1Sai Charan P G, 1Santhosh Bharathy, 1Pawan Kumar Garg, 1Sarbesh Tiwari, 1Pushpinder Singh Khera, 1Mayank Garg

1All India Institute of Medical Sciences, Jodhpur, India

Background:

Vertebral hemangiomas are benign vascular tumors characterized by proliferation of blood vessels. They represent about 2-3% of the spinal tumors. About 1% of vertebral hemangiomas cause bone expansion with extraosseous extension causing compression over spinal cord resulting compressive myelopathy. These types of hemangiomas are known as aggressive vertebral hemangiomas. Knowledge related to this pathology is important to avoid unnecessary biopsies.  There is multiple modality treatment available, that depends on the symptoms and size of the lesion. Trans-arterial embolization, percutaneous alcohol injection, radiotherapy and surgical managements are available for aggressive hemangiomas.

Material(s) and Method(s):

We herein describe three cases with aggressive vertebral hemangioma (two dorsal and one cervical vertebra). All patients presented with complaints of back pain, difficulty in walking with motor and sensory deficit. Imaging revealed bony involvement with epidural and paraspinal soft tissue component causing compression over spinal cord with resultant compressive myelopathy.

Result(s):

All three patients underwent endovascular embolization, two patients with dorsal vertebral involvement were embolized by polyvinyl alcohol (PVA) particles, post embolization revealed complete absence of tumoral blush. Follow-up magnetic resonance imaging (MRI) scan after 1 month showed some amount of residual enhancing soft tissue component in epidural and paravertebral space, later two of three patients were taken up for computed tomography (CT) guided percutaneous alcohol injection by right transpedicular approach using 18-gauge coaxial needle. Both patients reported significant improvement in the symptoms and complete recovery at the time of discharge and follow-up.

One patient with cervical vertebral involvement was embolized by onyx cast, subsequently selective catherization of feeders was done and embolized with PVA particles. Check angiogram revealed some persistent tumor blush via tortuous small feeders. The patient subsequently underwent surgical decompression and soft tissue excision. The preoperative embolization helped in reduction of blood loss during surgery. The patient also improved completely.

Conclusion(s):

Aggressive vertebral hemangiomas are rare form of benign tumor with aggressive behavior causing bony expansion, soft tissue formation with extension into pre, para and epidural spaces causing compressive myelopathy and neurological deficits.