Surgical management of vertebral fractures caused by aggressive hemangiomas. A series of case reports and a review

Relevance. Vertebral hemangioma (VH) is a combined group of spine vascular formations that destruct bone tissue of vertebrae. The clinically relevant VH forms cause pain syndrome or neurological deficit due to the progressive decrease of support ability in the affected vertebra or its pathologic fracture that occure within the clinical course of 3.6-10.9 percent of all aggressive VH. No algorithm for the surgical management of fractures in VH was found in the available studies.

The objective of this study was to determine the range of surgical techniques used for fractures in hemangioma affected vertebrae. Three case reports are presented. The available sources of 1983-2020 contain 15 studies on pathologic fractures associated with VH including 6 case reports and 9 reviews. They describe 3 anterior corpectomies with autograft bone substitutes, 1 vertebroplasty (kyphoplasty), 5 decompressions and anterior fixation with a hardware, 5 transpedicular fixations (TPF) and open vertebroplasties, 1 TPF and laminectomy. 80 percent of the outcomes featured the complete regression of neurological deficit. However, in 20 percent of the outcomes the neurological deficit never regressed completely due the long time that passed since the fractures occurred. We present three case reports that demonstrate the unique practice of surgical management for pathologic fractures in VH and involve L1 transcutaneous transpedicular balloon kyphoplasty, two-stage surgical treatment (L3-L5 transcutaneous transpedicular fixation and L4 neoplasm biopsy + anterior corporodesis); C7 vertebroplasty. The outcomes featured the complete reversal of pain syndrome in 1 post-op year without any loss in the induced stability.

Conclusion. It has been reported that aggressive VH bring the risk of pathologic fracture, particularly in biomechanically vulnerable vertebrae. The uncomplicated pathologic fractures and minor vertebral compressions can be managed with minimally invasive methods like vertebro- or kyphoplasties. If a non-supportive vertebral body has to be reconstructed or the decompression of spinal canal structures is indicated, the metal spondylosynthesis has to be adequate to lesion morphology and structure of the fracture. However, the available sources contain no conventional algorithm of choosing the management tactics for pathologic fractures in VH making further research on this subject relevant.

1. Zafeiris C.P., Lewkonia P., Jacobs W.B. Atypical vertebral hemangioma: an aggressive form of a benign disease. Case Report and Literature Review. J Musculoskelet Neuronal Interact. 2021;21(2):317-321.

2. Goraya G.S., Singhal S., Paul B.S., Paul G. Aggressive Vertebral Hemangioma: The Mystery of Spastic Legs Unveiled by a Purple Shoulder. Cureus. 2022;14(1):e21568. DOI: 10.7759/cureus.21568

3. Kravtsov M.N. Aggressive vertebral hemangiomas optimization of treatment tactics: PhD abstract. Saint-Petersburg, 2010. 24 p.

4. Acosta F.L. Jr., Sanai N., Chi J.H., Dowd C.F., Chin C., Tihan T., Chou D., Weinstein P.R., Ames C.P. Comprehensive management of symptomatic and aggressive vertebral hemangiomas. Neurosurg Clin N Am. 2008;19(1):17-29. DOI: 10.1016/j.nec.2007.09.010

5. Krueger E.G., Sobel G.L., Weinstein C. Vertebral hemangioma with compression of spinal cord. J Neurosurg. 1961;18:331-338.

6. McAllister V.L., Kendall B.E., Bull J.W. Symptomatic vertebral haemangiomas. Brain 1975;98:71-80. DOI: 10.1093/brain/98.1.71

7. Nguyen J.P., Djindjian M., Gaston A., Gherardi R., Benhaiem N., Caron J.P., Poirier J. Vertebral hemangiomas presenting with neurologic symptoms. Surg Neurol. 1987;27:391-7. DOI: 10.1016/0090-3019(87)90020-6

8. Laredo J.D., Reizine D., Bard M., Merland J.J. Vertebral hemangiomas: radiologic evaluation. Radiology. 1986;161(1):183-9. DOI: 10.1148/radiology.161.1.3763864

9. Kravtsov M.N., Manukovsky V.A., Manashchuk V.I., Svistov D.V. Diagnostics and treatment of aggressive spinal hemangiomas. Clinical recommendations. Мoscow, 2015. P. 35.

