Noncontiguous lumbar vertebral hemangiomas treated by posterior decompression, intraoperative kyphoplasty, and segmental fixation

Case report

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Vertebral hemangiomas are benign lesions and are often asymptomatic. Most vertebral hemangiomas that cause cord compression and neurological symptoms are located in the thoracic spine and involve a single vertebra. The authors report the rare case of lumbar hemangiomas in a 60-year-old woman presenting with severe back pain and rapidly progressive neurological signs attributable to 2 noncontiguous lesions. After embolization of the feeding arteries, no improvement was noted. Thus, the authors performed open surgery using a combination of posterior decompression, intraoperative kyphoplasty, and segmental fixation. The patient experienced relief from back and leg pain immediately after surgery. At 3 months postoperatively, her symptoms and neurological deficits had improved completely. To the authors' knowledge, this is the first description of 2 noncontiguous extensive lumbar hemangiomas presenting with neurological symptoms managed by such combined treatment. The combined management seems to be an effective method for treating symptomatic vertebral hemangiomas.

Abbreviation used in this paper:PMMA = polymethylmethacrylate.

Abstract

Vertebral hemangiomas are benign lesions and are often asymptomatic. Most vertebral hemangiomas that cause cord compression and neurological symptoms are located in the thoracic spine and involve a single vertebra. The authors report the rare case of lumbar hemangiomas in a 60-year-old woman presenting with severe back pain and rapidly progressive neurological signs attributable to 2 noncontiguous lesions. After embolization of the feeding arteries, no improvement was noted. Thus, the authors performed open surgery using a combination of posterior decompression, intraoperative kyphoplasty, and segmental fixation. The patient experienced relief from back and leg pain immediately after surgery. At 3 months postoperatively, her symptoms and neurological deficits had improved completely. To the authors' knowledge, this is the first description of 2 noncontiguous extensive lumbar hemangiomas presenting with neurological symptoms managed by such combined treatment. The combined management seems to be an effective method for treating symptomatic vertebral hemangiomas.

Vertebral hemangiomas are the most common benign spinal neoplasms, with a reported prevalence of 10%–12% in the general population.10,22 They occur most frequently in the thoracic spine, although up to 30% of lesions involve multiple levels.10 Only 0.9%–1.2% of these tumors lead to symptoms, which include varying degrees of pain, a neurological deficit, or a combination of both, predominantly in the thoracic spine.27,30

There is no consensus on the best therapeutic option for symptomatic vertebral hemangiomas. Vertebroplasty was first introduced in 1987 by Galibert et al.12 as an “alternative” treatment for vertebral hemangiomas, but it is now commonly applied to osteoporotic and metastatic fractures instead. There are only 4 case reports3,18,25,36 in English and 1 observational study15 describing the use of kyphoplasty for symptomatic vertebral hemangiomas, mostly by a percutaneous technique. Here we present the rare case of 2 noncontiguous lumbar hemangiomas with epidural extension that presented with cauda equina syndrome and were treated with a combination of posterior decompression, intraoperative kyphoplasty, and segmental fixation.

Case Report

History and Examination

This previously healthy 60-year-old woman presented to our department with persistent back pain occurring over 1.5 years and rapidly progressive weakness and numbness in the lower extremities occurring in the previous month. Two weeks before admission, she was unable to walk due to the sharp back pain that radiated down her anterior thighs although there had been no history of trauma. At admission, she also described numbness in the perineum and groins. She did not have bladder dysfunction but did have constipation. Conservative treatment with NSAIDs and electrical stimulation for 1 month failed to resolve her symptoms.

Neurological examination revealed localized tenderness over the spinous processes of the L-1 and L-3 vertebrae. Lumbar extension and bilateral flexion were painful and restricted. Motor weakness was present bilaterally in the lower limbs (motor power Grade 4/5). The straight leg raising test was strongly positive at 40° on the left side and 50° on the right side. Bilateral knee reflexes were weakened, and ankle reflexes were normal. The Babinski sign was absent, and there was no clonus. Sensation to pinprick was diminished in the perineum and L1–3 dermatomes on both legs. Urinary function was normal, whereas rectal examination showed decreased tone and sensation with reduced voluntary control.

