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Purpose: To discuss a treatment algorithm for vertebral hemangioma in children. Methods: Vertebral hemangioma (VH) is a rare cause of low back pain in children. In most cases, VHs present as incidental findings and do not require invasive diagnostic procedure. In case of symptomatic presentation, different approaches can be used. Over the years, we have developed a treatment algorithm for VH in children based on our clinical experience. In this manuscript, we propose a stepwise approach to treatment of VHs based on tumor extension and the degree of spinal cord/nerves compression with or without neurological deficit. Results: According to the proposed protocol, we discuss two cases of aggressive VH treated at our institution by a multidisciplinary team. The first case is about a young girl treated with percutaneous one-level posterior instrumentation followed by medical adjuvant therapy for an L4 "Stage 3" VH. The second case is about an 8-year-old boy with rapidly progressive myelopathy due to T11 "Stage 4" VH treated with a combined anterior and posterior surgery (i.e., posterior decompression and fusion followed by vertebrectomy and expandable cage placement) after preoperative arterial embolization. Conclusion: Given the lack of international guidelines and consensus with regard to treatment of VHs in children, we believe our proposal for a stepwise approach combining clinical and radiological characteristics of the lesion may help guide treatment of this condition in children. [ABSTRACT FROM AUTHOR]

Background: This study includes management of aggressive vertebral hemangioma (VH). VH is the most common primary tumor affecting the vertebral column. In 0.9–1.2% of patients, VH can become symptomatic and is termed as “aggressive vertebral hemangiomas.” They usually require surgery along with adjuvant modalities. Due to its relatively low incidence, there is sparse reporting in the open literature and lack of universal consensus on treatment protocol. We would like to present our institutional experience in managing aggressive VH by surgery along with adjuvant modalities and a comprehensive review of the literature. Materials and Methods: A retrospective review of records of VH cases managed surgically in the past 3 years at our institute was done. All the relevant records and imaging of the patients were retrieved. Results: Five patients were included in the study. All were male with four dorsal and one lumbar lesion. All were treated with surgery along with an adjuvant therapy. Selective arterial embolization was used in one patient, alcohol ablation in three, and vertebroplasty in one. Only one patient had gross total resection, and others had only decompression. Fixation was done in all. All showed good clinical improvement without any complications, except in one. Conclusion: Aggressive VH often requires surgery. Currently, a decompression surgery is preferred due to less morbidity with good clinical outcomes. Various adjuvant therapies have been described in literature to be used perioperatively; yet there is no universal consensus on a standard protocol. Each of them has its own advantages and limitations and thus needs to be carefully selected on an individual basis. Alcohol ablation is an established adjuvant modality, but has to be used with caution.

Background: Vertebral hemangioma is the most common benign tumor of the spine, diagnosed incidentally in most cases. In 0.4% of patients, the lesion is considered aggressive, causing neurological deficits. This subtype of hemangioma is characterized by strong postcontrast enhancement, cortical lysis, and epidural extension causing myelopathy and/or radiculopathy., Observations: A 52-year-old man presented with myelopathy symptoms, namely lower-limb hypoesthesia up to the T4-5 sensory level, right leg hyposthenia, and urinary incontinence. Imaging studies revealed a giant dumbbell-shaped lesion causing spinal cord compression, associated with signal alteration of the T3 vertebral body. The diagnosis of schwannoma was not certain given the radiological features, so a biopsy was planned and confirmed the diagnosis of vertebral hemangioma. Preoperative embolization, spinal fusion, and gross-total resection of the extravertebral component of the lesion were performed., Lessons: This report should raise awareness of the differential diagnosis of dumbbell-shaped spinal tumors and the therapeutic strategies available for aggressive vertebral hemangiomas, a rare lesion that should be managed in a multidisciplinary setting. https://thejns.org/doi/10.3171/CASE24190.

