The natural history and management of symptomatic and asymptomatic vertebral hemangiomas

Abstract

Fifty-nine cases of vertebral hemangioma were seen at the Mayo Clinic between 1980 and 1990. Vertebral hemangiomas were discovered incidentally in 35 patients, while pain was the presenting complaint in 13 patients. Five patients presented directly with progressive neurological deficit requiring surgery, and six patients had surgery elsewhere for spinal cord compression and were referred for follow-up evaluation. To better define the natural history of these lesions, a historical review of these patients was conducted; progression of an asymptomatic or painful lesion to neurological symptoms was found in only two cases (mean follow-up period 7.4 years, range 1 to 35 years). New-onset back pain followed by subacute progression (mean time to progression 4.4 months, range 0.25 to 12 months) of a thoracic myelopathy was the most common presentation for patients with neurological deficit. Initially, all 11 patients with spinal cord compression underwent decompressive surgery with full neurological recovery. Recurrent neurological symptoms were observed in three of six patients following subtotal tumor resection and postoperative administration of 1000 cGy or less radiation therapy (mean follow-up period 8.7 years, range 1 to 17 years). No recurrences were noted in four patients who had subtotal excision plus radiotherapy between 2600 and 4500 cGy. One other patient had gross total tumor removal without radiotherapy and has not had a recurrence. Based on these patients and a review of the literature, the authors recommend annual neurological and radiological examinations for patients with hemangiomas associated with pain, especially young females with thoracic lesions in whom spinal cord compression is most likely to develop. Radiation therapy or embolization is an effective therapeutic alternative for patients with severe medically refractory pain. Regular follow-up monitoring for patients with asymptomatic lesions is unnecessary unless pain develops at the appropriate spinal level. It is concluded that management of patients with a progressive neurological deficit should include preoperative angiography and embolization, decompressive surgery with the approach determined by the degree of vertebral involvement and site of spinal cord compression, and postoperative radiation therapy in patients following subtotal tumor removal. Operative management and complications are discussed.

Intramedullary spinal cord cavernous angioma in children: case report and literature review

“…Histopathology, immunohistochemistry, and electron microscopy show that all lesions are identical regardless of location [12]. Whereas spinal osseous cavernous malformations are highly vascular lesions with a high risk of massive intraoperative blood loss [9,12], intramedullary and intracerebral CAs are angiographically occult [1,2,8,12,13,17] and can be resected with negligible blood loss.…”

“…In 2002, Nagib and O'Fallon [14] summarized nine cases including their two personal cases, and in 2006, Bakir et al [3] reported another pediatric patient with ImCA: Although the number of reported pediatric cases with ImCA is small, we can outline some differences from that of the While ImCA in the adult occur more frequently in women than in men [12,17], with a female/male ratio of approximately 2:1, seven of ten cases of symptomatic ImCA reported in children were male, thus accounting for a male/ female ratio of 2:1. The hypothesis of a hormonal effect leading to a greater risk of bleeding in female adults does not seem to be verified in children, but the mean age at bleeding is 13.2 years (range [8][9][10][11][12][13][14][15][16][17] and can also suggest the hormonal influence of puberty.…”

Pain pattern in multiple vertebral hemangiomas involving non-adjacent levels: report of two cases

“…CT is the procedure of choice for patients with symptomatic hemangiomas, as it determines the extent of the lesion and the site of compression, if present, and it reveals lesions in other vertebrae that an X-ray may have failed to demonstrate [26,32,38]. Magnetic resonance imaging (MRI) is useful, especially in differentiating a hemangioma from other tumors; it is valuable in pre-operative planning and it can provide additional information regarding the aggressiveness of the lesion [14,27]. Spinal angiography is a useful diagnostic tool, especially in pre-operative planning, since it can demonstrate both the vascularity of the lesion and the origin of the feeding vessels [1,11,17,30].…”

“…Our review of the available literature has failed to locate any other reports of similar cases. Fox and Onorfio [14] reported six cases of multiple lesions (two to five affected vertebrae), but there is no information regarding pain pattern or alterations in clinical presentation between the various stages of followup. In addition, we found no report regarding the prognosis of the patient with multiple involvement.…”

“…The incidence of symptomatic hemangiomas is unknown. Fox and Onorfio [14] reported 13 patients out of 58 with symptomatic lesions. Patients with hemangiomas of the spine may remain asymptomatic for many years [30].…”