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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.

Background: Image-guided navigation systems (IGS) grant excellent clinical and radiological results, minimizing risks correlated with spinal instrumentation. However, there is some concern regarding the real need for IGS and its indications., Objective: To analyze the accuracy, technical aspect, and radiation exposure data of the principal IGS based on computed tomography (CT) imaging., Methods: The data of all patients treated for spinal instrumentation with the aid of an IGS system from January 2003 to March 2013 were retrospectively analyzed. We defined 2 groups: group I with an IGS system based on a preoperative CT scan; group II relied on an intraoperative CT scan. Screw accuracy was assessed with a postoperative CT scan control. Radiation dosage for patients was defined by using the technical parameters and dose report data. Statistical analysis was performed using the Fisher exact test with a significance of 5% (P value < .05)., Results: Two thousand twenty patients and 11,144 screws were analyzed. Group I had 794 patients (4246 screws); the accuracy was 96.1%. Group II had 1226 patients (6898 screws) treated, with 98.5% accuracy (P = .001). The radiation dose analysis showed better results in group II, with significant reduction of the effective dose to the patient., Conclusion: The IGS based on an intraoperative CT scan grants excellent results, eliminating the rate of reoperation for misplaced instrumentations (screws, plate, and cage) or for inadequate bone decompression. However, this technology cannot replace the surgical skills, experience, and knowledge necessary for spine surgery.