Imaging Examination, Hospital Course, and Treatment

Plain radiographs of the lumbar spine showed coarse vertical striations of the L-1 and L-3 vertebral bodies (Fig. 1A). Computed tomography showed an intraosseous “polka dot” appearance with ballooning and rupture of the posterior vertebral body wall of L-1 and L-3 (Fig. 1B–D). No fracture was present. Magnetic resonance imaging revealed vertebral tumors involving the entire L-1 and L-3 vertebral bodies with extension into the epidural space. These lesions were mildly hyperintense on both T1-weighted and T2-weighted images (Fig. 2A and B) and heterogeneously enhanced on a postcontrast T1-weighted image (Fig. 2C). There was also evidence of T2 signal abnormality within the cauda equina at the L-2 level on T2-weighted MR images and MR myelography images (Fig. 2B, D, and E). The epidural masses encroached on the anterior and anterolateral aspects of the spinal canal and filled both the neural foramina bilaterally (Fig. 2F). The thecal sac and nerve roots were compressed severely. These findings were highly suggestive of vertebral hemangioma with epidural extension at L-1 and L-3.

Fig. 1.
Fig. 1.

Lateral radiograph of the lumbar spine (A) showing coarse vertical striations in the L-1 and L-3 vertebral bodies. Sagittal reconstruction (B) and axial (C and D) CT scans showing the classic polka-dot appearance of the hemangiomas at the L-1 (C) and L-3 (D) levels with expansion and discontinuity of the posterior cortical wall of the vertebral bodies.

Fig. 2.
Fig. 2.

Sagittal MR images of the lumbar spine (A–C) showing vertebral tumors involving the entire L-1 and L-3 vertebral bodies, with epidural extension. These lesions appeared mildly hyperintense on both T1-weighted (A) and T2-weighted (B) images and highly enhanced on a postcontrast T1-weighted image (C). Note the T2 signal intensity changes within the cauda equina at the L-2 level on T2-weighted MR (B and E) and MR myelography (D) images. Representative T2-weighted axial image of L-1 (F) revealing severe thecal compression by the bi-lobulated epidural mass.

Angiography showed hypervascular lesions with feeding arteries from bilateral L-1 and L-3 lumbar arteries (Fig. 3A–D). After embolization with Gelfoam particles, no arterial supply to the lesions was visible angiographically (Fig. 3E and F). The patient did not report any improvement in her lower-extremity strength and sensation. In less than 24 hours following embolization, the patient underwent open surgery because of the severe compression of the spinal canal. The objectives of our surgery were to achieve adequate decompression, eliminate pain, and restore mechanical stability at the same time. The patient was placed prone on a radiolucent table and general anesthesia was induced. First, a wide laminectomy and bilateral foraminotomy at the L-1 and L-3 levels were performed. The epidural masses were resected as much as possible through the spaces lateral to the thecal sac. Decompression of the dural sac and nerve roots was accomplished. Given the discontinuity of the posterior wall of the affected vertebral bodies, bilateral L-1 and L-3 kyphoplasties were then carried out, ensuring no cement extrusion into the spinal canal by using radiology and direct vision intraoperatively. A Jamshidi needle was advanced into each vertebral body under fluoroscopic guidance. Then the needle was exchanged for an obturator, followed by a working cannula. Using a 3-ram drill, a channel was created through the cannula so that a balloon tamp could be inserted. Under fluoroscopic control, the bone tamp was then introduced into the vertebral body and inflated to create 2 cavities under manometric control. Once the desired cavities were obtained, the balloon was deflated and removed. Subsequently, highly viscous poly-methylmethacrylate (PMMA) was injected into the L-1 (10 ml) and L-3 (12 ml) cavities under low pressure, without anterior or posterior spread. Finally, a posterolateral fusion was completed using a T-12/L-2/L-4 pedicle screw system and autogenous bone grafts. Total blood loss was 500 ml, and no transfusion was needed perioperatively.

