Surgical Management of Aggressive Vertebral Hemangiomas Presenting with Epidural Spinal Cord Compression: a Report of 2 Cases and Review of the Literature

Introduction: Vertebral hemangiomas are the most common benign tumors of the spine often found incidentally on imaging or autopsy. Rarely, some tumors are locally destructive and can be associated with back pain or neurologic deficits and are classified as atypical or aggressive hemangiomas, to which management can include separation surgery with circumferential decompression and fusion.

Methods: Two patients at our institution presented with progressive leg weakness, numbness, and incontinence over a two-week period consistent with ASIA-B and ASIA-D spinal cord injuries at T9 and T3 respectively. Imaging was consistent with atypical vertebral hemangioma with contrast enhancement and hypodensity of these expansile bony lesions on the T1 MRI sequences. One patient was treated pre-operatively by embolization with particles resulting in decrease in tumor blush. Both patients received urgent posterior spinal instrumented fusion with decompression for separation surgery with resultant increase in motor function post operatively. Pathology confirmed thick-walled blood vessels with fibroadipose soft tissue consistent with hemangioma without malignancy.

Results: Atypical and aggressive hemangiomas have a characteristic appearance on imaging and may present clinically similar to extradural spinal tumors with epidural compression and resultant instability. Our experience and literature review suggests prompt treatment with decompression and fusion in these cases.

Conclusion : In addition to decompression and fusion, our experience suggests that pre-operative embolization is a useful adjunct for treatment although studies suggest may lead to higher risk for fracture. For Enneking stage 3 aggressive hemangiomas, adjuvant radiation oncology consultation should be considered as was in our two cases due to reported lower rates of recurrence. These cases add to the few reported high grade vertebral hemangiomas and illustrate considerations and rationale for effective surgical treatment.