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Surgical management of symptomatic vertebral hemangiomas: a single institution experience and literature review


      Vertebral hemangiomas (VHs), formed from a vascular proliferation in bone marrow spaces limited by bone trabeculae, are the most common benign tumors of the spine. While most VHs remain clinically quiescent and often only require surveillance, rarely they may cause symptoms. They may exhibit active behaviors, including rapid proliferation, extending beyond the vertebral body, and invading the paravertebral and/or epidural space with possible compression of the spinal cord and/or nerve roots (“aggressive” VHs). An extensive list of treatment modalities is currently available, but the role of techniques such as embolization, radiotherapy, and vertebroplasty as adjuvants to surgery has not yet been elucidated. There exists a need to succinctly summarize the treatments and associated outcomes to guide VH treatment plans.
      In this review article, a single institution's experience in the management of symptomatic VHs is summarized along with a review of the available literature on their clinical presentation and management options, followed by a proposal of a management algorithm.

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        • Rodallec Mathieu H.
        • et al.
        Diagnostic imaging of solitary tumors of the spine: what to do and say.
        Radiographics. 2008; 28: 1019-1041
        • Huvos AG.
        Hemangioma, lymphangioma, angiomatosis/lymphangiomatosis, glomus tumor.
        (editor)in: Huvos AG Bone tumors: diagnosis, treatment, and prognosis. 2nd ed. Saunders, Philadelphia1991: 553-578
        • Sansur C.A.
        • Pouratian N.
        • Dumont A.S.
        • Schiff D.
        • Shaffrey C.I.
        • Shaffrey M.E.
        PartII: spinal-cord neoplasms--primary tumours of the bony spine and adjacent soft tissues.
        Lancet Oncol. 2007; 8: 137-147
        • Unni K.Krishnan
        • Inwards Carrie Y.
        Dahlin's bone tumors: general aspects and data on 10,165 cases.
        Lippincott Williams & Wilkins, 2010
        • Corniola Marco V.
        • et al.
        Thoracic aggressive vertebral hemangiomas: multidisciplinary management in a hybrid room.
        Eur. Spine J. 2020; 29: 3179-3186
        • Fox Mark W.
        • Onofrio Burton M.
        The natural history and management of symptomatic and asymptomatic vertebral hemangiomas.
        J. Neurosurg. 1993; 78: 36-45
        • Goldstein C.L.
        Spinal hemangiomas: results of surgical management for local recurrence and mortality in a multicenter study.
        Spine Phila. Pa (Phila Pa 1986). 1976; 2015: 656-664
        • Jiang Liang
        • et al.
        Diagnosis and treatment of vertebral hemangiomas with neurologic deficit: a report of 29 cases and literature review.
        The Spine Journal. 2014; 14: 944-954
        • Murphey MD
        • Fairbairn KJ
        • Parman LM
        • Baxter KG
        • Parsa MB
        • Smith WS.
        From the archives of the AFIP. Musculoskeletal angiomatous lesions: radiologic-pathologic correlation.
        Radiographics. 1995; 15: 893-917
        • Cross JJ
        • Antoun NM
        • Laing RJ
        • Xuereb J.
        Imaging of compressive vertebral haemangiomas.
        Eur. Radiol. 2000; 10: 997-1002
        • Gaudino S
        • Martucci M
        • Colantonio R
        • et al.
        A systematic approach to vertebral hemangioma.
        Skeletal Radiol. 2015; 44: 25-36
        • Wang B.
        • Meng N.
        • Zhuang H.
        • Han S.
        • Yang S.
        • Jiang L.
        • et al.
        The role of radiotherapy and surgery in the management of aggressive vertebral hemangioma: aretrospective study of 20 patients.
        Med. Sci. Monit. 2018; 24: 6840-6850
        • Baudrez Vincent
        • Galant Christine
        • Berg Bruno C.Vande
        Benign vertebral hemangioma: MR-histological correlation.
        Skeletal Radiol. 2001; 30: 442-446
        • Alexander Justin
        • et al.
        Vertebral hemangioma: an important differential in the evaluation of locally aggressive spinal lesions.
        Spine. 2010; 35: E917-E920
        • Laredo J.D.
        • et al.
        Vertebral hemangiomas: radiologic evaluation.
        Radiology. 1986; 161: 183-189
        • Carnasale PG
        • Campbell WC
        • Canale ST
        • Beaty JH
        Benign tumors of bone Campbell's Operative Orthopaedics.
        110th ed. Mosby/Elsevier, Philadelphia, PA2003: 793-812
        • Klekamp Jörg
        • Madjid Samii
        Surgery of spinal tumors. Springer Science & Business Media, 2007
        • McAllister V.L.
        • Kendall B.E.
        • Bull J.W.
        Symptomatic vertebral haemangiomas.
        Brain. 1975; 98: 71-80
        • Doppman John L.
        • Oldfield Edward H.
        • Heiss John D.
        Symptomatic vertebral hemangiomas: treatment by means of direct intralesional injection of ethanol.
        Radiology. 2000; 214: 341-348
        • Hart JL
        • Edgar MA
        • Gardner JM
        Vascular tumors of bone.
        Semin Diagn Pathol. 2014; 31: 30-38
        • Dorfman HD
        • Czerniak B.
        Vascular lesions.
        (editors)in: Dorfman HD Czerniak B Bone tumors. Mosby, St. Louis1998: 729-814
        • Hameed M
        • Wold LE
        (editors)in: Fletcher CDM Bridge JA Hogendoorn P Mertens F WHO classification of tumours of soft tissue and bone. 4th ed. IARC Press, Lyon2013 (and 332)
        • Campanacci M.
        in: Campanacci M Bone and soft tissue tumors. Springer, Padova: Piccin Nuova Libraria & Wien1999: 599-618
        • Rudnick J
        • Stern M.
        Symptomatic thoracic vertebral hemangioma: a case report and literature review.
        Arch. Phys. Med. Rehabil. 2004; 85: 1544-1547
        • Pastushyn Anatoly I.
        • Slin'ko Eugen I.
        • Mirzoyeva Gyulnara M.
        Vertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients.
        Surgical neurology. 1998; 50: 535-547
        • Laredo JD
        • Assouline E
        • Gelbert F
        • Wybier M
        • Merland JJ
        • Tubiana JM.
        Vertebral hemangiomas: fat content as a sign of aggressiveness.
        Radiology. 1990; l77: 467-472
      1. Ross JS, Masaryk TJ, Modic MT, Carter JR, Mapstone T, Dengel FH. Vertebral hemangiomas: MR imaging. Radiology 1987;165(1):165–9.

