Treatment of vertebral hemangioma : what the interventional radiologist can do ? Hatem Rajhi .MD Department of Radiology and Interventional Radiology- Charles Nicolle Hospital Tunis -Tunisia

PURPOSE To illustrate through a series of observations documented therapeutic methods in the interventional treatment of vertebral hemangiomas

INTRODUCTION Vertebral Hémangioma (VH) The most common benign tumor of the spine • Multiple in 25% of cases • Peak incidence: 40-60 years • Slow-growing lesion • benign vascular dysplasia           capillary           Cavernous (most common)          or Venous (Picture taken from website:www.back.com/causes-tumors-benign.html)

INTRODUCTION When to treat a spinal hemangioma?   Usually asymptomatic, discovered incidentally.   Only 0.9% to 1.2% of cases become symptomatic:          Aggressive Hemangioma            Local pain, Radiological aggressiveness Neurologic deficit

Background: Semiology of vertebral Hemangioma Radiographic findings Vertical striations and trabeculations “Honeycomb” appearence. CT axial image “Polka dot” appearance of the involved vertebra MRI increased signal on T1- and T2 weighted images (intralesional fat)

Signs of aggressiveness on imaging of Vertebral Hemangioma Spine level between T3 to T10 • Involvement of the entire vertebral body • Extension to the posterior arch • Discontinuous cortical bone  • Lytic appearence • Paraspinal or intra ductal expansion • Low signal intensity on T1-weighted images • Intense enhancement after contrast injection

CASE N°1 A 18 years old patient 09/08/2007  Neurological dysfunction due to spinal cord compression. Radiographic findings: aggressive vertebral hemangioma T3 10/08/2007 bilateral T3 laminectomy  Follow-up: worsening paraparesis Immediate revision surgery: epidural hematoma evacuation

Significant improvement of motor deficit. Histologic diagnose: capillary hemangioma

April 2009 (20 months later) High back pain Spastic paraparesis Bilateral Babinski signs

Is there an explanation for the current neurological symptoms ? MRI sequences a,b,c sagittale T2-weighted images d : sagittale T1 weighted images with contrast injection e : axial T1 weighted image with contrast injection a b c d e Is there an explanation for the current neurological symptoms  ?

What could be proposed? A. Reoperation B. Transarterial Embolization C. Surgery with preoperative embolization D. vertebroplasty E. Radiotherapy

What could be proposed? A. Reoperation B. Transarterial Embolization C. Surgery with preoperative embolization D. vertebroplasty E. Radiotherapy

What arterial branches to explore? A. The celiac trunk and superior mesenteric artery  B. The dorsal intercostal arteries C. The lumbar arteries D. The thoracic and abdominal aorta

What arterial branches to explore? The celiac trunk and superior mesenteric artery  B. The dorsal intercostal arteries C. The lumbar arteries D. The thoracic and abdominal aorta

Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

The anterior spinal artery was identified in T10 left The anterior spinal artery was identified in T10 left. Is there a risk of embolization of T3. A. yes B. no C. Distrust

The anterior spinal artery was identified in T10 left. Is there a risk of embolization of T3. A. Yes B. No C. Distrust

Embolization Right T4 Right T5

Selective angiography of the pedicle of the left T3 intercostal artery We can embolize at this level? A. Yes B. No

Selective angiography of the pedicle of the left T3 intercostal artery We can embolize at this level? A. Yes B. No

Surgical resection is limited because of: A. The involvement of the anterior arch B. The epidural extension C. The involvement of the posterior arch

Surgical resection is limited because of: A. The involvement of the anterior arch B. The epidural extension C. The involvement of the posterior arch

What can we do. A. Surgery as part of the angioma was embolized B What can we do ? A. Surgery as part of the angioma was embolized B. Vertebroplasty C. Sclerotherapy  with Absolute ethanol D. There is no other treatment E. There is another alternative ?

What can we do. A. Surgery as part of the angioma was embolized B What can we do ? A. Surgery as part of the angioma was embolized B. Vertebroplasty C. Sclerotherapy  with Absolute ethanol D. There is no other treatment E. There is another alternative?