10. Enneking W.F., Spanier S.S., Goodman M.A. A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res. 2003;(415):4-18. DOI: 10.1097/01.blo.0000093891.12372.0f

11. Jawad M.U, Scully S.P. In Brief: Classifications in Brief: Enneking Classification: Benign and Malignant Tumors of the Musculoskeletal System. Clinical Orthopaedics and Related Research. 2010;468(7):2000-2002. DOI:10.1007/s11999-010-1315-7

12. Zaborovskii N.S., Ptashnikov D.A., Mikhaylov D.A., Smekalenkov O.A., Masevnin S.V. Oncological principles in spinal tumor surgery. Hir. Pozvonoc. 2021;18(2):64-72. In Russian. DOI: 10.14531/ss2021.2.64-72

13. Kit O.I., Zakondyrin D.E., Rostorguev E.E., Yundin S.V. Specifics of epidural compression syndrome surgery in patients with spinal malignancy. Creative Surgery and Oncology. 2022;12(1):21-27. In Russian. DOI: 10.24060/2076-3093-2022-12-1-21-27

14. Patchell R.A., Tibbs P.A., Regine W.F., Payne R., Saris S., Kryscio R.J., Mohiuddin M., Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005;366(9486):43-648. DOI: 10.1016/S0140-6736(05)66954-1

15. Al-Omair A., Masucci L., Masson-Cote L., Campbell M., Atenafu E.G., Parent A., Letourneau D., Yu E., Rampersaud R., Massicotte E., Lewis S., Yee A., Thibault I., Fehlings M.G., Sahgal A. Surgical resection of epidural disease improves local control following postoperative spine stereotactic body radiotherapy. Neuro Oncol. 2013;15(10):1413-1419. DOI: 10.1093/neuonc/not101

16. Ostrovskij V.V., Bazhanov S.P., Arsenievich V.B., Likhachev S.V., Zaretskov V.V., Mizyurov S.A., Papaev A.V. Neuroorthopedic approach to treating a patient with schwannoma and aggressive hemangioma at a single spinal motion segment: a case study. Spine Surgery. 2022;19(2):67-73. In Russian. DOI: 10.14531/ss2022.2.67-73

17. Greenspan A., Klein M.J., Bennett A.J., Lewis M.M., Neuwirth M., Camins M.B. Case report 242. Hemangioma of the T6 vertebra with a compression fracture, extradural block and spinal cord compression. Skeletal Radiol. 1983;10(3):183-188. DOI: 10.1007/BF00357777

18. Graham J.J., Yang W.C. Vertebral hemangioma with compression fracture and paraparesis treated with preoperative embolization and vertebral resection. Spine (Phila Pa 1976). 1984;9(1):97-101. DOI: 10.1097/00007632-198401000-00022

19. Schwartz T.H., Hibshoosh H., Riedel C.J. Estrogen and progesterone receptor-negative T11 vertebral hemangioma presenting as a postpartum compression fracture: case report and management. Neurosurgery. 2000;46(1):218-221.

20. Chi J.H., Manley G.T., Chou D. Pregnancy-related vertebral hemangioma. Case report, review of the literature, and management algorithm. Neurosurg Focus. 2005;19(3):E7. DOI: 10.3171/foc.2005.19.3.8

21. Vinay S., Khan S.K., Braybrooke J.R. Lumbar vertebral haemangioma causing pathological fracture, epidural haemorrhage, and cord compression: a case report and review of literature. J Spinal Cord Med. 2011;34(3):335-9. DOI: 10.1179/2045772311Y.0000000004

