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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Contributed by Harini Seshadri
Contributed by Harini Seshadri
Preoperative embolization of a spinal hemangioma
Preoperative embolization of a spinal hemangioma
Introduction :
Introduction :
A hemangioma is the most common tumor of the spine. It has been found in close to 11% of autopsy specimens. Females are somewhat more commonly affected.
A hemangioma is the most common tumor of the spine. It has been found in close to 11% of autopsy specimens. Females are somewhat more commonly affected.
Hemangiomas are often an incidental finding on CT and MR imaging and often frequently found on plain radiographs of spine. Most common presenting complaint is back pain either due to collapse of vertebral body or encroachment of neural foramina. However, patient who presents with back pain with history of a previous incidentally noted hemangioma should not misdirect the clinician to think of hemangioma as the cause and metastasis, infection, osteoporotic compression fractures and other common etiologies of back pain must be ruled out.
Hemangiomas are often an incidental finding on CT and MR imaging and often frequently found on plain radiographs of spine. Most common presenting complaint is back pain either due to collapse of vertebral body or encroachment of neural foramina. However, patient who presents with back pain with history of a previous incidentally noted hemangioma should not misdirect the clinician to think of hemangioma as the cause and metastasis, infection, osteoporotic compression fractures and other common etiologies of back pain must be ruled out.
On Histopathology, hemangiomas can be of two types, cavernous and capillary. Cavernous hemangiomas are large blood spaces with no intervening bone while capillary hemangiomas are thin walled capillaries separated by normal bone.
On Histopathology, hemangiomas can be of two types, cavernous and capillary. Cavernous hemangiomas are large blood spaces with no intervening bone while capillary hemangiomas are thin walled capillaries separated by normal bone.
Given that hemangiomas are a benign entity, no treatment is generally applied for asymptomatic lesions. Painful hemangiomas can be treated by endovascular embolization which is found to relieve spinal compression from epidural extension. Other options include vertebroplasty and transpedicular ethanol injection with its attendant complications.
Given that hemangiomas are a benign entity, no treatment is generally applied for asymptomatic lesions. Painful hemangiomas can be treated by endovascular embolization which is found to relieve spinal compression from epidural extension. Other options include vertebroplasty and transpedicular ethanol injection with its attendant complications.
Case Record:
Case Record:
A 58-year-old man presented with back pain and difficulty in walking for three months. There was no history of trauma or fall. The pain was constant and nagging.
A 58-year-old man presented with back pain and difficulty in walking for three months. There was no history of trauma or fall. The pain was constant and nagging.
The patient gave history of pulmonary Koch’s and took AKT for six months. Currently has no cough or fever.
The patient gave history of pulmonary Koch’s and took AKT for six months. Currently has no cough or fever.
Patient has no comorbidities. He was operated for benign hyperplasia of prostate in 2016.
Patient has no comorbidities. He was operated for benign hyperplasia of prostate in 2016.
On Examination: He was afebrile. Tenderness was noted at D6 level. There was no swelling.
On Examination: He was afebrile. Tenderness was noted at D6 level. There was no swelling.
Laboratory tests showed a hemoglobin of 10.2. All other lab parameters were within normal range.
Laboratory tests showed a hemoglobin of 10.2. All other lab parameters were within normal range.
Neurologic examination revealed weakness 3/5 of lower limbs, hyperreflexia of deep tendon reflex of lower limbs, hypoesthesia under D 6 level, and no sphincteric dysfunction.
Neurologic examination revealed weakness 3/5 of lower limbs, hyperreflexia of deep tendon reflex of lower limbs, hypoesthesia under D 6 level, and no sphincteric dysfunction.