What does this alternative. A. radiofrequency ablation B What does this alternative ? A. radiofrequency ablation B. direct embolization ?

What does this alternative ? A. Radiofrequency ablation B. Direct embolization ?

Which embolic agent to use ? A. Ethanol B. Coils C. Embospheres D. Biological Glue

Which embolic agent to use ? A. Ethanol B. Coils C. Embospheres D. Biological glue

Which type of radiographic guidance ? A. Fluoroscopy B. CT scanner C. Ultrasonography

Which type of radiographic guidance ? A. Fluoroscopy B. CT scanner C. Ultrasonography

Sclerotherapy with Glubran 2 by direct puncture under CT guidance

Sclerotherapy with Glubran 2 by direct puncture under CT guidance

Sclerotherapy with Glubran 2 by direct puncture under CT guidance

Sclerotherapy with Glubran 2 by direct puncture under CT guidance

Sclerotherapy with Glubran 2 by direct puncture under CT guidance

Is surgery indicated ? A. Yes B. No

Is surgery indicated ? A. Yes B. No

What time limits ? A. In 7 days so that the inflammation decreases B. In one month C. Within 48 hours of embolization D. The time limits is not important

What time limits ? A. In 7 days so that the inflammation decreases B. In one month C. Within 48 hours of embolization D. The time limits is not important

Surgery should include : T 3 Laminectomy T 3 Vertebrectomy C. Laminectomy and osteosynthesis D. Osteosynthesis

Surgery should include: A. T 3 Laminectomy B. T 3 Vertebrectomy C. Laminectomy and osteosynthesis D. Osteosynthesis

Osteosynthesis T1 to T6

Favorable evolution with recovery of motor function of lower extremities. Is the treatment achieved ? A . Yes B . No

Favorable evolution with recovery of motor function of lower extremities. Is the treatment achieved? A . Yes B . No

To treat vertebral body of T3 must be associate : A. Surgery by anterior approach B. Percutaneous Vertebroplasty C. Sclerotherapy with Glubran 2 under CT guidance

To treat vertebral body of T3 must be associate : A. Surgery by anterior approach B. Percutaneous Vertebroplasty C. Sclerotherapy with Glubran 2 under CT guidance

Percutaneous Vertebroplasty

Significant improvement with gait recovery actually walking without  cane

PERCUTANEOUS VERTEBROPLASTY

PERCUTANEOUS VERTEBROPLASTY Percutaneous injection of acrylic cement in a pathologic vertebral body  Double effet: Pain relief Vertebral stabilization

PERCUTANEOUS VERTEBROPLASTY Patient preparation Systematic radiological assessment: X-ray + CT + MRI Anesthesia consultation before the procedure. Search for contraindications Informed consent obtained from the patient

Absolute Contraindications - Pregnancy; - coagulation disorders; - Contraindications to anesthesia and prolonged  prone position; - Allergy to PMMA; - Systemic or local infections; - Spinal cord compression with neurological deficit

Relative Contraindications - Pedicles fracture Vertebral body collapse with retropulsion of fracture fragment causing spinal canal compromise Severe vertebral body collapse

Technique Fluoroscopic C-arm Guidance CT guidance General anesthesia or local analgesia with or without conscious sedation

Equipment Bone cement :PMMA Bone Needles 11 G 10 cm (thoracic spine) 15 cm (lumbar spine) Surgical hammer Combination pliers

Cement preparation Methylmethacrylate powder is mixed with methylmethacrylate monomer liquid. Metallic powder is added to PMMA in order to enhance the visibility of the cement. The preparation is mixed until it becomes like toothpaste Cement volume vary between 2 and 10 ml

Cement injection Transpedicular approach Unipedicular or Bipedicular

Cement injection Postero lateral approach - pedicular lysis - osteosynthesis

Incidents Vascular leakage of cement - the operator should adjust the needle direction - or stop the injection immediately. Risk of Pulmonary embolism