Purpose: 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. Methods: 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. Results: 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). Conclusion: 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. [ABSTRACT FROM AUTHOR]

Vertebral hemangiomas are the most common benign vertebral tumors and are usually asymptomatic. Aggressive subtypes of the tumor, called aggressive VHs (AVHs), can become symptomatic with extraosseous extensions and require surgical removal. We present a case of AVH in a 36-year-old man presenting with low back pain and right leg pain that persisted for three months. Imaging studies showed a Th12 vertebral tumor that extended into the spinal canal and was squeezing the spinal cord. Computed tomography (CT)-guided biopsy indicated vertebral hemangimoa. Following preoperative arterial embolization, piecemeal gross total resection was attained under navigation guidance. He was left with no neurological deficit and remained well at the 12-month postoperative folow-up. Since AVHs are benign tumor, piecemeal removal of the tumor can be selected. However, disadvantage of the approach include difficulty of making decision how much to remove the front part of the vertebral body close to thoracic descending aorta. Furthermore, when the tumor tissue is too hard to curett, manipulation in tight spaces near the spinal cord carries the risk of damaging it. Navigation-guided drill is highly helpful for real-time monitoring of ongoing tumor resection. It enables safely resection of the tumor especially in the anterior cortical surface of the vertebral body and easily resection even hard tumors. This method results in reducing residual tumor and maintaining safety resection. [ABSTRACT FROM AUTHOR]

Competing Interests: Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.

Objective. To evaluate the outcomes of the differentiated surgical treatment in patients with aggressive vertebral hemangiomas. Material and Methods. The study included 127 patients with aggressive vertebral hemangiomas operated on in 2013–2016. The tumor lo- calization was cervical in 9.5% of cases, thoracic in 59.8 % and lumbar in 30.7 %. Patients were divided into two groups: Group I (n = 110) with type IIIA aggressive hemangiomas, and Group II (n = 17) with type IIIB aggressive hemangiomas. Preoperative assessment included clinical and neurological examination, VAS, ODI, JOA, Weinstein-Boriani-Biagini classification, and radiography; MSCT and MRI studies of the spine were performed before treatment and in 12 months after surgery. Results. Patients in Group I underwent puncture vertebroplasty. Back pain was 6 VAS, after 12 months – 2 VAS. The average preop- erative ODI score was 32 and decreased to 9 in 12 months after surgery. In Group II, patients underwent decompression and stabiliza- tion with intraoperative open vertebroplasty of the affected vertebra. Preoperative embolization of tumor vessels was performed in two of 17 patients to reduce intraoperative blood loss. Preoperative back pain was 6 VAS, in 12 months after surgery – 2 VAS. The ODI score showed the improvement in all patients as compared to preoperative values. Conclusion. Puncture vertebroplasty ensures the achievement of good functional result in 95.4 % of cases of type IIIA aggressive hemangioma. Decompression and stabilization surgery with intraoperative open vertebroplasty provides good functional result in 93.4 % of cases of type IIIB aggressive hemangioma. The use of vertebroplasty in type IIIB aggressive hemangiomas allows for vertebral segment stabilization with a low risk of the tumor recurrence.

We describe the clinical outcomes in patients with aggressive vertebral hemangiomas (AVHs) after total tumor excision and discuss the treatment options for AVHs. A retrospective data review of 15 patients (6 men, 9 women) with AVHs who underwent total excision between 1996 and 2018 was performed. In total, 13 thoracic and 2 lumbar lesions were involved with 8 type A−D tumors and 7 type B−D tumors based on the Weinstein-Boriani-Biagini classification. All tumors showed low or low-iso signal intensity by T1-weighted magnetic resonance imaging. All patients received a combination of preoperative transarterial embolization and total tumor excision including the tumor margins. Eleven patients underwent total tumor excision as the initial surgery (total en bloc spondylectomy = 10 patients, piecemeal total tumor excision = 1 patient), and 4 underwent it as either a revision procedure 2 weeks after ineffective laminectomy or in the long-term follow-up (4–14 years) as a piecemeal total tumor excision. Intraoperative blood loss ranged from 150 to 3400 mL (mean, 1314 mL). None of the cases had a recurrence during the mean follow-up period of 128.4 ± 88.6 months. Low signal intensity on T1-weighted magnetic resonance imaging was observed in all the patients with AVHs. The long-term clinical results of the preoperative transarterial embolization and total tumor excision were satisfactory. The effect of decompressive incomplete tumor excision is temporary for AVHs, and repeated tumor excision may be necessary because of tumor recurrence in the long term. Reliable total tumor excision during the initial surgery is desirable. [ABSTRACT FROM AUTHOR]

