- February 2008 - Volume 31 · Issue 2:
Vertebral hemangiomas are benign vascular tumors. There are 3 histological types of vertebral hemangioma: capillary, cavernous, and mixed.1,2
Hemangiomas are most frequently localized in the spine and occur in approximately 10% of the world’s population.1 These tumors usually involve a solitary lesion localized in the vertebral body. Although there is a predilection for the thoracic region of the spine, hemangiomas also may occur in the cervical or lumbar spines. Vertebral hemangiomas represent 2% to 3% of all radiographically detectable spinal tumors.1,2
Symptomatic vertebral hemangiomas are rare and represent <1% of all hemangiomas; however, if untreated, they can lead to serious neurological deficits.3,4 This article presents a case of multiple vertebral hemangiomas in the thoracic region causing spinal cord compression secondary to epidural extension.
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Figure 1: MRI showing high intensity lesions involving the T3, T6-T8, and T10-T11 vertebrae.
A 58-year-old man presented with severe pain in the dorsal region and bilateral progressive foot numbness of 3 months’ duration. He had bilateral diffuse weakness of the lower extremities that was equal for both sites.
On examination, there was tenderness to fist percussion over the mid-dorsal spine. A Romberg test was positive. The patient demonstrated 1/4 knee-jerk and ankle-jerk reflexes bilaterally, as well as a positive tension sign at 45° on the left side. There were no signs of paraparesis in the lower extremities, but subjective nondermatomal sensory loss was noted bilaterally. No other long tract signs were apparent. There was no gait disturbance, and the patient’s bladder and bowel functions were not affected.
Laboratory studies yielded normal values. T1- and T2-weighted magnetic resonance imaging (MRI) of the thoracic spine revealed high intensity lesions involving the T3, T6-T8, and T10-T11 vertebrae (Figure 1). The T3 lesion had a soft tissue component that resulted in compression of the left T3-T4 neural foramen without an expansion in the vertebral body and epidural extension.
In the T6-T8 vertebral region, the right pedicles and articular processes were involved. In addition, the left pedicle and the articular process as well as the laminar and spinous processes were involved in the T8 vertebral region. At the T7-T8 level, an epidural soft tissue component with a thickness of 4 to 5 mm was present, causing thoracic spinal cord compression (Figure 2). In the T10-T11 vertebrae, 2 focal lesions were present.
With these MRI findings, the lesions were typical for multiple vertebral hemangiomas. Because the patient’s compressive neurological symptoms had developed slowly, nonsurgical measures such as spinal embolization or radiotherapy were considered. As the lesions were present at multiple thoracic vertebrae, the T3 through T12 vertebral region was irradiated. A total dose of 40 Gy was administered in 20 fractions, 5 days per week, in a 4-week period.
One month after irradiation, the patient’s foot numbness and pain symptoms resolved. At his 1- and 3-month follow-up visits, the patient’s reflexes had returned to normal bilaterally, and the remainder of the related neurological examination was normal.
Magnetic resonance imaging obtained 2 years after irradiation the hemangiomas involving the T3-T4 and T6-T7 vertebral bodies were stable (Figure 3). The thickness of the epidural soft tissue component in the T7-T8 level was decreased (2-3 mm) with minimal spinal cord compression (Figure 4). Three years after irradiation, the neurological examination was normal.
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Figure 2: MRI showing an epidural soft tissue component at the T7-T8 level that caused thoracic spinal cord compression. Figure 3: MRI obtained 2 years after irradiation showing hemangiomas involving the T3-T4 and T6-T7 vertebral bodies were stable. Figure 4: MRI obtained 2 years after irradiation showing decreased thickness of the epidural soft tissue component at the T7-T8 level with minimal spinal cord compression.
Vertebral body hemangiomas are benign lesions and account for 4% of all spinal tumors. The most common type of presentation is an incidental inactive lesion requiring no treatment. An active lesion with spinal cord compression or nerve root compression is seen rarely.3
The diagnosis is made by radiologic studies. If at least one third of the vertebral body is involved, a honeycomb appearance is observed on radiographs. Sometimes compression fractures can be seen. The thickened vertical trabeculae causing axial cuts, which is called polka dot, can be seen on computed tomography.5,6
Magnetic resonance imaging plays the main role in the diagnosis of the hemangiomas. The differentiation between intra- and extraosseous hemangiomas is important as extraosseous hemangiomas are associated more frequently with symptomatic lesions. Inactive hemangiomas have a predominantly fatty avascular stroma showing a high signal of equivalent intensity on both T1- and T2-weighted MRI, but active lesions have a soft tissue hypervascular stroma showing low signal intensity on T1-weighted MRI.7,8
Symptomatic vertebral hemangiomas are rare. The incidence rate of female to male changes between 2 to 1 and 9 to 2. The most frequent symptom is pain. Motor dysfunction may occur if there is spinal cord compression. As with our patient, symptoms usually occur in the fourth or fifth decade of life. The level of the symptomatic lesion in our patient was the lower thoracic spine, which is consistent with the most common location for symptomatic vertebral hemangiomas. Off all lesions with extraosseous protrusion, 90% are located in the thoracic level, and 75% of these are located between T3 and T9.2,6,9,10
Treatment of vertebral hemangiomas is indicated if symptoms such as neurological deficits or severe pain develop. The most common treatment option for painful lesions is radiotherapy. If radiotherapy is used as a single treatment modality, a total dose of 30 to 40 Gy in 15 to 20 fractions is recommended11-13; the most recommended dose is 40 Gy.
