Direct epidural ethanol injection in aggressive vertebral hemangiomas to decompress the central canal: a multistep percutaneous treatment strategy

Abstract

Background: Vertebral hemangiomas are incidental and typically, asymptomatic lesions of the spine, present in 10-12% of the population. However, aggressive vertebral hemangiomas (AVHs) can compromise the spinal canal, leading to spinal cord or nerve root compression, and require timely treatment to prevent permanent neurological deficits. Surgical management is challenging owing to the high vascularity of AVHs, and carries a significant risk of perioperative blood loss. Intraosseous ethanol injection is commonly used for sclerotization, but may not adequately deal with epidural components.

Objective: To carry out a staged treatment with an image-guided puncture and ethanol injection of the epidural component in 12 patients.

Methods: We retrospectively analyzed 12 patients with symptomatic AVHs who underwent targeted epidural ethanol injection followed by vertebral body cement augmentation, between 2017 and 2024, at three tertiary hospitals. Data collection included pre- and post-treatment imaging and clinical outcomes.

Results: Among 12 patients (mean age 50, women 50%), all had extensive epidural involvement and were symptomatic, including spinal cord compression and pain. Reduction in size of more than 75% of the epidural hemangioma was achieved in 8 cases, with 11 patients experiencing complete symptom resolution. Laminectomy was performed in 3 cases, while corpectomy was avoided in all cases. Two patients had neurological worsening, with one achieving complete resolution and the other having mild residual impairment after rehabilitation due to a small spinal cord ischemic lesion. No other major complications occurred.

Conclusion: Direct epidural ethanol injection provides a minimally invasive alternative to surgery, such as corpectomy, including rapid size reduction of the compressive epidural component, and potentially, prevents retrograde flow into arterial collaterals. Adding vertebroplasty enhances vertebral stability.

Keywords: CT; Spine; Vascular Malformation.

Figure 1. Adult patient presented with an aggressive vertebral hemangioma at T2, accompanied by mild signs of myelopathy and localized pain. During the first treatment session, the extensive epidural components of the hemangioma, visible on preinterventional MRI (A, C), failed to opacify during intraosseously injected contrast agent in CT (B, D).

Figure 2. Adolescent patient with an aggressive vertebral hemangioma at T2, accompanied by an extensive epidural component. Baseline MRI images show severe spinal canal stenosis and spinal cord compression: in sagittal fat-suppressed, contrast-enhanced, T1-weighted (A) and transverse T2-weighted images (B) the typical imaging characteristics of an aggressive vertebral hemangioma are visible. CT-guided direct epidural punctures were performed in both the left (C) and right (D) epidural components, through the laminae, via coaxial needle approach, in different sessions. Visible compartmentalization of the epidural pouch is observed following contrast injection on the left (C). Follow-up MRI after left-sided (E) and right-sided (F) sclerotherapy shows thrombosis within the respective treated compartment (note that the E and F images are at slightly different levels). Final follow-up in Figure 4.

Figure 3. Illustration of the technique. When transpedicular access cannot opacify the epidural component of the hemangioma (A), a direct epidural puncture through the lamina (B) or a direct route, if accessible, for ethanol injection is possible. Depending on the degree of postinterventional size reduction (C), a second injection into a different compartment may be necessary (D). After sufficient decompression of the spinal canal (E), cement augmentation is recommended for final stabilization (F).

Figure 4. The previously mentioned adolescent patient underwent fat-suppressed, contrast-enhanced, T1-weighted MRI before (A, C) and after (B, D) three sessions of percutaneous ethanol injection, dorsal decompression, and vertebroplasty. A significant reduction in size (>75%) of the epidural components of the hemangioma is clearly visible, accompanied by a complete resolution of the spinal cord compression.