Radiological Findings:
Radiological Findings:
On MRI (Fig. 1) the lesion was well defined, T1 and T2 hyperintense, seen in the D6 vertebral body with large enhancing soft tissue component measuring 5x3.7x3 cm extending into the right paravertebral region laterally via D5-D6 neural foramen and extension into the spinal canal, displacing the dorsal cord to the left side. No associated cord signal seen. Normal curvature of spine is maintained. Rest of the vertebral bodies and intervertebral discs are normal. Diffuse posterior disc bulge at L5-S1 level. These findings are consistent with vertebral body hemangioma at multiple levels (D4, D6, D7 and D9) , largest at D6 level with a large soft tissue component with intraspinal extension and mass effect.
On MRI (Fig. 1) the lesion was well defined, T1 and T2 hyperintense, seen in the D6 vertebral body with large enhancing soft tissue component measuring 5x3.7x3 cm extending into the right paravertebral region laterally via D5-D6 neural foramen and extension into the spinal canal, displacing the dorsal cord to the left side. No associated cord signal seen. Normal curvature of spine is maintained. Rest of the vertebral bodies and intervertebral discs are normal. Diffuse posterior disc bulge at L5-S1 level. These findings are consistent with vertebral body hemangioma at multiple levels (D4, D6, D7 and D9) , largest at D6 level with a large soft tissue component with intraspinal extension and mass effect.
The CT scan (Fig. 2) howed a minimally expansile lesion with coarse trabecular pattern with the classical 'polka dot' sign.
The CT scan (Fig. 2) howed a minimally expansile lesion with coarse trabecular pattern with the classical 'polka dot' sign.
Fig. 1
Fig. 1
Fig. 2
Fig. 2
Interventional treatment:
Interventional treatment:
Hence, preoperative embolization was planned followed by six level transpedicular fixation.
Hence, preoperative embolization was planned followed by six level transpedicular fixation.
Under local anesthesia, through a right transfemoral arterial access , a Cobra catheter was used to selectively catheresise the target posterior intercostal arteries using co-axial technique (Fig. 3a,3b). A microcatheter was then advanced. Embolization was achieved using embospheres (100 – 300 microns) (Fig. 4a, 4b). The patient was operated (Fig. 5,6) two days later, with intraprocedural blood loss of 750 ml and histopathology was suggestive of hemangioma.
Under local anesthesia, through a right transfemoral arterial access , a Cobra catheter was used to selectively catheresise the target posterior intercostal arteries using co-axial technique (Fig. 3a,3b). A microcatheter was then advanced. Embolization was achieved using embospheres (100 – 300 microns) (Fig. 4a, 4b). The patient was operated (Fig. 5,6) two days later, with intraprocedural blood loss of 750 ml and histopathology was suggestive of hemangioma.
Fig. 3a
Fig. 3a
Fig. 3b
Fig. 3b
Fig. 4a
Fig. 4a
Fig. 4b
Fig. 4b
Fig. 5
Fig. 5
Fig. 6
Fig. 6
Discussion :
Discussion :
Spinal hemangioma are the most primary tumor of spine1 . Usually benign, this lesion is of vascular origin and like hemangioma in other parts of the body usually involves a proliferation of normal capillary and venous structures 2. According to one study, they have been identified in about 11 % of patients at general autopsy 3. These lesions are usually an incidental finding often found on CT and MR imaging of the body ad spine, and frequently in radiographs of the thoracolumbar spine. A minority of these lesions can be associated with symptoms, primarily involving back pain and neurologic complaints with estimates of 0.9% to 1.2% becoming symptomatic5. Symptom can involve severe back pain worsened by movement; however mild to moderate pain can also be a presenting complaint. In case of neurogenic pain, hemangiomas usually extend into the spinal canal or neural foramina. Although the exact etiology and inciting factor of spinal hemangioma genesis are not well understood, a well-known characteristic of this benign lesion includes vascular proliferation of capillaries similar to hemangioma in other parts of the body. Proliferation subsequently causes displacement of bone and in rarer cases, erosion into spinal canal. Unlike infantile hemangioma, hemangiomas of spine do not spontaneously regress.