        • Nguyen JP
        • Djindjian M
        • Gaston A
        • Gherardi R
        • Benhaiem N
        • Caron JP
        • et al.
        Vertebral hemangiomas presenting with neurologic symptoms.
        Surg. Neurol. 1987; 27: 391-397
        • Gaston A
        • Nguyen JP
        • Djindjian M
        • Le Bras F
        • Gherardi R
        • Benhaiem N
        • et al.
        Vertebral haemangioma: CT and arteriographic features in three cases.
        J. Neuroradiol. 1985; 12: 21-33
        • Friedman D.P.
        Symptomatic vertebral hemangiomas: MR findings.
        Am. J. Roentgenol. 1976; 167 (1996): 359-364
        • Winfield JM
        • Poillucci G
        Apparent diffusion coefficient of vertebral haemangiomas allows differentiation from malignant focal deposits in whole-body diffusion-weighted MRI.
        Eur. Radiol. 2018; 28: 1687-1691
        • Shi YJ
        • Li XT.
        Differential diagnosis of hemangiomas from spinal osteolytic metastases using 3.0 T MRI: comparison of T1-weighted imaging, chemical-shift imaging, diffusion-weighted and contrast-enhanced imaging.
        Oncotarget. 2017; 8: 71095-71104
        • Morales KA
        • Arevalo-Perez J
        • Peck KK
        • Holodny AI
        • Lis E
        • Karimi S.
        Differentiating atypical hemangiomas and metastatic vertebral lesions: the role of T1-weighted dynamic contrast-enhanced MRI.
        AJNR Am. J. Neuroradiol. 2018; 39: 968-973
      2. McEvoy SH, Farrell M, Brett F, Looby S. Haemangioma, an uncommon cause of an extradural or intradural extramedullary mass: case series with radiological pathological correlation. Insights Imaging. 2016 doi:10.1007/s13244-015-0432-y., 7(1):87-98.

