hatem rajhi.md department of radiology and interventional radiology- charles nicolle hospital tunis...

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

Vertebral 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-tumors-benign.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 HemangiomaRadiographic findings

Vertical striations and trabeculations“Honeycomb” appearence.

MRIincreased signal on T1- and T2 weighted images (intralesional fat)

CT axial image

“Polka dot” appearance of the involved vertebra

Signs of aggressiveness on imaging of Vertebral Hemangioma

• Spine level between T3 to T10

• 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 T1-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 T3

10/08/2007 bilateral T3 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 b c d e

MRI sequencesa,b,c sagittale T2-weighted imagesd : sagittale T1 weighted images with contrast injectione : axial T1 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 EmbolizationC. 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 arteriesC. The lumbar arteriesD. The thoracic and abdominal aorta

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

Which embolic agent to use ?

A. Coils

B. Embospheres

C. Curaspon

D. Ethanol

E. Biological Glue


A. CoilsB. Embospheres

C. Curaspon

D. Ethanol

E. Biological Glue

The anterior spinal artery was identified in T10 left. Is there a risk of embolization of T3.

A. yesB. noC. Distrust

The anterior spinal artery was identified in T10 left. Is there a risk of

embolization of T3.

A. Yes

B. NoC. Distrust

Embolization

Right T4

Right T5

Selective angiography of the pedicle of the left T3 intercostal artery

We can embolize at this level?

A. Yes

B. No

Selective angiography of the pedicle of the left T3 intercostal artery

We can embolize at this level?

A. YesB. No

Surgical resection is limited because of:

A. The involvement of the anterior archB. The epidural extensionC. The involvement of the posterior arch

Surgical resection is limited because of:

A. The involvement of the anterior archB. The epidural extensionC. 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

E. There is another alternative?

What does this alternative ?

A. radiofrequency ablation

B. direct embolization ?

What does this alternative ?

A. Radiofrequency ablation

B. Direct embolization ?


A. Ethanol

B. Coils

C. Embospheres

D. Biological Glue


A. Ethanol

B. Coils

C. EmbospheresD. Biological glue

Which type of radiographic guidance ?

A. Fluoroscopy

B. CT scanner

C. Ultrasonography

Which type of radiographic guidance ?

A. FluoroscopyB. CT scanner

C. Ultrasonography

Sclerotherapy with Glubran 2 by direct puncture under CT guidance

Is surgery indicated ?

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

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 VertebrectomyC. Laminectomy and osteosynthesis

D. Osteosynthesis

Osteosynthesis T1 to T6

• 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 . YesB . No

To treat vertebral body of T3 must be

associate :

A. Surgery by anterior approach

B. Percutaneous Vertebroplasty

C. Sclerotherapy with Glubran 2 under CT guidance

Percutaneous Vertebroplasty

Significant improvement with gait recoveryactually walking without cane

PERCUTANEOUS VERTEBROPLASTY

•Percutaneous injection of acrylic cement in

a pathologic vertebral body

•Double effet:

Pain relief

Vertebral stabilization


Patient preparation

Systematic radiological assessment: X-ray + CT + MRI

• Anesthesia consultation before the procedure.

• Informed consent obtained from the patient

• Search for contraindications


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

- Pedicles fracture

- Vertebral body collapse with retropulsion of

fracture fragment causing spinal canal compromise

- Severe vertebral body collapse

Relative Contraindications

• Fluoroscopic C-arm• Guidance

• CT guidance

• General anesthesia or local analgesia with or without conscious sedation

Technique

Bone cement :PMMA

Bone Needles 11 G 10 cm (thoracic spine) 15 cm (lumbar spine)

Surgical hammerCombination pliers

Equipment

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 preparation

• Transpedicular approach Unipedicular or Bipedicular

Cement injection

Postero lateral approach - pedicular lysis - osteosynthesis

Cement injection

• Vascular leakage of cement - the operator should adjust the needle direction - or stop the injection immediately.

Risk of Pulmonary embolism

Incidents

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 cement leakage

Intervertebral disc cement leakage

Without major complications

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

Vertebroplasty Results

SHORT TERM MEDIUM TERM0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Partial improvement

Significant improvement

Complete regression

CASE N°2 48 year old woman treated by percutaneous

vertebroplasty in 2008 for aggressive vertebral hemangioma T12 with improvement of symptoms.

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

a b c d e fMRI sequencesa: sagittale T2 weighted imageb,c : sagittale T1 weighted imagesd,e : sagittale T1 weighted images with contrast injectionf: axial T1 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 T12

E. Osteoporotic fracture

What is the explanation of the recent symptoms?

A. Herniated disc

B. Spondylodiscitis

C. Vertebral metastasis D. Reactivation of aggressive Angioma T12

E. Osteoporotic fracture

Which procedure could be proposed as a treatment?

A. SurgeryB. Arterial embolizationC. Surgery with preoperative embolizationD. VertebroplastyE. Sclerotherapy with Ethanol

Which procedure could be proposed as a treatment?

A. SurgeryB. Arterial embolization

C. Surgery with preoperative embolizationD. Vertebroplasty

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

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

SCLEROTHERAPY WITH ETHANOL

•CT guidance

• Intravenous conscious sedation and analgesia

Technique

-Without significantly changing the absolute nature of the alcohol, we have made alcohol radioopaque by mixing it with contrast media

• Transpedicular approach Unipedicular Bipedicular

• Postero lateral apparoch

Technique

Potential risk of venous runoff

- Avoided by slow injection of Ethanol

Pleural complications and intercostal arteries injury

- Avoided by transpedicular approach

Incidents

Risk of collapse of the vertebral body

-Decreased by injecting a small volume of alcohol

Complications

•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

CONCLUSION

MERCI Thank you

hatem rajhi.md department of radiology and interventional radiology- charles nicolle hospital tunis...

Documents

radiotherapy slide

biological glue slide

contrast injection slide

capillary hemangioma

abdominal aorta slide

involved vertebra slide

embolic agent

sagittale t1 weighted