Fig. 3.
Fig. 3.

Preembolization angiograms of the right (A and C) and left (B and D) lumbar arteries showing prominent staining within the L-1 and L-3 vertebrae. Embolization was performed with Gelfoam particles. Postembolization angiograms showing no vascular supply within L-1 (E) or L-3 (F) vertebrae.

Posttreatment Course

The postoperative period passed uneventfully. The patient's complaints of pain in her back and both legs disappeared soon after surgery. At pathological examination, the tumors proved to be cavernous hemangioma. Her rectal function returned to normal after 1 month, and she became asymptomatic and was able to walk unaided for more than 500 m at a follow-up at 3 months.

Postoperative radiography showed good cement fill in the vertebral bodies and maintained height of the involved bodies. Follow-up radiography obtained 16 months after surgery showed solid arthrodesis and maintenance of spinal alignment without collapse of the involved bodies (Fig. 4A and B). Both CT and MRI performed at this time demonstrated good decompression of the spinal canal and significant resolution of the epidural components without recurrence (Fig. 4C–E).

Fig. 4.
Fig. 4.

Follow-up anteroposterior (A) and lateral (B) radiographs obtained 16 months after surgery showing maintenance of spinal alignment without collapse of the involved bodies. Sagittal reconstruction CT scans (C) at this time demonstrating successful enhancement after kyphoplasty. Representative T2-weighted midsagittal (D) and axial (E) MR images at the L-1 level showing good decompression of the spinal canal and significant resolution of the epidural extension.

Discussion

Most vertebral hemangiomas are asymptomatic, with only 0.9%–1.2% becoming symptomatic.27,30 The thoracic spine is the most commonly affected level.10 Lesions in the lumbar spine can cause cauda equina syndrome2 and compression of the medullary conus.31 The age distribution peaks between the 4th and 5th decades, and there is a slight female predominance.30 Up to one-third of cases involve multiple levels, but the cases in the literature to date have presented with neurological symptoms generally at one level only.10 In addition, extensive hemangiomas of the spine that cause neurological deficits are exceedingly rare.14 To our knowledge, ours is the first case of 2 noncontiguous extensive lumbar vertebral hemangiomas that caused neurological symptoms at the same time.

Multiple mechanisms have been documented for neurological impairment caused by vertebral hemangiomas, including expansion of bony elements, epidural expansion of tumor tissue, disturbance of local blood flow, or rarely, compression fracture of the vertebra.10,11,30 Pregnancy, particularly during the third trimester, is also a recognized risk factor for symptomatic conversion.17,27

The typical radiographic feature of vertebral hemangiomas is a vertically striated or “honeycomb” pattern due to trabecular thickening. This pattern appears on CT and MRI as a “polka-dot” pattern.22 CT best defines bony architecture and is the best diagnostic imaging method for vertebral hemangiomas.10 MRI offers the advantage of superior soft-tissue resolution, and is helpful in accurately demonstrating the extraosseous extension of the tumor and the extent of the neural compression.11 The signal intensity depends on the amount of fat present.11 Low fat content with a hypo- or isointense signal on a T1-weighted image and a hyperintense signal on a T2-weighted image is associated with hypervascularity and increased potential to become symptomatic.19,31 Vertebral hemangiomas are brightly enhanced with contrast because of their vascularity.31 In our case, the MRI signal characteristics of the lesions, which were a mild hyperintense signal on both T1-weighted and T2-weighted images, are not fully consistent with those in the earlier reported studies. On postcontrast images, however, the epidural extensions were more strongly enhanced than were the vertebral bodies. This was indicative of vascular tissue involvement.

Treatment options for symptomatic hemangiomas include radiotherapy, direct alcohol injection, surgical decompression, transarterial embolization, vertebroplasty and kyphoplasty.1,10,13,15,30 However, none of these is satisfactory when applied alone.

