Case report Thoracic vertebral hemangioma causing lower limb
Case report Thoracic vertebral hemangioma causing lower limb spastic paresis Tariq ALOTAIBI¹ Mohammed alfawareh. MD² 1. King Saud university, Riyadh , Saudi Arabia 2. Consultant of orthopedic and spine surgery , Spine surgery department , National neuroscience institute , King Fahad medical city
What is vertebral hemangioma? Slow growing intraosseous vascular tumor Benign in origin Histologically, it has 3 types: capillary, cavernous and Mixed Causing local compression if aggressive (rare)
Introduction The most common benign vertebral tumor Incidental finding on autopsy Asymptomatic in adult Symptomatic in children with few cases reported Rarely symptomatic in adult (0. 9 -1. 2) Mc. Allister VL, Kendall BE, Bull JW. Symptomatic vertebral hemangiomas. Brain. 1975; 98 (1): 71 -80. Murugan L, Samson RS, Chandy MJ (2002) Management of symptomatic vertebral hemangiomas: review of 13 patients Neurol India 50(3): 300– 305
Thoracic common More vertebral hemangioma are more likely to be symptomatic Incidence about 10 -12% Aich RK, Deb AR, Banerjee A, Karim R, Gupta P (2010) Symptomatic vertebral hemangioma: treatment with radiotherapy. J Cancer Res Ther 6: 199– 203 Nassar SI, Hanbali FS, Haddad MC, Fahl MH (1998) Thoracic vertebral hemangioma with extradural extension and spinal cord compression. Case report. Clin Imaging 22(1): 65– 68
Case report Eighteen years old Male One month history of radiating mid thoracic back pain lower limb weakness Decreasing sensation in both lower legs
Physical Examination Lower limbs power was decreased; 3/5 all over Exaggerated deep tendon reflexes, with bilateral sustained clonus Sensation was impaired below T 10, there was bilateral spasticity and Babinski sign
Radiological Imaging X ray Plain x-ray of the spine showed the lesion at T 8 with vertical trabeculation (jail bar appearance) There is mild scoliotic deformity with convexity toward the right side
CT scan CT without contrast showed diffuse T 8 body coarse trabeculation referred as (corduroy cloth) sign
Axial view There is an expansion of the body and laminas causing spinal stenosis Trabiculation seen as (polka dot sign. ) Tumor was extending to both pedicles, laminas and the base of the transverse processes bilaterally
MRI T 8 extensive high signal intensity body lesion on T 2 , T 1 and stained with contrast Tumor extending to the neuronal causing mass effect over spinal cord at that level
Management Decompression and fixation from T 5 through T 10 on an emergency bases Permanent biopsy samples reported as blood vessels proliferation and dilated spaces with no malignant cells consistent with Hemangioma
Post-op Uneventful post-op recovery Spasticity; improved over time Power; returning to normal
Rehabilitation Patient was referred to rehabilitation and recovered near complete after 6 weeks of extensive physiotherapy and rehabilitation Discharged walking independently Minimal weakness and near normal sensations
Discussion Most vertebral hemangiomas are asymptomatic which require no treatment The most common presenting symptom is back pain Radiological diagnosis (CT is the gold standard ) Spastic para-paresis in our case reflects an aggressive hemangioma, which can result in permanent paraplegia if not managed appropriately Hiari A, Nawaiseh B, Jaber H (1998) Magnetic resonance imaging in the diagnosis of vertebral haemangiomas. East Mediterr Health J 4(1): 149– 155 Laredo JD, Reizine D, Bard M, Merland JJ. Vertebral hemangiomas: radiologic evaluation. Radiology. 1986; 161(1): 183– 9.
Conclusion Young age back pain! Rare but can present with sever symptoms Full recovery if managed appropriately Needs high index of suspension, malignant?
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