Hypervascular spinal tumors: influence of the embolization technique on perioperative hemorrhage

Abstract

Background and purpose: Corporectomy is an effective treatment for vertebral metastases; however, massive perioperative hemorrhage is often associated with this procedure. We compared preoperative particle, particle-coil, and coil embolizations of hypervascular spinal tumors prior to vertebral body replacement to determine which prevented perioperative hemorrhage most effectively.

Methods: The vertebral tumors of 59 patients were embolized prior to corporectomy. In 26 cases, only coils were used for the proximal occlusion of feeding segmental arteries. Twenty-four patients received a combination of polyvinyl alcohol (PVA) particles and coils, and nine tumors were embolized with particles alone. We compared intraoperative blood loss between the three groups and 10 other patients who did not undergo embolization prior to corporectomy.

Results: Estimation of intraoperative hemorrhage showed a median value of 4350 mL in patients without embolization, 2650 mL in cases of coil embolization, 1850 mL in cases of particle-coil embolization, and 1800 mL in cases of particle embolization. The difference between unembolized patients and those who underwent coil embolization was not statistically significant. Particle and particle-coil embolizations showed very similar results, and reduced hemorrhage significantly as compared to unembolized and proximal coil occlusion cases. Residual bleeding came from the venous system and the neighborhood of the embolized region.

Conclusion: Particle embolization prior to corporectomy can reduce perioperative hemorrhage. The additional benefit of proximal coil occlusion of arterial feeders is questionable.

fig 1.

Diagram shows range of variation of intraoperative hemorrhage in corporectomy procedures according to embolization technique. Minimum, median, and maximum values of estimated blood loss are indicated for each group of patients

fig 2.

Comparisons of estimated median blood loss and statistical significance (U test) of no vs coil (N.S.), coil vs particle-coil (P = .05), no vs particle-coil (P = .01), and no vs particle embolization (P = .01) are shown. No significant difference could be demonstrated between the two particle techniques. The table shows mean and median blood losses and the standard deviation. Additionally, the number of transfused units of packed red blood cells (300 ml each) is indicated

fig 3.

The stages of a patient with renal cell carcinoma who underwent corporectomy 24 hours after embolization are shown. A, Abdominal aortogram shows an angiomatous pattern of vascularization. A strong tumor blush and enlarged feeding segmental arteries are visible. B, No residual tumor staining is visible after coil embolization with occlusion of the segmental pedicles at the level of L4 and L5 on both sides. C, Twenty-four hours after embolization, the corporectomy procedure had to be interrupted because massive hemorrhage (6800 ml) occurred during preparation and stabilization. A control angiogram showed revascularization of the tumor through collateral branches of the iliolumbar truncus. After reembolization with PVA particles, the vertebral body replacement could be completed in a second session with a blood loss of 2200 ml. D, A radiograph of the lumbar spine shows the dorsal and ventral internal fixation and the titanium basket in place.