Vertebral hemangioma is one of the most frequent benign tumors of the spine. About 1% of these tumors become aggressive and symptomatic. The aggressive vertebral hemangiomas associated with pregnancy represent an extremely rare condition, and obstetricians should be aware of this pathology in case of subacute onset of motor deficit and paraplegia, especially during the third trimester. The association with pregnancy favors the rapid onset of neurological symptomatology and raises particular issues in terms of prompt diagnosis and treatment, with the aim to prevent both maternal and fetal morbidity. We report a rare case of aggressive thoracic hemangioma during pregnancy. The severe and rapidly progressive neurological deficit caused by the vertebral tumor required complex postpartum interventional and neurosurgical treatment. [ABSTRACT FROM AUTHOR]

To evaluate the efficiency of a comprehensive treatment strategy for patients with Enneking stage 3 thoracic aggressive vertebral hemangioma (AVH). A retrospective analysis of radiographic and clinical outcomes was performed for 17 patients who received treatment for Enneking stage 3 thoracic AVH accompanied by pain and neurologic deficits between January 2010 and February 2015. A visual analog scale (VAS) was used to clinically evaluate the level of pain. Neurologic examinations were performed to assess the patients' sensory symptoms, motor deficits, and Frankel grade. The average operative time was 181.8 ± 37.1 minutes, and the average intraoperative blood loss was 1226.5 ± 151.2 mL (range, 900–1450 mL). All patients underwent preoperative embolization to minimize intraoperative blood loss. All patients experienced immediate pain relief and resolution of their neurologic symptoms. All 17 patients achieved Frankel grade D at the final follow-up; moreover, they reported that their pain was relieved (mean VAS score, 2.82 ± 0.81; P < 0.05) and their neurologic deficits had resolved. No surgery-related complications were noted. No patients exhibited signs of recurrence. We recommend a comprehensive treatment strategy for patients with Enneking stage 3 thoracic AVH that includes preoperative embolization, vertebroplasty, posterior decompression, and internal fixation. We recommend that absorbable gelatin sponge particles be used for intraoperative embolization prior to the injection of bone cement, which may significantly reduce intraoperative bleeding, operative time, and occurrence of surgery-related complications. [ABSTRACT FROM AUTHOR]

Aggressive hemangiomas invade the spinal canal and/or paravertebral space and may cause cord compression and neurological symptoms. Radiation therapy was recognized as an effective strategy for the treatment of aggressive hemangiomas. Here, it is reported the first case of aggressive vertebral hemangioma treated by a combination of intraoperative radiation therapy and kyphoplasty (Kypho-IORT).

