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Year : 2014  |  Volume : 48  |  Issue : 2  |  Page : 163-167
Percutaneous vertebroplasty in painful refractory vertebral hemangiomas

1 Department of Neurology, Seven Hills Hospital, Visakhapatnam, Andhra Pradesh, India
2 Department of Interventional Neuroradiology, Seven Hills Hospital, Visakhapatnam, Andhra Pradesh, India

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Date of Web Publication13-Mar-2014


Background: Painful vertebral hemangiomas are often inadequately managed medically. We evaluated the outcome of percutaneous vertebroplasty (PVP) in the treatment of painful vertebral hemangiomas refractory to medical management.
Materials and Methods: 14 patients (four thoracic and ten lumbar vertebra) with painful vertebral hemangiomas presenting with severe back pain for more than 6 months not responding to medical therapy were treated by vertebroplasty. Cross sectional imaging of the spine with magnetic resonance was done. Blood investigations were done to exclude coagulopathy excluded. PVP was performed under local anesthesia.
Results: The pain intensity numeric rating scale (PI-NRS-11) of these patients was in the range of 7-10 (Severe Pain). After vertebroplasty 8 patients were completely free of pain (PI NRS Score 0) while 6 were significantly relieved (PI-NRS Score 1-3). No complications were observed. Two patients with associated radicular pain had good pain relief following PVP. No recurrence was found during 36 months of postoperative followup.
Conclusion: PVP is a safe and effective procedure in patients with painful vertebral hemangiomas refractory to medical management.

Keywords: Hemangioma, polymethyl methacrylate, percutaneous vertebroplasty

How to cite this article:
Narayana R V, Pati R, Dalai S. Percutaneous vertebroplasty in painful refractory vertebral hemangiomas. Indian J Orthop 2014;48:163-7

How to cite this URL:
Narayana R V, Pati R, Dalai S. Percutaneous vertebroplasty in painful refractory vertebral hemangiomas. Indian J Orthop [serial online] 2014 [cited 2019 Dec 14];48:163-7. Available from:

   Introduction Top

Vertebral hemangiomas are benign, malformed vascular tumors composed of newly formed blood vessels with normal capillary, venous, or veno-capillary structure and without arterio-venous shunt. They primarily involve the vertebra and may extend to the epidural space. There are two microscopic types of vertebral hemangiomas which frequently coexist. They are cavernous and capillary hemangiomas. Cavernous hemangiomas are composed of large dilated blood vessels closely clustered together and hence they are not separated by normal bone tissue. Capillary hemangiomas are formed of thin walled capillary vessels of various sizes separated by normal bone tissue. [1]

Percutaneous vertebroplasty (PVP) is the procedure of injecting bone cement i.e. polymethyl methacrylate (PMMA) percutaneously into the vertebral body under fluoroscopic guidance. PVP was developed in France in the late 1980s, principally for treatment of vascular bone lesions such as hemangioma and subsequently found to be useful in treating painful vertebral metastasis and painful osteoporotic vertebral compression. [2],[3],[4] After introduction of PVP in North America, the procedure has become increasingly popular during the past decade. PVP has proven successful in providing dramatic and prompt pain relief in most patients with painful vertebral hemangioma, allowing rapid patient mobilization.

   Materials and Methods Top

The spinal magnetic resonance imaging was studied in detail. Pathologies other than vertebral hemangiomas were excluded. 14 patients with vertebral hemangiomas, four had associated vertebral osteoporotic compression fracture, presented between November 2006 and April 2013, were included in the study. Back pain was diagnosed by the patient's history, clinical examination and quantified by pain intensity numeric rating scale (PI-NRS) [Table 1]. [5] Patients' previous medical records and imaging were reviewed. Based on the history and clinical findings, relevant imaging including magnetic resonance (MR) was done [Figure 1]a.
Figure 1: (a) Magnetic resonance imaging T2W sagital view showing L4 vertebral hemangioma (b) Needle position under fluoroscopy (antero-posterior and lateral view), (c) Lateral view fluoroscopy after vertebroplasty demonstrating good cement filling

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Table 1: The pain intensity NRS (0-10)

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The MR of the above 14 patients were normal except for vertebral hemangiomas in all and osteoporotic vertebral fractures in four of them. Bone densitometry and isotope bone scanning were not done.

