Aggressive vertebral hemangioma of the thoracic spine without typical radiological appearance

Abstract

Purpose: Vertebral hemangioma (VH) is virtually vascular malformation, which is usually asymptomatic. Only 3.7 % of VH may become active and symptomatic, and 1 % may invade the spinal canal and/or paravertebral space. Treatment protocols for active or aggressive VHs are still in controversy. Reported treatments include radiotherapy, vertebroplasty, direct alcohol injection, embolization, surgery and a combination of these modalities.

Methods: A 41-year-old lady was presented with 18 month history of intermittent back pain. CT revealed T5 osteolytic lesion with epidural and paravertebral extension. The first CT guided biopsy yielded little information.

Results: Histopathological diagnosis of the second biopsy was VH. Vertebroplasty, posterior decompression and fixation were performed followed by postoperative radiotherapy. Her symptoms were resolved immediately after the operation. At 12 months follow-up, no recurrence was detected by CT with contrast enhancement.

Conclusion: Surgical decompression, vertebroplasty and fixation are safe and effective for aggressive VH. More attention is needed in determining the algorithm for the diagnosis and treatment of aggressive VH.

Fig. 1

a, b Anterioposterior radiography showed the eagle sign (thin arrow). c–e CT scan (axial, sagittal and coronal) revealed an osteolytic lesion in T5 vertebral body, left pedicles and lamina. The cortex of T5 vertebral body was partially disrupted. f, g. The lesion was heterogeneously hypointense on T1-weighted image and hyperintense on T2-weighted image. H. The lesion was hyperintense on fat suppression image. I. Axial MR image showed the vertebral tumor extended into the spinal canal and paravertebral region (thick arrow). J. CT scan obtained during the first biopsy carried out in another hospital showed the tip by a transpedicular approach

Fig. 2

The second biopsy carried out in our centre shows the tip of the trocar placed in the paravertebral soft tissue

Fig. 3

Another vertebral hemangiomas case who had neurological deficit with typical radiological findings. a Axial CT scan showed the classical ‘‘honeycomb’’ sign. The laminar lesion extruded into the canal with bony compression. b The lesion gave a salt and pepper appearance in axial MR image. The lesion had both epidural (thin arrow) and paravertebral (thick arrow) extension

Fig. 4

a Intra-operative vertebroplasty. After vertebroplasty and pedicle screw fixation, the dura was exposed. b Intra-operative picture after laminectomy. After left facetomy, the soft tumor mass was clearly exposed and then resected. c Lateral radiography before closure

Fig. 5

Our suggested protocol (PUTH) for the diagnosis and management of aggressive vertebral hemangioma with neurological deficit. It is based on literature review and our previous experience. § our first suggested treatment choice. *classical CT findings are honeycomb and vertically oriented vertebral lucencies separated by thickened trabecular bone; classical MRI findings are a salt and pepper appearance and significantly enhanced by gadolinium