What is the treatment approach for symptomatic vertebral hemangioma?

Treatment Approach for Symptomatic Vertebral Hemangioma

The treatment of symptomatic vertebral hemangioma should follow a stepwise approach based on clinical presentation, with vertebroplasty being the first-line intervention for painful lesions without neurological deficit, while surgical decompression with or without preoperative embolization is indicated for cases with neurological compromise.

Clinical Presentation and Evaluation

Vertebral hemangiomas are common benign vascular tumors that are typically asymptomatic but can occasionally become symptomatic, presenting with:

• Local back pain (most common symptom)
• Radicular pain
• Neurological deficits due to spinal cord compression
• Pathological fractures

Diagnostic Workup

• MRI is the imaging modality of choice for diagnosing vertebral hemangiomas
• CT scan helps evaluate bony involvement and structural integrity
• Angiography may be necessary if embolization is being considered

Treatment Algorithm Based on Clinical Presentation

1. Painful Vertebral Hemangioma WITHOUT Neurological Deficit

First-line treatment:

• Percutaneous vertebroplasty - provides immediate pain relief and structural support 1
  • Performed under local anesthesia with fluoroscopic guidance
  • Long-term pain resolution has been demonstrated with follow-up of 5.8 years 1

Alternative options:

• Transarterial embolization alone - effective for pain relief in intraosseous hemangiomas 2
• Radiation therapy - for patients who are not candidates for vertebroplasty

2. Vertebral Hemangioma WITH Neurological Deficit

First-line treatment:

• Surgical decompression with preoperative embolization 2, 3
  • Transarterial embolization followed by laminectomy is safe and effective for cord compression without instability 2
  • Preoperative embolization significantly reduces intraoperative blood loss 2

Treatment based on extent of involvement:

• For lesions causing stenosis without instability:

  • Laminectomy with or without preoperative embolization

• For lesions with extraosseous extension:

  • Vertebrectomy preceded by embolization and followed by reconstruction 2
  • Consider subtotal resection with adjuvant radiation for residual tumor 3

• For lesions with vertebral body compression fracture:

  • Decompression with stabilization using transpedicular screws and rods 4

Surgical Approaches

The extent of surgical resection should be determined by the degree of neurological compromise and tumor location:

• Subtotal resection or gross-total resection with vertebroplasty is generally sufficient 3
• En bloc resection provides similar oncological outcomes but carries higher morbidity and should be avoided 3
• Intraoperative vertebroplasty can be used to augment the anterior column or obliterate residual tumor 3

Adjuvant Therapies

• Radiation therapy may be used for residual tumor after subtotal resection 3
• Vertebroplasty can be combined with surgical approaches for better outcomes 1

Outcomes and Follow-up

• Patients treated with vertebroplasty show complete resolution of pain symptoms with stability at long-term follow-up 1
• Surgical decompression with or without embolization results in improvement of neurological deficits and pain relief 2
• Regular follow-up imaging is recommended to monitor for potential recurrence

Important Considerations

• Potential complications of vertebroplasty include cement leakage (observed in 12.5% of cases) 1
• Preoperative embolization should be considered for highly vascular lesions to reduce intraoperative bleeding
• The risk of recurrence is low when appropriate treatment is selected based on clinical presentation

The management of symptomatic vertebral hemangiomas requires careful assessment of symptoms, imaging findings, and patient factors to determine the optimal treatment approach.