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Radiology
Vertebroplasty in vertebral body hemangioma.
A 13-year-old boy had a fall from a bicycle one year back. Six months following the fall, he started having low backache. Since the two months, he has radiating pain, tingling and numbness of both legs. He had normal bladder and bowel control. His vital parameters were stable.
Plain films of the lumbar spine had shown classical findings of the an L4 hemangioma with compression.
An MRI examination of the spine done in Feb 2005 had confirmed the L4 vertebral body hemangioma with epidural venous congestion causing compression of the thecal sac. There was a pathological fracture with compression of the vertebral body.
The patient visited our department for consultation in June 2005. Examination confirmed tenderness on L4 spinous process.
Transarterial embolisation was planned.
The angiogram showed extreme vascularity and an aneurysm in the venous phase which was located in the lumbar canal.
Selective catheterization of the lumbar artery was performed and high flow branches were occluded with NBCA (Cyanoacrylate glue). The aneurysm was also thus excluded. The residual blush was obliterated by embolisation with PVA particles.
Following embolisation, the patient' symptoms of tingling sensations were relieved partially; however the pain persisted.
After much deliberation, the patient was offered percutaneous vertebroplasty as a definitive treatment.
A bilateral posterolateral approach was used to place two needles inside the L4 vertebral body under fluoroscopic guidance. One needle was a 11G bone biopsy needle and the other was a13G bone biopsy needle.
Under fluoroscopic guidance, methyl methacrylate was injected into the vertebral body through both the needles. Thus the entire vertebral body was filled with cement.
DISCUSSION:
Vertebral body hemangiomas are common and have an incidence of 10% in the population. Most often, these are incidentally detected and are asymptomatic. More common in adults, rare in children but when present in the later age group, vertebral hemangiomas are usually symptomatic. These lesions are thought to be venous malformations of the vertebral body.
Our patient had backache due to weakening of the vertebral body due to hemangioma leading to its fracture and collapse. The pain associated with the fracture fragments was due to raw nerve endings at the fracture margins. The tingling sensations in the legs were due to compression of the thecal sac due to the epidural venous extension of the hemangioma
Three months had passed from the time of the MR imaging of the hemangioma to the vertebral body angiogram and embolisation. At the time of angiography, an aneurysmal pouch was detected in the spinal canal. The aneurysm was embolised with superselective catheterization and glue injection into the feeding artery and aneurysm. The high flow areas in the hemangiomas leading to enlarged intraspinal epidural veins were treated with glue. The rest of the vascularity of the vertebral body was obliterated with PVA particles. Post embolisation films, showed rapid decrease in the epidual plexus leading to decompression of the thecal sac. This lead to decrease in the tingling sensation in the feet, however the pain due to the microfractures in the vertebral body continued.
It was therefore, decided to perform percutaneous vertebroplasty and stabilize the fracture fragments. Since the vertebral body in question was the L4 vertebral body, a posterolateral approach was preferred to the conventional transpedicular approach. Four milliliters of cement was deposited in the hemangioma. There was immediate relief of pain following the procedure.
The patient had a good post operative recovery with no neurological deficit and relief from pain. He will be kept under regular follow up to see the natural course of the epidural extension of the hemangioma.
FAQs.
Q:What is vertebral body hemangioma? Is it present since birth? Is it familial?
A: A vertebral body hemangioma, simply put, is like a venous malformation of the vertebral body. This means that veins of the vertebral body have an abnormal response to natural remodeling-repair mechanisms in the vertebral body in question. The most common site is usually the thoracic vertebral body. However, there may be multiple lesions involving more than one segment. Less often, these can also be part of complex metameric diseases like SAMS (spinal arteriovenous metameric syndrome), commonly called Cobb's syndrome, Klippel Trenauny Syndrome and Parks Weber syndrome. Autopsy studies rarely show vertebral body hemangioma at birth. The incidence of finding of vertebral body hemangiomas increases with increasing age suggesting the acquired nature of the disease. Trigger factors for this abnormal response are not known. This is not a hereditary disease.
Q: What are the symptoms and signs of this disease and how is this diagnosed?