Spinal hemangioma are the most primary tumor of spine1 . Usually benign, this lesion is of vascular origin and like hemangioma in other parts of the body usually involves a proliferation of normal capillary and venous structures 2. According to one study, they have been identified in about 11 % of patients at general autopsy 3. These lesions are usually an incidental finding often found on CT and MR imaging of the body ad spine, and frequently in radiographs of the thoracolumbar spine. A minority of these lesions can be associated with symptoms, primarily involving back pain and neurologic complaints with estimates of 0.9% to 1.2% becoming symptomatic5. Symptom can involve severe back pain worsened by movement; however mild to moderate pain can also be a presenting complaint. In case of neurogenic pain, hemangiomas usually extend into the spinal canal or neural foramina. Although the exact etiology and inciting factor of spinal hemangioma genesis are not well understood, a well-known characteristic of this benign lesion includes vascular proliferation of capillaries similar to hemangioma in other parts of the body. Proliferation subsequently causes displacement of bone and in rarer cases, erosion into spinal canal. Unlike infantile hemangioma, hemangiomas of spine do not spontaneously regress.
The incidence of spinal hemangiomas has been reported as 11% in autopsy studies3.
The incidence of spinal hemangiomas has been reported as 11% in autopsy studies3.
Most are incidentally noted and can be characterized on radiographs and cross-sectional imaging.
Most are incidentally noted and can be characterized on radiographs and cross-sectional imaging.
Females are somewhat more affected than males 8. Incidence has also been reported on MRI studies to be as high as 27%8.
Females are somewhat more affected than males 8. Incidence has also been reported on MRI studies to be as high as 27%8.
Grossly, specimens can show periosteal elevation. Two histological types of hemangiomas of vertebra can occur, capillary and cavernous.
Grossly, specimens can show periosteal elevation. Two histological types of hemangiomas of vertebra can occur, capillary and cavernous.
Cavernous angioma involve large blood vessels not separated by normal bone. Capillary angioma involve thin walled capillaries separated by normal bone. There is a capsule surrounding the lesion with adjacent bone potentially exhibiting osteolysis9.
Cavernous angioma involve large blood vessels not separated by normal bone. Capillary angioma involve thin walled capillaries separated by normal bone. There is a capsule surrounding the lesion with adjacent bone potentially exhibiting osteolysis9.
The primary goal of a thorough history and physical examination is twofold in the setting of a symptomatic hemangioma. A clinician must rule out more concerning etiologies and assess patient’s health status in the setting of planned intervention.
The primary goal of a thorough history and physical examination is twofold in the setting of a symptomatic hemangioma. A clinician must rule out more concerning etiologies and assess patient’s health status in the setting of planned intervention.
History taking should intensity of pain, quality of pain, radiation, exacerbating and relieving factors.
History taking should intensity of pain, quality of pain, radiation, exacerbating and relieving factors.
Hemangiomas tend to present in the thoracic spine and present with pain in one location. Pain in multiple locations are likely to suggest metastasis.
Hemangiomas tend to present in the thoracic spine and present with pain in one location. Pain in multiple locations are likely to suggest metastasis.
Physical examination primarily involves a thorough back examination that includes visual inspection of overlying skin, assessing curvature of spine and observing the gait.
Physical examination primarily involves a thorough back examination that includes visual inspection of overlying skin, assessing curvature of spine and observing the gait.
The range of motion should be assessed.
The range of motion should be assessed.
Special maneuvers to assess for radiculopathy should be performed including straight leg raising test for lower back and spurling maneuver in the setting of cervical radiculopathy.
Special maneuvers to assess for radiculopathy should be performed including straight leg raising test for lower back and spurling maneuver in the setting of cervical radiculopathy.
Finally, physical examination should include evaluation of gastrointestinal and genitourinary systems.
Finally, physical examination should include evaluation of gastrointestinal and genitourinary systems.
The role of imaging is critical in the evaluation of a hemangioma including lesion size, site and degree of lytic involvement of the spinal cord and neural foramina.