Vertebral hemangiomas are radiosensitive lesions that respond to administration of 30–40 Gy.1,10,22 Most reports recommend radiotherapy as an adjuvant therapy, primarily after subtotal removal of the vertebral hemangioma.1,10,22,27 However, the effects of radiotherapy are delayed, and radiation carries the risks of radionecrosis and radiation-induced myelitis.1,22 Injection of alcohol, as a sclerosing agent, into the symptomatic vertebral hemangioma has been used to obliterate and shrink the malformation.4,6 However, such treatment has been reported to result in serious complications, including Brown-Séquard's syndrome and pathological fractures.6,28 In this study, we omitted radiotherapy and alcohol injection because of their potential hazards.

Surgical decompression is recommended when a significant or progressive neurological deficit is present.1,4,10,22,27,30 The surgery may range from vertebrectomy with reconstruction to decompressive laminectomy, depending on the location of the lesion and the rate of neurological decline.4,10,27,32 If there is only vertebral body involvement with or without soft-tissue extension anteriorly, vertebrectomy followed by reconstruction is a good option. When the vertebral body is involved with lateral and posterior soft-tissue components, a decompressive laminectomy with removal of the soft-tissue components is a good option.32 In cases with rapid and progressive neurological deficit, laminectomy and immediate decompression are mandatory.10 In spite of all of these options, some authors have reported a 6% mortality rate in their surgical groups.30 The most common reason for perioperative morbidity in vertebral hemangioma surgery is intraoperative blood loss or postoperative epidural hematoma.1,10

Transarterial embolization is a useful preoperative adjunct to reduce perioperative hemorrhage and associated morbidity.1,4,10,26 Embolization has also been described as the sole treatment for symptomatic cases, but there are few long-term studies on the outcomes and complications of its use as such.1,18 Acosta et al.1 figured that embolization may be effective as the sole therapy for painful symptoms referable to intraosseous vertebral hemangioma, but that it is only preparation for surgery to resolve neurological symptoms related to extensive lesions. In the present case, angiography demonstrated that the tumors were fed by bilateral L-1 and L-3 lumbar arteries, so preoperative embolization was performed. Although there was no clinical improvement after embolization, this procedure decreased intraoperative blood loss, facilitated surgery, and resulted in no need for blood transfusion.

Percutaneous vertebroplasty, usually with PMMA, is a relatively new technique for treating symptomatic vertebral hemangiomas.13,17 Patients with pathological compression fracture and intractable back pain are good candidates for vertebroplasty.13 The mechanism by which vertebroplasty results in pain relief is unclear but may be related to stabilization of microfractures, prevention of further compression, and PMMA-chemical ablation of pain-sensitive neural roots within the vertebral body.5 Despite its high success rate of 71.4%–91.6%,5,13 this technique may cause several feared complications, such as extravertebral leakage of cement into the spinal canal and pre- and paravertebral venous plexus, with consequent neurological deficit or pulmonary embolism.29 Extravertebral leakage of cement into the spinal canal and pre- and paravertebral venous plexus has resulted in irreversible paralysis in some patients, and in a number of deaths.21,33 Moreover, vertebroplasty is a palliative treatment that does not prevent further progression of hemangiomas.17 Thus, vertebroplasty is contraindicated for patients presenting with a neurological deficit from an expansile vertebral hemangioma.1,4,6