Background Context: Aggressive (Enneking stage 3, S3) vertebral hemangiomas (VHs) are rare, which might require surgery. However, the choice of surgery for S3 VHs remains controversial because of the rarity of these lesions.Purpose: We reported our experience of treating S3 VHs, and evaluated the effectiveness and safety of intraoperative vertebroplasty during decompression surgery for S3 VHs.Study Design: This is a retrospective study.Patient Sample: Thirty-nine patients with a definitive pathologic diagnosis of aggressive VHs who underwent primary decompression surgery in our department were included in this study.Outcome Measures: Basic data such as surgical procedure, surgical duration, estimated blood loss during surgery, and pathology were collected. The modified Frankel grade was used to evaluate neurologic function. Enneking staging was based on radiological findings.Methods: We retrospectively examined aggressive VHs with neurologic deficits. Surgery was indicated if the neurologic deficit was severe or developed quickly or if radiotherapy was ineffective. Decompression surgery was performed. Intraoperative vertebroplasty during posterior decompression has been used since 2009. If contrast-enhanced computed tomography (CT) revealed a residual lesion, we recommended adjuvant radiotherapy with 40-50 Gy to prevent recurrence. Patients' basic and surgical information was collected. The minimum follow-up duration was 18 months. This study was partially funded by Peking University Third Hospital, Grant no. Y71508-01.Results: Average age of the 39 patients with S3 VHs who underwent primary decompression surgery was 46.2 (range, 10-69) years. All patients had neurologic deficits caused by aggressive VHs. Aggressive VH lesions were located in the cervical, thoracic, and lumbar spine in 2, 32, and 5 patients, respectively. The decompression-alone group had 17 patients, and the decompression plus intraoperative vertebroplasty group had 22. There were no statistically significant intergroup differences in preoperative information (p>.05). The average estimated blood losses were 1,764.7 mL (range, 500-4,000 mL) and 1,068.2 mL (range, 300-3,000 mL) in the decompression-alone group and decompression plus vertebroplasty group, respectively (p=.017). One patient who underwent primary decompression alone without adjuvant radiotherapy experienced recurrence after the first decompression. The average follow-up was 50.2 (range, 18-134) months, and no cases of recurrence were observed at the last follow-up.Conclusions: Our results suggest that posterior decompression effectively provides symptom relief in patients with aggressive (S3) VHs with severe spinal cord compression. Intraoperative vertebroplasty is a safe and effective method for minimizing blood loss during surgery, whereas adjuvant radiotherapy or vertebroplasty helps in minimizing recurrence after decompression. [ABSTRACT FROM AUTHOR]

OBJECTIVE Vertebral hemangiomas are common tumors that are benign and generally asymptomatic. Occasionally these lesions can exhibit aggressive features such as bony expansion and erosion into the epidural space resulting in neurological symptoms. Surgery is often recommended in these cases, especially if symptoms are severe or rapidly progressive. Some surgeons perform decompression alone, others perform gross-total resection, while others perform en bloc resection. Radiation, embolization, vertebroplasty, and ethanol injection have also been used in combination with surgery. Despite the variety of available treatment options, the optimal management strategy is unclear because aggressive vertebral hemangiomas are uncommon lesions, making it difficult to perform large trials. For this reason, the authors chose instead to report their institutional experience along with a comprehensive review of the literature. METHODS A departmental database was searched for patients with a pathological diagnosis of "hemangioma" between 2008 and 2015. Medical records were reviewed to identify patients with aggressive vertebral hemangiomas, and these cases were reviewed in detail. RESULTS Five patients were identified who underwent surgery for treatment of aggressive vertebral hemangiomas during the specified time period. There were 2 lumbar and 3 thoracic lesions. One patient underwent en bloc spondylectomy, 2 patients had piecemeal gross-total resection, and the remaining 2 had subtotal tumor resection. Intraoperative vertebroplasty was used in 3 cases to augment the anterior column or to obliterate residual tumor. Adjuvant radiation was used in 1 case where there was residual tumor as well. The patient who underwent en bloc spondylectomy experienced several postoperative complications requiring additional medical care and reoperation. At an average follow-up of 31 months (range 3-65 months), no patient had any recurrence of disease and all were clinically asymptomatic, except the patient who underwent en bloc resection who continued to have back pain. CONCLUSIONS Gross-total resection or subtotal resection in combination with vertebroplasty or adjuvant radiation therapy to treat residual tumor seems sufficient in the treatment of aggressive vertebral hemangiomas. En bloc resection appears to provide a similar oncological benefit, but it carries higher morbidity to the patient.