Original ArticlesVertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients
Section snippets
Subjects (patient population)
The medical records of 86 patients who were diagnosed as having vertebral hemangiomas were retrospectively reviewed. These cases represented the consecutive neurosurgical experience in our department over a 42-year period beginning in 1952. All cases were followed through January 1995, when this retrospective chart review was undertaken. We also reviewed all radiologic studies. Where it was possible, patients were contacted by telephone to obtain additional information. We also reviewed methods
Course of asymptomatic patients
Some asymptomatic patients (34 patients, 60.7%) were not seen again after the first examination and their natural history is unknown. The other 22 (39.3%) patients who were asymptomatic at first examination later were seen to have signs of disease progression. Eleven (50%) of these patients developed pain and four others (18.1%) developed neuroimaging signs of spinal cord compression in their first 10 years of follow-up. The remaining seven patients (31.8%) stayed asymptomatic during the
Neuroimaging features
Plain film was a valuable, simple method to suggest the diagnosis of a vertebral hemangioma. In 67% (43) of plain films we found signs of vertebral involvement. Vertically striated vertebral bodies produced a “corduroy cloth” appearance found in 40.6% (26) patients (14 with capillary type, 8 cavernous and 4 mixed). A coarse “honeycomb” appearance was seen in 26.4% (17) patients (8 patients with cavernous type, 5 mixed, 4 capillary type). Expansion of the vertebral body was a useful sign; it was
Neurologic examination
Factors that expedite the disease’s course or led to disease manifestation were considered to be predisposing factors. Pregnancy, a condition that induces increased system and abdominal pressure and a sudden axial load was determined to be an aggravating factor, more commonly noticed among the group with cavernous hemangiomas (66.6%) than among the group with capillary ones (28.1%). Pregnancy was an exception and acted as a provoking factor in six women with capillary hemangiomas compared with
Management with respect to pathologic type
All asymptomatic patients were followed with annual neurologic and radiologic examinations without any treatment. In cases of disease progression, patients with pain, radicular signs, and sometimes with signs of subarachnoid space compression on neuroimaging and without prominent long-tract neurological signs had radiotherapy (1000–4000 cGy). Patients had a repeated course of radiotherapy if the first was ineffective or if pain recurred. The shortest interval between courses was 6 months and no
Pathology
Pathological specimens were obtained from all 64 surgical interventions. In 32 cases the pathologic diagnosis was a capillary hemangioma; 18 cases were cavernous hemangiomas; and 14 cases were mixed. Histology found that vertebral hemangiomas were composed of newly formed blood vessels in most cases with normal (capillary, venous, or veno-capillary) structure and without arteriovenous shunts. There were two main microscopic types of vertebral hemangiomas which frequently coexisted (mixed type).
Outcome
The follow-up period ranged from 6 to 180 months. It was difficult to determine in precise terminology the degree of recovery, especially when the patient had mild neurologic deficits before operation. For this purpose we used two scales. The first one was patients’ ability to lead an independent life, and the second was a scale of neurologic signs (weakness, sensory loss, spasticity, abnormal reflexes). Among patients with cavernous type hemangiomas, 27.5% had full recovery, 16.7% had good
Discussion
Vertebral hemangioma is considered to be a benign lesion of bone usually of dysembryogenetic origin or a hamartomatous lesion 1, 2, 7, 13, 25, 46, 57, 69. As a dysembryogenetic lesion, hemangiomas may produce highly vascular honeycomb-like lesions within bone, atrophy, and thickening trabeculae simultaneously 26, 28, 21, 30, 35, 37, 46, 66. Also, such tumors may have long asymptomatic period. On the other hand, they may behave as true neoplasms producing a vascular soft-tissue epidural mass
Conclusions
Our study confirms that there are differences in clinical course, imaging appearance, and outcome among pathological types of vertebral hemangiomas. Based on these findings we attempted to identify signs characterizing each group. These signs do not give precise prediction, but help us to understand the natural history of such lesions more fully and help in planning treatment approaches based on the type of pathology Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8
Acknowledgements
The authors wish to express thanks to Marc Stone, M.D., for his editorial assistance.
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