Another percutaneous modality, kyphoplasty, is a modification of vertebroplasty in which an inflatable bone tamp is used to create a cavity within the vertebral body prior to cement injection. It has been used successfully to treat painful vertebral hemangiomas with or without neurological compromise, as described in 5 English-language publications (Table 1). In most of the cases, percutaneous kyphoplasty was used alone and resolved the patients' pain immediately without any complications. Jones et al.18 suggested that kyphoplasty should be the first-line treatment for painful vertebral hemangiomas without neurological compromise. Hadjipavlou et al.15 found kyphoplasty, as an adjunct to open surgery, to be an effective option for the treatment of symptomatic vertebral hemangiomas in the short term. Moore et al.25 pointed out that kyphoplasty combined with open posterior fixation is a useful technique for treating complicated hemangiomas. Both vertebroplasty and kyphoplasty can provide significant pain relief, increased mobility, and improved quality of life in 70%–95% of patients in the short term.24 Compared with vertebroplasty, kyphoplasty provides advantages of decreased cement leakage and partial restoration of vertebral height.18,36 The rate of cement leakage was given in an up-to-date meta-analysis as 7% following kyphoplasty and as 20% following vertebroplasty.7 In a systematic review of clinical studies, the authors reported cement extravasation in 9% of patients after kyphoplasty and in 41% after vertebroplasty.16 The combination of the low-pressure injection and higher viscosity of the cement inserted into the void diminishes the risk of extravertebral extrusion.36 A different hypothesis to explain the decreased cement leakage is “impaction or autografting” of cancellous bone by the inflatable bone tamps from the center of the vertebral body to the periphery, effectively lining the cavity with a layer of higher-density bone.34 Consequently, patients with vertebral fissures, especially in the posterior edge of the vertebral body, may be candidates for kyphoplasty.23 Due to the posterior cortical destruction of the affected bodies in the present case, we preferred kyphoplasty over vertebroplasty largely based upon the decreased extravasation rate with kyphoplasty.

TABLE 1:

Summary of the use of kyphoplasty for treating symptomatic vertebral hemangiomas

Authors & YearType of PublicationNo. of PatientsLevel of TreatmentResultsNotes
Atalay et al., 2006case report1sacralimmediate & sustained reliefkyphoplasty is effective & safer than open surgery
Zapalowicz et al., 2008case report1cervical (C-7)immediate & sustained relief at 13 moskyphoplasty was used to avoid potential cement leakage into spinal canal
Jones et al., 2009case report2lumbar (L-5) & thoracic (T-12)immediate & sustained reliefkyphoplasty may lead to fewer op risks vs traditional treatments
Moore et al., 2012case report2thoracic (T-12 & T-6)immediate & sustained reliefkyphoplasty combined w/ open posterior fixation is useful for complicated hemangiomas
Hadjipavlou et al., 2007prospective, observational study66 lumbar & 5 thoracicimmediate & sustained relief at 6 mosauthors recommend kyphoplasty as sole treatment or w/ either alcohol ablation or open surgery as an adjunct

Recently, procedures similar to kyphoplasty have been developed. One new product is the cement-directing kyphoplasty system (Soteira, Inc.), which involves deployment of a self-expanding implant in the center of the vertebral body using a unipedicular approach, with the implant openings oriented toward the anterior of the vertebral body. Cement flows into the cement director, through the openings, and fills the anterior, superior, and inferior uncompacted bone spaces. Better control of cement flow and a physical barrier to posterior cement flow are provided, potentially reducing the risk of leakage into the basivertebral vein and spinal canal.35 The authors of a prospective randomized study reported a similar product called the shield kyphoplasty system (Soteira, Inc.), which was also performed using a unipedicular approach. This unilateral Soteira technique was comparable to unilateral kyphoplasty regarding leakage and surgery time, was better than unilateral vertebroplasty regarding leakage, and gave the same pain relief as the other 2 techniques.8 A competitor is Vesselplasty (A-Spine), where a porous balloon is inflated within the vertebral body and filled with cement without removing the balloon, thus reducing the risk of cement leakage.9 Because none of these advanced products were available, we performed only standard kyphoplasty in our case.