Spinal canal and epidural extravasation of cement Incidents Spinal canal and epidural extravasation of cement - Low risk < 1 % - Associated with vertebral fracture: Pedicles posterior wall posterior arch

Incidents Foraminal leakage of ciment Risk of compression of the nerve root

Paravertebral cement leakage Incidents Paravertebral cement leakage Intervertebral disc cement leakage Without major complications

Vertebroplasty Results The analgesic effect is immediate and complete  in the vast majority of cases according to various studies. The frequency of complications is highly variable  depending on the series (1% to 13.5%) It's mostly technical incidents  without major consequences

Vertebroplasty Results H Rajhi and al in 2011: 100% improvement at least partially in the short and medium term Complete regression of pain in the medium term up 57.1% of cases

CASE N°2 48 year old woman treated by percutaneous vertebroplasty in 2008 for aggressive vertebral hemangioma T12 with improvement of symptoms.

Re-consulted in March 2011 for development of inflammatory back pain with sciatica and sphincter dysfunction.

a b c d e f MRI sequences a: sagittale T2 weighted image b,c : sagittale T1 weighted images d,e : sagittale T1 weighted images with contrast injection f: axial T1 weighted image with contrast injection

What is the explanation of the recent symptoms. A. Herniated disc B What is the explanation of the recent symptoms? A. Herniated disc B. Spondylodiscitis C. Vertebral metastasis D. Reactivation of aggressive Angioma T12 E. Osteoporotic fracture

What is the explanation of the recent symptoms? A. Herniated disc B. Spondylodiscitis C. Vertebral metastasis D. Reactivation of aggressive Angioma T12 E. Osteoporotic fracture

Which procedure could be proposed as a treatment. A. Surgery B Which procedure could be proposed as a treatment? A. Surgery B. Arterial embolization C. Surgery with preoperative embolization D. Vertebroplasty E. Sclerotherapy with Ethanol

Which procedure could be proposed as a treatment? A. Surgery B. Arterial embolization C. Surgery with preoperative embolization D. Vertebroplasty E. Sclerotherapy with Ethanol

The decision was to achieve  sclerotherapy with ethanol injection in the anterior epidural component

Sclerotherapy with ethanol injection

Sclerotherapy with ethanol injection

Sclerotherapy with ethanol injection

Sclerotherapy with ethanol injection

The outcome was favorable with disappearance of sphincter dysfunction and sciatica and improvement of the low back pain

Control MRI in April 2012 (1 year after sclerotherapy)

Control MRI in April 2012 (1 year after sclerotherapy)

SCLEROTHERAPY WITH ETHANOL Direct percutaneous injection of Absolute alcohol Induces: Thrombosis, edema and sclerosis of the Hemangioma Shrinkage of the lesion with  radiculomedullary decompression

SCLEROTHERAPY WITH ETHANOL Intraosseous venography can be performed before alcohol injection          Provides information on the route of preferential venous drainage of the hemangioma          Chek for risk of paravertebral and intra ductal leakage        

Technique CT guidance Intravenous conscious sedation and analgesia

Technique Unipedicular Bipedicular Transpedicular approach Unipedicular Bipedicular Postero lateral apparoch -Without significantly changing the absolute nature of the alcohol, we have made alcohol radioopaque by mixing it with contrast media

Incidents Potential risk of venous runoff - Avoided by slow injection of Ethanol Pleural complications and intercostal arteries injury - Avoided by transpedicular approach

Complications Risk of collapse of the vertebral body -Decreased by injecting a small volume of alcohol

CONCLUSION A number of methods have been used in the treatment of symptomatic and aggressive vertebral hemangioma, but none of them is optimal. The therapeutic approach depends on the clinical context, the topography and the involvement of the lesion. The decision is multidisciplinary

CONCLUSION The interventional radiologist plays an important role:        - Knowledge of the limitations and benefits of each Interventional procedure - Changes in products available   - perfect control of techniques    - Risk Measurement

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