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

Lumbar vertebral hemangioma mimicking lateral spinal canal stenosis: case report and review of literature

Context Hemangiomas are the commonest benign tumors of the spine. Most occur in the thoracolumbar spine and the majority are asymptomatic. Rarely, hemangiomas cause symptoms through epidural expansion of the involved vertebra, resulting in spinal canal stenosis, spontaneous epidural hemorrhage, and pathological burst fracture. Findings We report a rare case of a 73-year-old woman, who had been treated for two months for degenerative neurogenic claudication. On admission, magnetic resonance imaging and computed tomographic scans revealed a hemangioma of the third lumbar vertebra protruding to the epidural space producing lateral spinal stenosis and ipsilateral nerve root compression. The patient underwent successful right hemilaminectomy for decompression of the nerve root, balloon kyphoplasty with poly-methyl methacrylate (PMMA) and pedicle screw segmental stabilization. Postoperative course was uneventful. Conclusion In the elderly, this rare presentation of spinal stenosis due to hemangiomas may be encountered. Decompression and vertebral augmentation by means balloon kyphoplasty with PMMA plus segmental pedicle screw fixation is recommended.

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.

Balloon kyphoplasty as a single or as an adjunct procedure for the management of symptomatic vertebral haemangiomas

Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective.

Current treatment strategies and outcomes in the management of symptomatic vertebral hemangiomas

OBJECTIVE

We analyzed the outcome of patients with symptomatic vertebral hemangiomas treated at University of California, San Francisco, over a 20 year period. Treatment included transarterial embolization, embolization followed by surgical decompression or vertebral reconstruction with arthrodesis, and percutaneous vertebroplasty alone.

METHODS

All medical, surgical, and radiological records were reviewed retrospectively. All patients underwent follow-up neurological examination and evaluation of back pain.

RESULTS

Sixteen patients diagnosed with symptomatic vertebral hemangiomas causing pain or neurological deficit were treated at University of California, San Francisco, between 1984 and 2004. Mean follow-up was 81 months. Seven of nine patients undergoing surgical decompression and tumor resection reported pain relief and demonstrated improvement in neurological deficit when present. Two patients had recurrent myelopathy: one was successfully treated with a second decompressive surgery, whereas the second underwent a staged vertebrectomy. All three patients undergoing vertebrectomy had cord compression from extraosseous tumor growth. Preoperative embolization reduced expected intraoperative blood loss in four patients. Three of four patients who underwent transarterial embolization alone experienced resolution of back pain. Two of four patients treated with vertebroplasty had long-term pain relief.

CONCLUSION

Transarterial embolization followed by laminectomy is a safe and effective procedure for the treatment of cord compression by vertebral hemangioma causing stenosis without instability or deformity. Vertebrectomy preceded by embolization and followed by reconstruction can be used to treat cord compression from extraosseous tumor extension. Transarterial embolization without decompression is an effective treatment for painful intraosseous hemangiomas. Vertebroplasty is useful for improving pain symptoms, especially when vertebral body compression fracture has occurred in patients without neurological deficit, but is less effective in providing long-term pain relief.

Symptomatic cavernous hemangioma of the occipital condyle treated with methacrylate embolization

BACKGROUND

Cavernous hemangiomas of the cranial base are rare tumors. No case of symptomatic intraosseous angioma affecting the occipital condyle has been reported. This particular case was treated with surgical embolization using acrylic resin.

CASE DESCRIPTION

A 20-year-old man with a 1-year history of neck pain and torticollis was referred to our hospital. Neuroradiological examination revealed the typical picture of an intraosseous cavernous hemangioma located in the right occipital condyle. The patient was operated through a suboccipital approach. Biopsy and direct embolization with methacrylate was performed. The definitive pathological diagnosis confirms the neuro-radiological suspicion of intraosseous cavernous hemangioma. The follow-up of the patient (4 years) revealed no recurrence of pain or abnormal posture.

CONCLUSIONS

A rare case of cranial base cavernous hemangioma is reported. Methacrylate embolization can be a good option for the treatment of this uncommon lesion.

Brown-Sequard syndrome after management of vertebral hemangioma with intralesional alcohol. A case report

STUDY DESIGN

This report describes Brown-Sequard syndrome after intralesional injection of absolute alcohol into vertebral hemangioma.

OBJECTIVE

To discuss whether the described technique is safe in the management of vertebral hemangiomas.

SUMMARY OF BACKGROUND DATA

The management of vertebral hemangiomas remains controversial. There have been reports of successful management using intralesional absolute alcohol.

METHODS

The clinical and radiologic features of the reported complication are detailed.

RESULTS

Intralesional injection of absolute alcohol caused Brown-Sequard syndrome.

CONCLUSION

This case shows that intralesional alcohol injection cannot be considered a safe technique for management of vertebral hemangiomas with spinal cord compression.

Vertebral haemangiomas with spinal cord compression: the place of preoperative percutaneous vertebroplasty with methyl methacrylate

We report on cervical and two thoracic vertebral haemangiomas with neurological disturbance successfully treated by percutaneous vertebroplasty followed by decompression surgery. Vertebroplasty consolidates the vertebral body and reduces the risk of haemorrhage. Subsequent surgery may be limited to decompressive laminectomy and resection of the epidural extension of the haemangioma. embolisation was also carried out in one case. Complete neuroimaging workup, including CT, myelo-CT and MRI, is necessary prior to treatment.