22. Haque M.U., Wilson A.N., Blecher H.D., Reich S.M. Lumbar hemangioma masking a plasma cell tumor--case report and review of the literature. Spine J. 2013;13(8):e11-15. DOI: 10.1016/j.spinee.2013.01.050

23. Moles A., Hamel O., Perret C., Bord E., Robert R., Buffenoir K. Symptomatic vertebral hemangiomas during pregnancy. J Neurosurg Spine. 2014;20(5):585-591. DOI: 10.3171/2014.2.SPINE13593

24. Staikou C., Stamelos M., Boutas I., Koutoulidis V. Undiagnosed vertebral hemangioma causing a lumbar compression fracture and epidural hematoma in a parturient undergoing vaginal delivery under epidural analgesia: a case report. Can J Anaesth. 2015;62(8):901-906. DOI: 10.1007/s12630-015-0381-4

25. Knechtle B., Nikolaidis P.T., Lutz B., Rosemann T., Baerlocher C.B. Pathologic fracture of the thoracic spine in a male master ultra-marathoner due to the combination of a vertebral hemangioma and osteopenia. Medicina (Kaunas). 2017;53(2):131-137. DOI: 10.1016/j.medici.2017.02.003

26. Fereydonyan N., Taheri M., Kazemi F. Recurrent symptomatic vertebral hemangioma during two consecutive pregnancies: Case report and review of the literature. Surg Neurol Int. 2017;8:105. DOI: 10.4103/sni.sni_93_17

27. Kilic K., Unal E., Toktas Z.O., Aker F.V., Akakın A., Kilic T. Post-traumatic Progressive Vertebral Hemangioma Induced by a Fracture. Case Rep Surg. 2017;2017:8280678. DOI: 10.1155/2017/8280678

28. Bourghli A., Abduljawad S.M., BoissiÈre L., Khalifa H., Obeid I. Aggressive Thoracic Hemangioma Leading to Secondary Kyphosis with Paraparesis in the Postpartum Period. A Case Report. Int J Spine Surg. 2020;14(3):418-425. DOI: 10.14444/7055

29. Liu C.-L., Yang D.-J. Paraplegia Due to Vertebral Hemangioma during Pregnancy. Spine. 1988;13(1):107-108. DOI:10.1097/00007632-198801000-00025

30. Nayak R., Singh H., Khwaja G., Chowdhury D., Gupta M. Pregnancy related symptomatic vertebral hemangioma. Annals of Indian Academy of Neurology. 2014;17(1):120. DOI:10.4103/0972-2327.128577

31. Li C., Zhang H.B., Zhang H., Li Q., Zhang J., Wang J., Guo K.J., Wang L.X. Severe pathological fractures caused by vertebral hemangiomas with posterior decompression, bone cement augmentation and internal fixation. Orthop Traumatol Surg Res. 2016;102(4):489-494. DOI: 10.1016/j.otsr.2016.01.024

32. Wang G.X., Mu Y.D., Che J.Y., Zhang G.F., Jiang G., Gao C.P. Compressive myelopathy and compression fracture of aggressive vertebral hemangioma after parturition: A case report and review of literature. Medicine (Baltimore). 2019;98(50):e18285. DOI: 10.1097/MD.0000000000018285

33. Miziurov S.A., Ostrovskij V.V., Zaretskov V.V., Arsenievich V.B., Likhachev S.V., Zaretskov A.V., Papaev A.V. Balloon kyphoplasty for surgical treatment of aggressive vertebral hemangiomas (literature review). Genij Ortopedii. 2021;27(6):821-826. In Russian. DOI: 10.18019/1028-4427-2021-27-6-821-826

34. Arsenievich V.B., Likhachev S.V., Zaretskov V.V., Ostrovskij V.V., Bazhanov S.P., Mizyurov S.A., Stepukhovich S.V. Open vertebroplasty for cervical spine aggressive hemangioma. Spine Surgery. 2021;18(1):53-60. In Russian. DOI: 10.14531/ss2021.1.53-60