The role of imaging is critical in the evaluation of a hemangioma including lesion size, site and degree of lytic involvement of the spinal cord and neural foramina.
Radiograph shows typical trabecular pattern with vertical striations. The density of the vertebral body is often increased giving it a sclerotic appearance.
Radiograph shows typical trabecular pattern with vertical striations. The density of the vertebral body is often increased giving it a sclerotic appearance.
Vertebral body size and height should remain unaffected.
Vertebral body size and height should remain unaffected.
On CT, hemangiomas have characteristic corduroy appearance.
On CT, hemangiomas have characteristic corduroy appearance.
Given that the vast majority of hemangiomas are asymptomatic and are a benign entity, treatment and intervention are usually not employed in asymptomatic patients. In the settings of symptomatic patients, endovascular and percutaneous vertebroplasty are affected for pain relief11. Most studies found near complete symptomatic relief and significant reduction in intraoperative blood loss.
Given that the vast majority of hemangiomas are asymptomatic and are a benign entity, treatment and intervention are usually not employed in asymptomatic patients. In the settings of symptomatic patients, endovascular and percutaneous vertebroplasty are affected for pain relief11. Most studies found near complete symptomatic relief and significant reduction in intraoperative blood loss.
However , this approach is not without its own drawbacks.
However , this approach is not without its own drawbacks.
Endovascular embolization has also been used by some as a sole therapy for vertebral hemangiomas.14 Hekser et al. were the first to report reversal of spinal cord compression following percutaneous embolization of feeding vessels.15 However, this may not be helpful in the setting of acute spinal cord compression and neurological deterioration. Embolization followed by surgery is another option that is highly propagated in the present era. However, there are few reports where preoperative embolization failed to reduce the intraoperative blood loss. This is due to the fact that though transarterial embolization may occlude the feeding vessels, it may fail to destroy the hemangioma due to an intervening capillary bed that separates the hemangioma from the arterial feeders. Reflux of the embolization material into the lumbar and intercostal arteries may occur and this may lead to spinal cord infarction with severe pain and paresis.16 In case of recurrent or residual disease, a second attempt is not possible because feeding arteries have already been occluded. Another drawback is that when the vertebral bodies were collapsed and converted into a solid mass, the success rate of preoperative embolization has not been good.
Endovascular embolization has also been used by some as a sole therapy for vertebral hemangiomas.14 Hekser et al. were the first to report reversal of spinal cord compression following percutaneous embolization of feeding vessels.15 However, this may not be helpful in the setting of acute spinal cord compression and neurological deterioration. Embolization followed by surgery is another option that is highly propagated in the present era. However, there are few reports where preoperative embolization failed to reduce the intraoperative blood loss. This is due to the fact that though transarterial embolization may occlude the feeding vessels, it may fail to destroy the hemangioma due to an intervening capillary bed that separates the hemangioma from the arterial feeders. Reflux of the embolization material into the lumbar and intercostal arteries may occur and this may lead to spinal cord infarction with severe pain and paresis.16 In case of recurrent or residual disease, a second attempt is not possible because feeding arteries have already been occluded. Another drawback is that when the vertebral bodies were collapsed and converted into a solid mass, the success rate of preoperative embolization has not been good.
Onyx enables a more rapid and visible embolization than particles and is less technically demanding with no documented incidence of catheter entrapment and adhesion than traditional liquid embolic agents, such as n-butyl cyanoacrylate.
Onyx enables a more rapid and visible embolization than particles and is less technically demanding with no documented incidence of catheter entrapment and adhesion than traditional liquid embolic agents, such as n-butyl cyanoacrylate.
Particulate agents, including Embosphere (BioSphere Medical, Rockland, Mass) and polyvinyl alcohol (PVA) are favored, because they penetrate the capillary bed beyond potential arteriolar anastomoses.
Particulate agents, including Embosphere (BioSphere Medical, Rockland, Mass) and polyvinyl alcohol (PVA) are favored, because they penetrate the capillary bed beyond potential arteriolar anastomoses.