A: Most often, these are incidental findings of no clinical significance and occur in approximately 10% of the general population. The symptoms at presentation depend on the severity of vertebral body involvement. When the lesion is confined to the vertebral body itself, the symptoms maybe in the form of backache (local pain) and tenderness at the site. When it is outside the confines of the vertebral body and compressing the thecal sac, there maybe complaints of slowly progressive neurological deficit due to cord compression or the nerve root compression. The neurological deficit may be present as tingling sensations, weakness in both legs and/or as bladder and bowel disturbance. Collapse of the vertebral body may lead to kyphotic deformity.
Diagnosis is based on plain radiographs, CT scan and MRI which confirm the lesion. The most appropriate is the MR to show the extent of involvement and epidural extension of the lesion. It will also show the changes in spinal cord if present.
Q: What is the natural course of the disease? What are the treatment options?
A: The natural course of the disease is very variable; untreated, backache will persist to a variable extent in most patients. In some, there may be progressive neurological deficit.
Controversies in the management of these lesions are reflected by the range of treatment options available. Options include radiation therapy, embolization, surgical resection, vertebroplasty, and intralesional injection of a sclerosing agent etc. These approaches can be used alone or in combination.
Before the advent of embolisation and percutanoues vertebroplasty, surgery was commonly performed on vertebral body hemangiomas with intraspinal extension.
Surgery was either laminectomy with stabilization using metallic prostheses or corpectomy followed by bone graft and stabilization using metallic prostheses. Presently, surgery is usually reserved for refractory cases and in those complicated by vertebral collapse with neural compression. It is ideally preceded by lesion embolization and may be combined with postoperative radiation therapy, especially when pain occurs with neurologic compression.
CT-guided direct injection of ethanol as a sclerosing agent has been used to treat vertebral hemangiomas complicated by cord and nerve root compression. This method has been shown to be effective and safe, providing symptomatic relief and lesion obliteration.
Radiation therapy was often performed. This was used either as primary treatment for alleviating pain (probably as a result of its anti-inflammatory properties), for facilitating reossification, or for postsurgical care to prevent recurrence and relapse of symptoms. Obliteration of the lesion may occur with radiotherapy but this effect is not prompt enough to alleviate cord compression.
Percutaneous vertebroplasty is the latest technique used for effective treatment of vertebral body hemangiomas. The vertebral body is directly punctured with wide bore bone needles and liquid cement is used to fill the space of the vertebral body hemangioma thus obliterating the hemangioma and strengthening the bone in the process. Pain relief is due to stabilization of fracture fragments and ablation of the nerve endings by exothermic reaction.
Q:What are the guidelines for choice of the option?
A: In our department, the first line of treatment is transarterial embolisation of the vertebral body hemangioma. If there is intraspinal extension with neurological deficit, then percutaneous CT guided ablation using absolute alcohol of the hemangioma is done. This is then followed by percutaneous vertebroplasty. If there is no intraspinal extension, then embolisation is followed by percutaneous vertebroplasty.
Q:What are the risks associated with interventional procedure?
A: Interventional procedure for the treatment of vertebral body hemangioma includes transarterial embolisation, percutaneous CT guided ablation, percutaneous vertebroplasty. Transarterial embolisation carries a risk of non target embolisation into the spinal arteries leading to neurological deficit which maybe be transient or long lasting. Percutaneous ablation may cause increase in the thecal sac compression with transient neurological worsening which recovers over few weeks. Percutaneous vertebroplasty carries risk of epidural extension of the cement leading to spinal canal stenosis, pulmonary embolism. In ideal setting these risks can be minimized by better fluoroscopy machines and experience in treating these diseases.
Q: Is percutaneous vertebroplasty permanent?
A: Yes. Cement injected is sterile, stable, inert and has permanent effect on the vertebral body.
Q: What is the cost of the procedure?
A: The cost of the procedure in our institute covers the cost of disposable consumables used for the procedure. Transarterial embolisation costs around Rs. 40,000. Percutaneous vertebroplasty costs around Rs. 25,000. Percutaneous CT ablation costs around Rs. 2000.
Case 23: Contributed by Drs.Wuppalapati
Siddhartha and Manish Shrivastava
Other Cases
A 13-year-old boy had a fall from a bicycle one year back. Six months following the fall, he started having low backache. Since the two months, he has radiating pain, tingling and numbness of both legs. He had normal bladder and bowel control. His vital parameters were stable.