In their study of 117 patients, Templin et al10 reported complete pain relief was achieved in only 39% of patients who were treated with doses between 20 and 34 Gy, whereas complete pain relief was achieved in 82% of patients who were treated with doses between 36 and 40 Gy. In our patient, complete pain relief was achieved with 40 Gy in 20 fractions. We agree that in most cases, the treatment dose should be between 36 and 40 Gy to obtain optimum pain relief.
Another treatment option is embolization; however, embolization is neither a diagnostic modality nor a routine management strategy for vertebral hemangiomas. Embolization may be used as a preoperative adjunct or as a treatment strategy in certain rare circumstances, but it is associated with risks that may or may not justify its use. In the potential watershed area of the mid-thoracic spine, embolization may be more dangerous than resection. However, in a report by Hekster et al, embolization alone was successful in reducing neurological symptoms.10,14
Surgical intralesional resection, either anteriorly or posteriorly, also has been advocated. Early reports in the literature tended to use laminectomy with or without fusion. Fox and Onofrio15 thoroughly outlined the surgical management of these lesions based on the degree and pattern of vertebral involvement. Corpectomy with strut graft reconstruction is the most appropriate intervention based on the degree of anterior vertebral involvement.
In cases with spinal cord compression, a decompressive laminectomy usually is performed.16 For patients who undergo a subtotal excision, postoperative radiotherapy should be added to the treatment since postoperative radiotherapy can significantly decrease the number of recurrences.5 Fox and Onofrio15 reported when circumstances dictated that an inaccessible tumor be left in place, a dose of >26 Gy was preventative for tumor recurrence. In children, surgery becomes the main role for the treatment of vertebral hemangiomas so as to protect them from the harmful effects of radiotherapy.
Although vertebral hemangiomas are common, those that cause compressive neurological symptoms are insidious in onset. In cases of rapidly progressing neurological deficits, surgical decompression with vertebral corpectomy and spinal reconstruction is indicated. If neurological symptoms develop slowly, nonsurgical measures such as radiotherapy or embolization are reasonable.
- Hillman J, Bynke O. Solitary extradural cavernous hemangiomas in the spinal canal: report of five cases. Surg Neurol. 1991; 36(1):19-24.
- Nguyen JP, Djindjian M, Gaston A, et al. Vertebral hemangiomas presenting with neurologic symptoms. Surg Neurol. 1987; 27(4):391-397.
- McAllister VL, Kendall BE, Bull JW. Symptomatic vertebral haemangiomas. Brain. 1975; 98(1):71-80.
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- Bremnes RM, Hauge HN, Sagsveen R. Radiotherapy in the treatment of symptomatic cervical vertebral hemangiomas: technical case report. Neurosurgery. 1996; 39(5):1054-1058.
- Pastushyn AI, Slin’ko EI, Mirzoyeva GM. Vertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients. Surg Neurol. 1998; 50(6):535-547.
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- Laredo JD, Assouline E, Gelbert F, Wybier M, Merland JJ, Tubiana JM. Vertebral hemangiomas: fat content as a sign of aggressiveness. Radiology. 1990; 177(2):467-472.
- Healy M, Herz DA, Pearl L. Spinal hemangiomas. Neurosurgery. 1983; 13(6):689-691.
- Templin CR, Stambough JB, Stambough JL. Acute spinal cord compression caused by vertebral hemangioma. Spine J. 2004; 4(5):595-600.
- Heyd R, Strassman G, Filipowicz I, Borowsky K, Martin T, Zamboglou N. Radiotherapy in vertebral hemangioma [in German]. Rontgenpraxis. 2001; 53(5):208-220.
- Guedea F, Majo J, Guardia E, Canals E, Craven-Bartle J. The role of radiotherapy in vertebral hemangiomas without neurological signs. Int Orthop. 1994; 18(2):77-79.
- Schild SE, Buskirk SJ, Frick LM, Cupps RE. Radiotherapy for large symptomatic hemangiomas. Int J Radiat Oncol Biol Phys. 1991; 21(3):729-735.
- Hekster RE, Luyendijk W, Tan TI. Spinal cord compression caused by vertebral haemangioma relieved by percutaneous catheter embolization. Neuroradiology. 1972; 3(3):160-164.
- Fox MW, Onofrio BM. The natural history and management of symptomatic and asymptomatic vertebral hemangioma. J Neurosurg. 1993; 78(1):36-45.
- Krueger EG, Sobel GL, Weinstein C. Vertebral hemangioma with compression of spinal cord. J Neurosurg. 1961; 18(5):331-338.
Drs Aksu and Fayda are from the Department of Radiation Oncology, Faculty of Medicine, Kocaeli University, Dr Saynak is from the Department of Radiation Oncology, Faculty of Medicine, Trakya University, and Dr Karadeniz is from the Department of Radiotherapy, Istanbul University Oncology Institute, Turkey.
Drs Aksu, Fayda, Saynak, and Karadeniz have no relevant financial relationships to disclose.
Correspondence should be addressed to: Gorkem Aksu, MD, Department of Radiation Oncology, Faculty of Medicine, Kocaeli University, Umuttepe, Turkey.