However, safe particulate embolization requires large volumes and slow injection rates, resulting in lengthy injection and fluoroscopic times21.
However, safe particulate embolization requires large volumes and slow injection rates, resulting in lengthy injection and fluoroscopic times21.
Transpedicular ethanol injection has been employed in treatment of spinal hemangioma, however with its attendant complications. Radiation therapy has been also been used to treat painful considering spinal hemangiomas are radiosensitive lesion13 and reports have shown symptomatic improvement following radiotherapy17. However , radiotherapy is not without its attendant complications ( includes delayed effects of radiation and radionecrosis of spinal cord and
Transpedicular ethanol injection has been employed in treatment of spinal hemangioma, however with its attendant complications. Radiation therapy has been also been used to treat painful considering spinal hemangiomas are radiosensitive lesion13 and reports have shown symptomatic improvement following radiotherapy17. However , radiotherapy is not without its attendant complications ( includes delayed effects of radiation and radionecrosis of spinal cord and
vertebra).
vertebra).
Percutaneous ablation with ethanol or methyl methacrylate constitutes some of the newer options in the treatment of vertebral hemangiomas. Injection of ethanol causes intralesional thrombosis and destruction of the endothelium of the hemangioma. This leads to devascularization of the hemangioma, and thereby reduces its size alleviating the cord compression. However, for its success, it is necessary that the ethanol is injected into the vascular spaces of the hemangioma. This is critical in elderly patients as bone is quiet fibrotic and the vascular component of the hemangioma may be small. Moreover, the technique seems to be cumbersome as the needle has to be localized with the help of prior and intraoperative angiography. Neurological deterioration18, Infection due to extravasation of contrast material into paraspinal tissues, Brown Sequard syndrome 19, recurrence at 1 month followup and vertebral fracture have been reported as complications associated with alcohol ablation. Alcohol ablation deals with the vertebral hemangioma per se, but does not restore the strength of the vertebral body that has been fractured. So, this has to be supplemented with methyl methacrylate injection or instrumentation.
Percutaneous ablation with ethanol or methyl methacrylate constitutes some of the newer options in the treatment of vertebral hemangiomas. Injection of ethanol causes intralesional thrombosis and destruction of the endothelium of the hemangioma. This leads to devascularization of the hemangioma, and thereby reduces its size alleviating the cord compression. However, for its success, it is necessary that the ethanol is injected into the vascular spaces of the hemangioma. This is critical in elderly patients as bone is quiet fibrotic and the vascular component of the hemangioma may be small. Moreover, the technique seems to be cumbersome as the needle has to be localized with the help of prior and intraoperative angiography. Neurological deterioration18, Infection due to extravasation of contrast material into paraspinal tissues, Brown Sequard syndrome 19, recurrence at 1 month followup and vertebral fracture have been reported as complications associated with alcohol ablation. Alcohol ablation deals with the vertebral hemangioma per se, but does not restore the strength of the vertebral body that has been fractured. So, this has to be supplemented with methyl methacrylate injection or instrumentation.
Injection of methyl methacrylate is usually performed under fluoroscopic guidance and is indicated for stabilizing vertebral bodies at risk for collapse or to reduce pain. However, when a patient is paraparetic, methyl methacrylate may extend into the spinal canal and exacerbate spinal cord compression that is already present. In such cases, it is usually combined with laminectomy.20
Injection of methyl methacrylate is usually performed under fluoroscopic guidance and is indicated for stabilizing vertebral bodies at risk for collapse or to reduce pain. However, when a patient is paraparetic, methyl methacrylate may extend into the spinal canal and exacerbate spinal cord compression that is already present. In such cases, it is usually combined with laminectomy.20
References:
References:
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Acknowledgement:
Acknowledgement:
We are grateful to the spinal surgery unit at our institution for providing the intropertive photograph.
We are grateful to the spinal surgery unit at our institution for providing the intropertive photograph.
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