Plain films of the lumbar spine had shown classical findings of the an L4 hemangioma with compression.
 |  | |
Fig.
1 | Fig.
2 | |
An MRI examination of the spine done in Feb 2005 had confirmed the L4 vertebral body hemangioma with epidural venous congestion causing compression of the thecal sac. There was a pathological fracture with compression of the vertebral body.
The patient visited our department for consultation in June 2005. Examination confirmed tenderness on L4 spinous process.
Transarterial embolisation was planned.
The angiogram showed extreme vascularity and an aneurysm in the venous phase which was located in the lumbar canal.
|  |  |
Fig
3 | Fig
4 | Fig
5 |
Selective catheterization of the lumbar artery was performed and high flow branches were occluded with NBCA (Cyanoacrylate glue). The aneurysm was also thus excluded. The residual blush was obliterated by embolisation with PVA particles.
 |  |
| Fig
6 | Fig
7 |
Following embolisation, the patient' symptoms of tingling sensations were relieved partially; however the pain persisted.
After much deliberation, the patient was offered percutaneous vertebroplasty as a definitive treatment.
A bilateral posterolateral approach was used to place two needles inside the L4 vertebral body under fluoroscopic guidance. One needle was a 11G bone biopsy needle and the other was a13G bone biopsy needle.
Under fluoroscopic guidance, methyl methacrylate was injected into the vertebral body through both the needles. Thus the entire vertebral body was filled with cement.
 |  |
Fig
8 | Fig
9 |
 |  |
Fig
10 | Fig
11 |
 | |
Fig
12 | |
DISCUSSION:
Vertebral body hemangiomas are common and have an incidence of 10% in the population. Most often, these are incidentally detected and are asymptomatic. More common in adults, rare in children but when present in the later age group, vertebral hemangiomas are usually symptomatic. These lesions are thought to be venous malformations of the vertebral body.
Our patient had backache due to weakening of the vertebral body due to hemangioma leading to its fracture and collapse. The pain associated with the fracture fragments was due to raw nerve endings at the fracture margins. The tingling sensations in the legs were due to compression of the thecal sac due to the epidural venous extension of the hemangioma
Three months had passed from the time of the MR imaging of the hemangioma to the vertebral body angiogram and embolisation. At the time of angiography, an aneurysmal pouch was detected in the spinal canal. The aneurysm was embolised with superselective catheterization and glue injection into the feeding artery and aneurysm. The high flow areas in the hemangiomas leading to enlarged intraspinal epidural veins were treated with glue. The rest of the vascularity of the vertebral body was obliterated with PVA particles. Post embolisation films, showed rapid decrease in the epidual plexus leading to decompression of the thecal sac. This lead to decrease in the tingling sensation in the feet, however the pain due to the microfractures in the vertebral body continued.
It was therefore, decided to perform percutaneous vertebroplasty and stabilize the fracture fragments. Since the vertebral body in question was the L4 vertebral body, a posterolateral approach was preferred to the conventional transpedicular approach. Four milliliters of cement was deposited in the hemangioma. There was immediate relief of pain following the procedure.
The patient had a good post operative recovery with no neurological deficit and relief from pain. He will be kept under regular follow up to see the natural course of the epidural extension of the hemangioma.
FAQs.
Q:What is vertebral body hemangioma? Is it present since birth? Is it familial?
A: A vertebral body hemangioma, simply put, is like a venous malformation of the vertebral body. This means that veins of the vertebral body have an abnormal response to natural remodeling-repair mechanisms in the vertebral body in question. The most common site is usually the thoracic vertebral body. However, there may be multiple lesions involving more than one segment. Less often, these can also be part of complex metameric diseases like SAMS (spinal arteriovenous metameric syndrome), commonly called Cobb's syndrome, Klippel Trenauny Syndrome and Parks Weber syndrome. Autopsy studies rarely show vertebral body hemangioma at birth. The incidence of finding of vertebral body hemangiomas increases with increasing age suggesting the acquired nature of the disease. Trigger factors for this abnormal response are not known. This is not a hereditary disease.