Routine blood investigations for all these patients were done. Patients with low platelet count and coagulopathy were excluded. Patients with vertebral hemangiomas with severe back pain for more than 6 months, not responding to medical therapy were included in the study. All these patients received adequate analgesic therapy with two or more analgesics for more than 6 months. Informed, written consent obtained from all patient undergoing vertebroplasty after explaining the procedure in detail.

Patients were given 1.0 g of ceftriaxone intravenously 1 h prior to the procedure. All vertebroplasties were performed in the cathlab under high quality fluoroscopic guidance with patient positioned prone. The entire spine was examined with fluoroscopy in antero-posterior (AP) and lateral view and the level of hemangioma was marked with a metallic marker. The site of entry and the needle track was infiltrated with 10 ml of 2% xylocaine. The vertebra was approached with an 11G or 13G beveled cook bone biopsy needle from the trans-pedicular route. The needle was progressed into the vertebral body and positioned near the midline, approximately at the junction of the anterior one-third with the posterior two-third. The patient is asked to report any pain or discomfort especially in the ipsilateral leg during the progression of the needle from the skin to vertebra. AP and lateral fluoroscopic views confirmed the position of the needle [Figure 1]b. The bone cement (PMMA) is cooled to 4-8° centigrade 1 h prior to injection. The cement is prepared by mixing PMMA powder and liquid PMMA (Cook Medical Inc., USA) and is filled into 1 cc glass syringes then injected into the vertebra through the bone biopsy needle under constant fluoroscopic guidance in Lateral view. As we inject, the cement fills the vertebra backward and we keep injecting till the cement comes to the posterior fourth of the vertebra [Figure 1]c. Keeping a close watch on the movement of the cement is critical to avoid extra vasation either into the venous system, foramina, or other extra vertebral sites. Leakage of cement leads to compression of adjacent structures like spinal nerve roots, spinal cord and may lead to neurological deficits. We inject around 4-7 cc of cement into each vertebra. [6],[7],[8] The cement injection is completed within 60-90 s as the PMMA polymerizes in quick time. The needle is removed and the site of entry is secured. Patient is discharged from the hospital on the next day of the procedure.

   Results Top

We treated 14 patients of vertebral hemangioma with PVP. Among these patients, five were males and nine females. The average age of patients was 68 years (range 24-79 years). All these patients were evaluated clinically and with 11-point PI numerical rating scale. Their average pain score was 8.5 (range 7-10) [Table 2].
Table 2: List of patients underwent vertebroplasty

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After vertebroplasty pain was completely relieved in 8 (PI-NRS Score 0), and significantly relieved in 6 (PI-NRS Score 1-3) without any complications. Two patients with associated radicular pain had good pain relief following PVP. No recurrence was found during 36 months of postoperative followup.

Four patients had associated painful osteoporotic vertebral collapse. These patients were simultaneously treated with PVP in the same sitting without any complication [Figure 2]a-c. Up to three level vertebras can be safely treated with PVP in the same sitting. As the amount of PMMA injected into the vertebra is so small, that even if 3 level PVP does not pose a significant risk. [9]
Figure 2: (a) Fluoroscopic view (lateral) showing vertebral hemangioma with trabeculations. (b) Needle position. (c) Radiograph post vertebroplasty

