Treatment of vertebral hemangioma what the interventional radiologist

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 ØVertebral 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-tumorsbenign. 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 T 1 and T 2 weighted images (intralesional fat)

Signs of aggressiveness on imaging of Vertebral Hemangioma • Spine level between T 3 to T 10 • 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 T 1 -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 T 3 10/08/2007 bilateral T 3 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

a e b c d MRI sequences a, b, c sagittale T 2 -weighted images d : sagittale T 1 weighted images with contrast injection e : axial T 1 weighted image with contrast injection 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 ü 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? A. The celiac trunk and superior mesenteric artery ü 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 ü B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

�The anterior spinal artery was identified in T 10 left. Is there a risk of embolization of T 3. A. yes B. no C. Distrust

�The anterior spinal artery was identified in T 10 left. Is there a risk of embolization of T 3. ü A. Yes B. No ü C. Distrust

Embolization Right T 4 Right T 5

�Selective angiography of the pedicle of the left T 3 intercostal artery We can embolize at this level? A. Yes B. No

�Selective angiography of the pedicle of the left T 3 intercostal artery We can embolize at this level? A. Yes ü 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 üB. The epidural extension üC. The involvement of the posterior arch

�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. Vertebroplasty C. Sclerotherapy with Absolute ethanol D. There is no other treatment ü E. There is another alternative?

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

�What does this alternative ? A. Radiofrequency ablation ü 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 ü D. Biological glue

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

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

Sclerotherapy with Glubran 2 by direct puncture under CT guidance

�Is surgery indicated ? A. Yes B. No

�Is surgery indicated ? ü 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 ü C. Within 48 hours of embolization D. The time limits is not important

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

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

Osteosynthesis T 1 to T 6

• 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 ü B. No

�To treat vertebral body of T 3 must be associate : A. Surgery by anterior approach B. Percutaneous Vertebroplasty C. Sclerotherapy with Glubran 2 under CT guidance

�To treat vertebral body of T 3 must be associate : A. Surgery by anterior approach ü 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: üPain relief üVertebral 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

$Relative Contraindications - Pedicles fracture - Vertebral body collapse with retropulsion of fracture fragment$

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

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

Incidents �Paravertebral leakage cement �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 100% 90% 80% 70% 60% 50% Partial improvement 40% 30% Significant improvement 20% Complete regression 10% 0% SHORT TERM MEDIUM TERM

CASE N° 2 � 48 year old woman treated by percutaneous vertebroplasty in 2008 for aggressive vertebral hemangioma T 12 with improvement of symptoms.

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

a f b c d e MRI sequences a: sagittale T 2 weighted image b, c : sagittale T 1 weighted images d, e : sagittale T 1 weighted images with contrast injection f: axial T 1 weighted image with contrast injection

�What is the explanation of the recent symptoms? A. Herniated disc B. Spondylodiscitis C. Vertebral metastasis D. Reactivation of aggressive Angioma T 12 E. Osteoporotic fracture

�What is the explanation of the recent symptoms? A. Herniated disc B. Spondylodiscitis C. Vertebral metastasis ü D. Reactivation of aggressive Angioma T 12 E. Osteoporotic fracture

�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? ü A. Surgery B. Arterial embolization ü C. Surgery with preoperative embolization D. Vertebroplasty ü E. Sclerotherapy with Ethanol

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

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) April 2011 April 2012

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 • 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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