Preoperative embolization of hypervascular thoracic, lumbar, and sacral spinal column tumors: technique and outcomes from a single center

Abstract

The existing literature on preoperative spine tumor embolization is limited in size of patient cohorts and diversity of tumor histologies. This report presents our experience with preoperative embolization of hypervascular thoracic, lumbar, and sacral spinal column tumors in the largest series to date. We conducted a retrospective review of 228 angiograms and 188 pre-operative embolizations for tumors involving thoracic, lumbar and sacral spinal column. Tumor vascularity was evaluated with conventional spinal angiography and was graded from 0 (same as normal adjacent vertebral body) to 3 (severe tumor blush with arteriovenous shunting). Embolic materials included poly vinyl alcohol (PVA) particles and detachable platinum coils and rarely, liquid embolics. The degree of embolization was graded as complete, near-complete, or partial. Anesthesia records were reviewed to document blood loss during surgery. Renal cell carcinoma (44.2%), thyroid carcinoma (9.2%), and leiomyosarcoma (6.6%) were the most common tumors out of a total of 40 tumor histologies. Hemangiopericytoma had the highest mean vascularity (2.6) of all tumor types with at least five representative cases followed by renal cell carcinoma (2.0) and thyroid carcinoma (2.0). PVA particles were used in 100% of cases. Detachable platinum coils were used in 51.6% of cases. Complete, near-complete, and partial embolizations were achieved in 86.1%, 12.7%, and 1.2% of all cases, respectively. There were no new post-procedure neurologic deficits or other complications with long-term morbidity. The mean intra-operative blood loss for the hypervascular tumors treated with pre-operative embolization was 1745 cc. Preoperative embolization of hypervascular thoracic, lumbar, and sacral spine tumors can be performed with high success rates and a high degree of safety at high volume centers.

Figure 1

Patient with epidermoid cyst at the T2 vertebral level. Catheter angiogram of the right T2, T3, and T4 segmental arteries (common origin) shows no increased vascularity (Grade 0) at the T2 level (arrow) compared to the normal T3 and T4 levels (arrowheads).

Figure 2

Patient with leiomyosarcoma metastasis at the T12 vertebral level. Catheter angiogram of the right T12 segmental artery shows mildly increased vascularity (Grade 1) with tumor blush (arrow) that is slightly more prominent than the normal vertebral body.

Figure 3

Patient with renal cell carcinoma metastasis at the T5 vertebral level. Catheter angiogram of the right T5 segmental artery shows moderately increased vascularity (Grade 2) with considerable tumor blush (arrow) without arteriovenous shunting.

Figure 4

Patient with hemangiopericytoma at the T11 vertebral level. Catheter angiogram of the right T11 segmental artery shows severely increased vascularity (Grade 3) with intense tumor blush (arrow) and early arteriovenous shunting (arrowheads).

Figure 5

Patient with renal cell carcinoma metastasis at the T8 vertebral level. Catheter angiogram of the left T8 segmental artery shows severely increased vascularity (Grade 3) with intense tumor blush (arrow) and early arteriovenous shunting (arrowheads).

Figure 6

Post embo.tif. Post embolization angiogram of the left T8 segmental artery shows complete resolution of the tumor blush. The embolization was performed with PVA particles infused via a microcatheter (arrow) into the T8 segmental artery after occlusion of the ventral branch with coils (arrowhead).