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We had complex situations in two of our patients who underwent trans arterial embolization with poly vinyl particle polyvinyl alcohol (PVA) prior to vertebroplasty. During attempted vertebroplasty in one of them, the cement started leaking into the epidural vein without opacifying the vertebra. This was immediately identified and the procedure was postponed. The hemangioma was embolized and vertebroplasty was done in the next sitting [Figure 3]a-c. The other patient presented with pain and paraparesis in her early postpartum period. Cross sectional imaging demonstrated D4 vertebral hemangioma with extra vertebral extension. She underwent trans-arterial embolization, vertebroplasty followed by laminectomy with a favorable outcome.
Figure 3: (a) Magnetic resonance imaging T2W sagittal view showing L3 vertebral hemangioma and osteoporotic compression fracture of D12, (b) Fluoroscop ic view demonstrating needle position, (c) Vertebroplasty of L3 hemangioma and osteoporotic D12 vertebra

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All the patients underwent immediate post procedure CT scan following vertebroplasty to look for cement leak to extra vertebral sites or fracture. These patients were followed up for 6-36 months with an average of 9 months with no recurrence of pain or any other complication.

   Discussion Top

The true incidence of vertebral hemangiomas is not known. Different series have reported the incidence of vertebral hemangioma to be 10-27% based on autopsy series and imaging reviews. They are more common in females compared with males. Multiple hemangiomas are seen in 33% of the cases. The most common presentation in vertebral hemangioma patients is midline spinal pain. Otherwise most of them are asymptomatic. They required to be treated when they are symptomatic. They should be treated conservatively with analgesics and bed rest for at least 6 weeks. If they do not respond to the above therapies, more aggressive therapies such as surgical decompression, endovascular embolization, radiotherapy and vertebroplasty can be offered. Sometimes a combination of these therapies may be required.

Embolization with PVA particle alone is reported to produce usually transient remissions.10-12 Two patients in this series underwent embolization with PVA particles followed by vertebroplasty. These two patients were taken for vertebroplasty in a usual manner. However, during injection of PMMA, the bone cement flew off into the epidural venous plexus, suggesting the blood flow to be very high inside the vertebra. Hence, the procedures were abandoned and embolization was done in these patients to reduce excess vascularity. vertebroplasty was done safely in these patients after embolization in a separate sitting. These patients had a good short term and long term outcome. Angiogram may not be performed in all patients of vertebral hemangiomas before vertebroplasty. However, if the bone cement flies off the vertebra during injection due to high flow, the procedure must be abandoned and angio-embolization may be done before reattempting vertebroplasty.

Radiation therapy can be used to treat lesions associated with pain. [23] They are radiosensitive lesions and respond to administration of 3000-4000 cGy. Yang et al., [13] and Faria et al., [14] in their study have reported complete reversal of paraplegia of several weeks duration following radiation therapy alone. Radiation therapy as the sole management modality for patients with progressive neurological deficits has however, been controversial.

Vertebroplasty has a low rate of clinical complications, but potential complications can be devastating. Cement extra vasation is one of the possible complications of vertebroplasty. Incidences of cement leakage are less in hemangioma due to intact cortex compared with osteoporotic fracture. The leakage of cement can be into any structure around the vertebra. The relevance of this complication will be different in relation to the anatomical structure, which is invaded from the cement. Cement invasion into the vena cava, lungs, heart have been described. [15],[16] These major adverse events only occur in less than 1% of the patients, [17] and require immediate management.

PVP can be performed through unipedicular or bipedicular approach. However, in most instances a single injection through one pedicle is all that is required. [18],[19] If there is insufficient filling of the vertebral bodies, a second puncture through the contralateral pedicle may be performed. We performed PVP through unipedicular approach in all our patients. A total of 14 patients with vertebral hemangiomas treated by unipedicular PMMA injection, pain is completely relieved in 8 cases (PI-NRS Score 0) and significantly relieved in 6 cases (PI-NRS Score 1-3). High quality fluoroscopy and operator experience are important to avoid complications like neurologic deficits, fracture of vertebra and rib, hemorrhage, pneumothorax or hemothorax, and pulmonary embolus. [20],[21],[22]

We conclude that it is possible to treat painful vertebral hemangioma at single or multiple vertebral levels with or without vertebral collapse in the same sitting with excellent clinical outcome. Vertebral hemangiomas with high flow needs angio-embolization before a vertebroplasty.