        • Marymont J.V.
        • Shapiro W.M.
        Vertebral hemangioma associated with spinal cord compression.
        South. Med. J. 1988; 81: 1586-1587
        • Acosta Jr,
        • Frank L.
        • et al.
        Comprehensive management of symptomatic and aggressive vertebral hemangiomas.
        Neurosurg Clin North Am. 2008; 19: 17-29
        • Boriani Stefano
        • Weinstein James Neal
        • Biagini Roberto
        Primary bone tumors of the spine: terminology and surgical staging.
        Spine. 1997; 22: 1036-1044
        • Dang Lei
        • et al.
        Aggressive vertebral hemangioma of the thoracic spine without typical radiological appearance.
        Eur. Spine J. 2012; 21: 1994-1999
        • Bailey P
        • Bucy PC.
        Cavernous hemangioma of the vertebrae.
        J Am Med Assoc. 1929; 92: 1748-1751
        • Ghormley RK
        • Adson AW.
        Hemangioma of vertebrae.
        J Bone Joint Surg. 1941; 23: 887-895
        • Krueger Erich G.
        • Sobel Garrison L.
        • Weinstein Charles
        Vertebral hemangioma with compression of spinal cord.
        J. Neurosurg. 1961; 18: 331-338
        • Kato S
        • Kawahara N
        • Murakami H
        • Demura S
        • Yoshioka K
        • Okayama T
        • et al.
        Surgical management of aggressive vertebral hemangiomas causing spinal cord compression: long- term clinical follow-up of five cases.
        J. Orthop. Sci. 2010; 15: 350-356
        • Goldstein CL
        • Varga PP
        • Gokaslan ZL
        • et al.
        Spinal hemangiomas: results of surgical management for local recurrence and mortality in a multicenter study.
        Spine (Phila Pa 1976). 2015; 40: 656-664
        • Acosta Jr,
        • Frank L.
        • et al.
        Treatment of Enneking stage 3 aggressive vertebral hemangiomas with intralesional spondylectomy: report of 10 cases and review of the literature.
        Clin Spine Surg. 2011; 24: 268-275
        • Inoue Toshiyuki
        • et al.
        Total spondylectomy of a symptomatic hemangioma of the lumbar spine.
        J. Clin. Neurosci. 2007; 14.8: 806-809
        • Piper Keaton
        • Zou Liling
        Surgical management and adjuvant therapy for patients with neurological deficits from vertebral hemangiomas: a meta-analysis.
        SPINE. 2020; 45: E99-E110
        • Deramond H
        • Depriester C
        • Galibert P
        • Gars D Le
        Percutaneous vertebroplasty with polymethylmethacrylate: technique, indications, and results.
        Radiol. Clin. North Am. 1998; 36.3: 533-546
        • Guarnieri G
        • Ambrosanio G
        • Vassallo P
        • Pezzullo MG
        • Galasso R
        • Lavanga A
        • et al.
        Vertebroplasty as treatment of aggressive and symptomatic vertebral hemangiomas: up to 4 years of follow-up.
        Neuroradiology. 2009; 51: 471-476
        • Murugan L.
        • Samson R.S.
        • Chandy M.J.
        Management of symptomatic vertebral hemangiomas: review of 13 patients.
        Neurol. India. 2002; 50: 300
        • Singh Pankaj
        • et al.
        Treatment of vertebral hemangiomas with absolute alcohol (ethanol) embolization, cord decompression, and single level instrumentation: a pilot study.
        Neurosurgery. 2011; 68: 78-84
      3. Singh PK, Chandra PS, Vaghani G, et al. Management of pediatric single-level vertebral hemangiomas presenting with myelopathy by three-pronged approach (ethanol embolization, laminectomy, and instrumentation): a single-institute experience. Childs Nerv Sy. 2016;32(2):307-14.

        • Yao KC
        • Malek AM.
        Transpedicular N-butyl cyanoacrylate-mediated percutaneous embolization of symptomatic vertebral hemangiomas.
        J Neurosurg Spine. 2013; 18: 450-455
        • Teferi N
        • Abukhiran I
        • Noeller J
        • Helland LC
        • Bathla G
        • Ryan EC
        • et al.
        Vertebral hemangiomas: diagnosis and management. A single center experience.
        Clin. Neurol. Neurosurg. 2020; 190105745
        • Premat K
        • Clarencon F
        • Cormier E
        • et al.
        Long-term outcome of percutaneous alcohol embolization combined with percutaneous vertebroplasty in aggressive vertebral hemangiomas with epidural extension.
        Eur. Radiol. 2017; 27: 2860-2867
        • Kawahara N
        • Tomita K
        • Murakami H
        • Demura S
        • Yoshioka K
        • Kato S.
        Total en bloc spondylectomy of the lower lumbar spine: a surgical techniques of combined posterior-anterior approach.
        Spine. 2011; 36: 74-82
        • Yang Z-Y.
        • et al.
        Hemangioma of the vertebral column: a report on twenty-three patients with special reference to functional recovery after radiation therapy.
        Acta Radiol: Oncol. 1985; 24: 129-132
        • Heyd Reinhard
        • et al.
        Radiotherapy for symptomatic vertebral hemangiomas: results of a multicenter study and literature review.
        Int J Radiat Oncol* Biol* Phys. 2010; 77: 217-225