Surgical techniques for treating symptomatic vertebral hemangiomas need to be tailored for each patient according to the location of the tumor within the vertebra and the patient's symptoms.17 Gnanalingham et al.14 suggested combinations of embolization, vertebroplasty, and minimally invasive posterolateral instrumentation to treat extensive vertebral hemangiomas presenting with neurological deficits. However, patients who have cortical disruption should not undergo a percutaneous vertebral augmentation.20 Considering the severe thecal compression by epidural extension at 2 noncontiguous levels in our case, we decided to perform open surgery including intraoperative kyphoplasty for the following reasons: 1) Open surgery allows direct decompression of the epidural masses, thus relieving thecal compression immediately. 2) When performing kyphoplasty, an accurate puncture route can be visualized, leading to a decreased need for exposure to radiation. 3) During kyphoplasty and after laminectomy, we were able to ensure that there was no cement extravasation into the spinal canal, both by direct visualization of the posterior vertebral body wall and by radiological screening intraoperatively. 4) Use of instrumented fixation allows rigid stability, thus preventing the possible pathological fractures reported earlier. Patients undergoing extensive laminectomy may require posterior instrumentation for stabilization.32

Decompressive laminectomy, intraoperative kyphoplasty, and segmental fixation were combined in the present case, with a good result at least in the short term. This seems a safe and effective way to achieve adequate decompression, eliminate pain, and restore mechanical stability at the same sitting. The patient's pain disappeared, and she regained complete neurological function after surgery. To the best of our knowledge, ours is the first case of 2 noncontiguous lumbar hemangiomas with epidural extension causing cauda equina syndrome that was treated by such combined treatment. Although we did not encounter any recurrence at 16 months postoperation, further study and long-term follow-up are required to assess the efficacy of this combination of procedures.

Acknowledgments

We thank Kaiming Cao, Yang Meng, and Zhaoyu Ba for their help.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Wu, Huang. Acquisition of data: Yu, Qi. Analysis and interpretation of data: Wu, Yu, Zhao, Huang, Zhu, Qi. Drafting the article: Yu, Shen. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Wu.

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    Ahn HJhaveri SYee AFinkelstein J: Lumbar vertebral hemangioma causing cauda equina syndrome: a case report. Spine (Phila Pa 1976) 30:E662E6642005

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    Atalay BCaner HYilmaz CAltinors N: Sacral kyphoplasty for relieving pain caused by sacral hemangioma. Spinal Cord 44:1961992006

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    Chen HIHeuer GGZaghloul KSimon SLWeigele JBGrady MS: Lumbar vertebral hemangioma presenting with the acute onset of neurological symptoms. Case report. J Neurosurg Spine 7:80852007

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    Cohen JELylyk PCeratto RKaplan LUmanskyt FGomori JM: Percutaneous vertebroplasty: technique and results in 192 procedures. Neurol Res 26:41492004

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    Doppman JLOldfield EHHeiss JD: Symptomatic vertebral hemangiomas: treatment by means of direct intralesional injection of ethanol. Radiology 214:3413482000

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    Eck JCNachtigall DHumphreys SCHodges SD: Comparison of vertebroplasty and balloon kyphoplasty for treatment of vertebral compression fractures: a meta-analysis of the literature. Spine J 8:4884972008

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    Endres SBadura A: Shield kyphoplasty through a unipedicular approach compared to vertebroplasty and balloon kyphoplasty in osteoporotic thoracolumbar fracture: a prospective randomized study. Orthop Traumatol Surg Res 98:3343402012

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    Flors LLonjedo ELeiva-Salinas CMartí-Bonmatí LMartínez-Rodrigo JJLópez-Pérez E: Vesselplasty: a new technical approach to treat symptomatic vertebral compression fractures. AJR Am J Roentgenol 193:2182262009

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    Gangi AGuth SImbert JPMarin HDietemann JL: Percutaneous vertebroplasty: indications, technique, and results. Radiographics 23:e102003

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    Gnanalingham KKAfridi MBAbou-Zeid AHerwadkar A: Minimally invasive decompression and stabilisation for extensive haemangiomas of lumbar spine. Minim Invasive Neurosurg 53:2752782010

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    Hadjipavlou ATosounidis TGaitanis IKakavelakis KKatonis P: Balloon kyphoplasty as a single or as an adjunct procedure for the management of symptomatic vertebral haemangiomas. J Bone Joint Surg Br 89:4955022007

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    Hulme PAKrebs JFerguson SJBerlemann U: Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine (Phila Pa 1976) 31:198320012006

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    Inamasu JNichols TAGuiot BH: Vertebral hemangioma symptomatic during pregnancy treated by posterior decompression, intraoperative vertebroplasty, and segmental fixation. J Spinal Disord Tech 19:4514542006

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    Jones JOBruel BMVattam SR: Management of painful vertebral hemangiomas with kyphoplasty: a report of two cases and a literature review. Pain Physician 12:E297E3032009

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Article Information

Drs. Bin Yu, Bin Shen, and Weidong Zhao contributed equally to this work.

