. We conclude that a diagnosis of vertebral hemangioma should be considered in cases of intermittent neurologic symptoms of the lower extremities.

Vertebral hemangioma late results of retrograde embolization--stabilization with methyl methacrylate in two cases

In two cases of hemangioma of the D7 and L1 vertebral bodies intraoperative posterior filling of the angioma was described. The technique allowed a conveniently bloodless operation, which resulted in stabilization. No other stabilization was necessary. Six months after the procedure an increase of vertebral body density was seen radiologically.

The natural history and management of symptomatic and asymptomatic vertebral hemangiomas

Fifty-nine cases of vertebral hemangioma were seen at the Mayo Clinic between 1980 and 1990. Vertebral hemangiomas were discovered incidentally in 35 patients, while pain was the presenting complaint in 13 patients. Five patients presented directly with progressive neurological deficit requiring surgery, and six patients had surgery elsewhere for spinal cord compression and were referred for follow-up evaluation. To better define the natural history of these lesions, a historical review of these patients was conducted; progression of an asymptomatic or painful lesion to neurological symptoms was found in only two cases (mean follow-up period 7.4 years, range 1 to 35 years). New-onset back pain followed by subacute progression (mean time to progression 4.4 months, range 0.25 to 12 months) of a thoracic myelopathy was the most common presentation for patients with neurological deficit. Initially, all 11 patients with spinal cord compression underwent decompressive surgery with full neurological recovery. Recurrent neurological symptoms were observed in three of six patients following subtotal tumor resection and postoperative administration of 1000 cGy or less radiation therapy (mean follow-up period 8.7 years, range 1 to 17 years). No recurrences were noted in four patients who had subtotal excision plus radiotherapy between 2600 and 4500 cGy. One other patient had gross total tumor removal without radiotherapy and has not had a recurrence. Based on these patients and a review of the literature, the authors recommend annual neurological and radiological examinations for patients with hemangiomas associated with pain, especially young females with thoracic lesions in whom spinal cord compression is most likely to develop. Radiation therapy or embolization is an effective therapeutic alternative for patients with severe medically refractory pain. Regular follow-up monitoring for patients with asymptomatic lesions is unnecessary unless pain develops at the appropriate spinal level. It is concluded that management of patients with a progressive neurological deficit should include preoperative angiography and embolization, decompressive surgery with the approach determined by the degree of vertebral involvement and site of spinal cord compression, and postoperative radiation therapy in patients following subtotal tumor removal. Operative management and complications are discussed.

Vertebral hemangioma causing spinal cord compression during pregnancy

Hemangiomas of bone are extremely common vascular tumors that are most commonly discovered as incidental findings in the vertebral column. Infrequently, these benign lesions may cause local or radicular pain and neurologic deficits, from myeloradiculopathy to paralysis. This report describes the occurrence of a symptomatic vertebral hemangioma during pregnancy, in order to illustrate current methods for diagnosis and treatment of these lesions when associated with spinal cord compression. The possible mechanisms by which they may become symptomatic during pregnancy are reviewed.

Multiple vertebral hemangiomas with neurological signs. Case report

A case of multiple vertebral hemangiomas with progressive neurological deficit is presented. Successful treatment was accomplished using preoperative embolization, palliative surgical decompression, and postoperative radiation therapy. The patient has remained asymptomatic for 6 years. The authors review the role of current imaging modalities and options for therapeutic intervention. Preoperative embolization, palliative surgical decompression, and postoperative radiotherapy appear to provide a satisfactory outcome in patients with multiple hemangiomas and may represent an effective alternative to more aggressive surgical intervention.

Literature statistics do not support a growth stimulating role for female sex steroid hormones in haemangiomas and meningiomas

A literature review of pregnancy-related vertebral haemangiomas, pregnancy-related haemangiomas outside the nervous system and its coverings, and pregnancy-related meningiomas was performed. All three conditions tended to occur during the first pregnancy, the second or third trimester, to ameliorate postpartum, and to recur during a subsequent pregnancy. These results suggested a hormonal influence on the clinical expression of haemangiomas and meningiomas. To test whether a hormonal factor is also operative in the (not pregnancy related) symptomatic and asymptomatic counterparts of these conditions we also reviewed the literature concerning the symptomatic and asymptomatic haemangiomas and meningiomas for the following: frequency, sex and age distribution. No arguments were found to suggest that steroid hormones are strong factors in the development of asymptomatic and symptomatic lesions. The pregnancy-related counterparts have to be considered as subsets with their own behaviour.

Vertebral hemangiomas with cord compression: the role of embolization in five cases

Five new cases of vertebral hemangioma with cord compression are reported. The role of preoperative selective angiography with embolization in the management of these lesions is discussed in the light of the most important literature on this topic.