Q: What are the symptoms and signs of this disease and how is this diagnosed?
A: Most often, these are incidental findings of no clinical significance and occur in approximately 10% of the general population. The symptoms at presentation depend on the severity of vertebral body involvement. When the lesion is confined to the vertebral body itself, the symptoms maybe in the form of backache (local pain) and tenderness at the site. When it is outside the confines of the vertebral body and compressing the thecal sac, there maybe complaints of slowly progressive neurological deficit due to cord compression or the nerve root compression. The neurological deficit may be present as tingling sensations, weakness in both legs and/or as bladder and bowel disturbance. Collapse of the vertebral body may lead to kyphotic deformity.
Diagnosis is based on plain radiographs, CT scan and MRI which confirm the lesion. The most appropriate is the MR to show the extent of involvement and epidural extension of the lesion. It will also show the changes in spinal cord if present.
Q: What is the natural course of the disease? What are the treatment options?
A: The natural course of the disease is very variable; untreated, backache will persist to a variable extent in most patients. In some, there may be progressive neurological deficit.
Controversies in the management of these lesions are reflected by the range of treatment options available. Options include radiation therapy, embolization, surgical resection, vertebroplasty, and intralesional injection of a sclerosing agent etc. These approaches can be used alone or in combination.
Before the advent of embolisation and percutanoues vertebroplasty, surgery was commonly performed on vertebral body hemangiomas with intraspinal extension.
Surgery was either laminectomy with stabilization using metallic prostheses or corpectomy followed by bone graft and stabilization using metallic prostheses. Presently, surgery is usually reserved for refractory cases and in those complicated by vertebral collapse with neural compression. It is ideally preceded by lesion embolization and may be combined with postoperative radiation therapy, especially when pain occurs with neurologic compression.
CT-guided direct injection of ethanol as a sclerosing agent has been used to treat vertebral hemangiomas complicated by cord and nerve root compression. This method has been shown to be effective and safe, providing symptomatic relief and lesion obliteration.
Radiation therapy was often performed. This was used either as primary treatment for alleviating pain (probably as a result of its anti-inflammatory properties), for facilitating reossification, or for postsurgical care to prevent recurrence and relapse of symptoms. Obliteration of the lesion may occur with radiotherapy but this effect is not prompt enough to alleviate cord compression.
Percutaneous vertebroplasty is the latest technique used for effective treatment of vertebral body hemangiomas. The vertebral body is directly punctured with wide bore bone needles and liquid cement is used to fill the space of the vertebral body hemangioma thus obliterating the hemangioma and strengthening the bone in the process. Pain relief is due to stabilization of fracture fragments and ablation of the nerve endings by exothermic reaction.
Q:What are the guidelines for choice of the option?
A: In our department, the first line of treatment is transarterial embolisation of the vertebral body hemangioma. If there is intraspinal extension with neurological deficit, then percutaneous CT guided ablation using absolute alcohol of the hemangioma is done. This is then followed by percutaneous vertebroplasty. If there is no intraspinal extension, then embolisation is followed by percutaneous vertebroplasty.
Q:What are the risks associated with interventional procedure?
A: Interventional procedure for the treatment of vertebral body hemangioma includes transarterial embolisation, percutaneous CT guided ablation, percutaneous vertebroplasty. Transarterial embolisation carries a risk of non target embolisation into the spinal arteries leading to neurological deficit which maybe be transient or long lasting. Percutaneous ablation may cause increase in the thecal sac compression with transient neurological worsening which recovers over few weeks. Percutaneous vertebroplasty carries risk of epidural extension of the cement leading to spinal canal stenosis, pulmonary embolism. In ideal setting these risks can be minimized by better fluoroscopy machines and experience in treating these diseases.
Q: Is percutaneous vertebroplasty permanent?
A: Yes. Cement injected is sterile, stable, inert and has permanent effect on the vertebral body.
Q: What is the cost of the procedure?
A: The cost of the procedure in our institute covers the cost of disposable consumables used for the procedure. Transarterial embolisation costs around Rs. 40,000. Percutaneous vertebroplasty costs around Rs. 25,000. Percutaneous CT ablation costs around Rs. 2000.