What is the treatment for a hemangioma at T1-T2 in an adult with scoliosis?

Treatment of Vertebral Hemangioma at T1-T2 in an Adult with Scoliosis

Most vertebral hemangiomas at T1-T2 are asymptomatic incidental findings requiring only observation, but if this lesion is causing neurological symptoms or spinal cord compression, treatment should consist of preoperative transarterial embolization followed by surgical decompression with or without vertebroplasty, rather than en bloc resection which carries significantly higher morbidity without improved outcomes. 1, 2

Initial Assessment and Risk Stratification

The critical first step is determining whether this hemangioma is typical (benign, asymptomatic) or aggressive/atypical:

• Aggressive vertebral hemangiomas account for less than 1% of all spinal hemangiomas and are characterized by extraosseous expansion into the epidural space causing spinal cord compression 3
• Look specifically for: progressive walking difficulty, sensory disturbances in lower extremities, rapidly progressive neurological symptoms, or severe back pain 3, 4
• MRI findings suggesting aggressive behavior include: T1- and T2-weighted hyperintensity with extraosseous extension into the spinal canal, anterior or posterior spinal cord compression, and bony expansion with erosion 3, 1

Treatment Algorithm Based on Clinical Presentation

For Asymptomatic or Minimally Symptomatic Hemangiomas:

• Clinical observation with monitoring is the appropriate management strategy 4, 2
• Serial neurological examinations to detect any development of cord compression symptoms 2
• The presence of concurrent scoliosis requires annual clinical evaluation using Adam's forward bend test, as scoliosis management is independent of the hemangioma unless surgical intervention for the hemangioma is planned 5, 6

For Painful Intraosseous Hemangiomas Without Neurological Deficit:

• Transarterial embolization alone is effective for resolution of back pain in 75% of patients (3 of 4 patients in one series) 2
• Percutaneous vertebroplasty can be considered, particularly if vertebral body compression fracture has occurred, though it provides less reliable long-term pain relief compared to embolization 2
• Radiotherapy remains an option for pain control, though it is less commonly used as first-line treatment in the modern era 4, 2

For Hemangiomas Causing Spinal Cord Compression or Progressive Neurological Deficit:

This is the critical scenario requiring aggressive intervention:

• Preoperative transarterial embolization followed by surgical decompression is the gold standard approach 1, 7, 2

• Embolization significantly reduces intraoperative blood loss and should be performed when feasible 1, 2

• Surgical options in order of preference:

  • Laminectomy with gross-total or subtotal resection for cord compression from stenosis without instability 1, 2
  • Intraoperative vertebroplasty can be added to augment the anterior column or obliterate residual tumor 1
  • Vertebrectomy with reconstruction is reserved specifically for extraosseous tumor extension causing cord compression 1, 2

• Adjuvant radiation therapy should be used for residual tumor after subtotal resection 1, 7

Critical Evidence on Surgical Approach

Avoid en bloc spondylectomy unless absolutely necessary for oncological reasons (which is not the case for benign hemangiomas):

• En bloc resection provides similar oncological outcomes to gross-total or subtotal resection but carries significantly higher morbidity 1
• In one institutional series, the patient who underwent en bloc resection experienced multiple postoperative complications requiring reoperation and continued to have chronic back pain, while all patients who underwent less aggressive resection remained asymptomatic at 31-month follow-up 1
• Gross-total resection or subtotal resection combined with vertebroplasty or adjuvant radiation appears sufficient for aggressive vertebral hemangiomas 1

Special Considerations for Concurrent Scoliosis

The presence of scoliosis in this adult patient creates additional complexity:

• Preoperative evaluation is critical if surgical intervention for the hemangioma is planned, as cyanotic patients and those with significant scoliosis have increased surgical risk 5
• The scoliosis itself requires separate assessment: curves >50° in skeletally mature adults may warrant surgical intervention due to continued progression at approximately 1° per year 8
• MRI of the entire spine is mandatory before any surgical intervention to rule out neural axis abnormalities, particularly important given the concurrent scoliosis 8
• If the hemangioma requires surgery, coordinate with spine surgeons to determine if simultaneous correction of significant scoliosis is appropriate, though this substantially increases surgical complexity and risk 8

Multidisciplinary Approach

Given the complexity of aggressive vertebral hemangioma at T1-T2 with concurrent scoliosis:

• Interventional radiology for preoperative embolization planning 1, 7, 2
• Neurosurgery or spine surgery for decompression and reconstruction 1, 2
• Radiation oncology consultation for adjuvant therapy if residual tumor remains 1, 7
• Orthopedic spine surgery for scoliosis assessment and potential concurrent management 8

Common Pitfalls to Avoid

• Do not perform en bloc resection for benign hemangiomas—the morbidity far exceeds any theoretical benefit 1
• Do not proceed to surgery without preoperative embolization when feasible, as this significantly reduces blood loss 1, 2
• Do not use vertebroplasty alone for hemangiomas causing neurological deficit—decompression is required 2
• Do not delay surgical intervention if there are rapidly progressive neurological symptoms, as outcomes are better with early decompression 3, 1
• Do not overlook the need for spinal stability assessment, particularly at the cervicothoracic junction (T1-T2) where biomechanical forces are significant 1

Long-Term Outcomes

With appropriate treatment:

• No recurrence was observed in surgical series with average follow-up of 31-81 months 1, 2
• Resolution of neurological deficits occurs in the majority of patients undergoing timely decompression 1, 2
• Pain relief is achieved in 78% of patients (7 of 9) undergoing surgical decompression and tumor resection 2
• The combination of preoperative embolization, palliative surgical decompression, and postoperative radiotherapy provides satisfactory long-term outcomes and may represent an effective alternative to aggressive surgical intervention 7