Address correspondence to: Desheng Wu, M.D., Department of Spine Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China. email: eastspine@yahoo.com.

Please include this information when citing this paper: published online November 15, 2013; DOI: 10.3171/2013.10.SPINE13499.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Lateral radiograph of the lumbar spine (A) showing coarse vertical striations in the L-1 and L-3 vertebral bodies. Sagittal reconstruction (B) and axial (C and D) CT scans showing the classic polka-dot appearance of the hemangiomas at the L-1 (C) and L-3 (D) levels with expansion and discontinuity of the posterior cortical wall of the vertebral bodies.

  • View in gallery

    Sagittal MR images of the lumbar spine (A–C) showing vertebral tumors involving the entire L-1 and L-3 vertebral bodies, with epidural extension. These lesions appeared mildly hyperintense on both T1-weighted (A) and T2-weighted (B) images and highly enhanced on a postcontrast T1-weighted image (C). Note the T2 signal intensity changes within the cauda equina at the L-2 level on T2-weighted MR (B and E) and MR myelography (D) images. Representative T2-weighted axial image of L-1 (F) revealing severe thecal compression by the bi-lobulated epidural mass.

  • View in gallery

    Preembolization angiograms of the right (A and C) and left (B and D) lumbar arteries showing prominent staining within the L-1 and L-3 vertebrae. Embolization was performed with Gelfoam particles. Postembolization angiograms showing no vascular supply within L-1 (E) or L-3 (F) vertebrae.

  • View in gallery

    Follow-up anteroposterior (A) and lateral (B) radiographs obtained 16 months after surgery showing maintenance of spinal alignment without collapse of the involved bodies. Sagittal reconstruction CT scans (C) at this time demonstrating successful enhancement after kyphoplasty. Representative T2-weighted midsagittal (D) and axial (E) MR images at the L-1 level showing good decompression of the spinal canal and significant resolution of the epidural extension.

References

1

Acosta FL JrSanai NChi JHDowd CFChin CTihan T: Comprehensive management of symptomatic and aggressive vertebral hemangiomas. Neurosurg Clin N Am 19:17292008

2

Ahn HJhaveri SYee AFinkelstein J: Lumbar vertebral hemangioma causing cauda equina syndrome: a case report. Spine (Phila Pa 1976) 30:E662E6642005

3

Atalay BCaner HYilmaz CAltinors N: Sacral kyphoplasty for relieving pain caused by sacral hemangioma. Spinal Cord 44:1961992006

4

Chen HIHeuer GGZaghloul KSimon SLWeigele JBGrady MS: Lumbar vertebral hemangioma presenting with the acute onset of neurological symptoms. Case report. J Neurosurg Spine 7:80852007

5

Cohen JELylyk PCeratto RKaplan LUmanskyt FGomori JM: Percutaneous vertebroplasty: technique and results in 192 procedures. Neurol Res 26:41492004

6

Doppman JLOldfield EHHeiss JD: Symptomatic vertebral hemangiomas: treatment by means of direct intralesional injection of ethanol. Radiology 214:3413482000

7

Eck JCNachtigall DHumphreys SCHodges SD: Comparison of vertebroplasty and balloon kyphoplasty for treatment of vertebral compression fractures: a meta-analysis of the literature. Spine J 8:4884972008

8

Endres SBadura A: Shield kyphoplasty through a unipedicular approach compared to vertebroplasty and balloon kyphoplasty in osteoporotic thoracolumbar fracture: a prospective randomized study. Orthop Traumatol Surg Res 98:3343402012

9

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