   References Top

1.Gray F, Gherardi R, Benhaiem-Sigaux N. Vertebral hemangioma. Definition, limitations, anatomopathologic aspects. Neurochirurgie 1989;35:267-9.  Back to cited text no. 1
2.Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie 1987;33:166-8.  Back to cited text no. 2
3.Kaemmerlen P, Thiesse P, Bouvard H, Biron P, Mornex F, Jonas P. Percutaneous vertebroplasty in the treatment of metastases. Technic and results. J Radiol 1989;70:557-62.  Back to cited text no. 3
4.Kaemmerlen P, Thiesse P, Jonas P, Bérard CL, Duquesnel J, Bascoulergue Y, et al. Percutaneous injection of orthopedic cement in metastatic vertebral lesions. N Engl J Med 1989;321:121.  Back to cited text no. 4
5.Turk DC, Rudy TE, Sorkin BA. Neglected topics in chronic pain treatment outcome studies: Determination of success. Pain 1993;53:3-16.  Back to cited text no. 5
6.Lin DD, Gailloud P, Murphy KJ. Percutaneous vertebroplasty in benign and malignant disease. Neurosurg Q 2002;11:290-301.  Back to cited text no. 6
7.Cotten A, Dewatre F, Cortet B, Assaker R, Leblond D, Duquesnoy B, et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: Effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical followup. Radiology 1996;200:525-30.  Back to cited text no. 7
8.Belkoff SM, Mathis JM, Jasper LE, Deramond H. The biomechanics of vertebroplasty. The effect of cement volume on mechanical behavior. Spine (Phila Pa 1976) 2001;26:1537-41.  Back to cited text no. 8
9.Kaufmann TJ, Jensen ME, Ford G, Gill LL, Marx WF, Kallmes DF. Cardiovascular effects of polymethylmethacrylate use in percutaneous vertebroplasty. AJNR Am J Neuroradiol 2002;23:601-4.  Back to cited text no. 9
10.Gross CE, Hodge CH Jr, Binet EF, Kricheff II. Relief of spinal block during embolization of a vertebral body hemangioma. Case report. J Neurosurg 1976;45:327-30.  Back to cited text no. 10
11.Smith TP, Koci T, Mehringer CM, Tsai FY, Fraser KW, Dowd CF, et al. Transarterial embolization of vertebral hemangioma. J Vasc Interv Radiol 1993;4:681-5.  Back to cited text no. 11
12.Raco A, Ciappetta P, Artico M, Salvati M, Guidetti G, Guglielmi G. Vertebral hemangiomas with cord compression: The role of embolization in five cases. Surg Neurol 1990;34:164-8.  Back to cited text no. 12
13.Yang ZY, Zhang LJ, Chen ZX, Hu HY. Hemangioma of the vertebral column. A report on twenty three patients with special reference to functional recovery after radiation therapy. Acta Radiol Oncol 1985;24:129-32.  Back to cited text no. 13
14.Faria SL, Schlupp WR, Chiminazzo H Jr. Radiotherapy in the treatment of vertebral hemangiomas. Int J Radiat Oncol Biol Phys 1985;11:387-90.  Back to cited text no. 14
15.Quesada N, Mutlu GM. Images in cardiovascular medicine. Pulmonary embolization of acrylic cement during vertebroplasty. Circulation 2006;113:e295-6.  Back to cited text no. 15
16.Barragán-Campos HM, Vallée JN, Lo D, Cormier E, Jean B, Rose M, et al. Percutaneous vertebroplasty for spinal metastases: Complications. Radiology 2006;238:354-62.  Back to cited text no. 16
17.Nussbaum DA, Gailloud P, Murphy K. A review of complications associated with vertebroplasty and kyphoplasty as reported to the Food and Drug Administration medical device related web site. J Vasc Interv Radiol 2004;15:1185-92.  Back to cited text no. 17
18.Kim AK, Jensen ME, Dion JE, Schweickert PA, Kaufmann TJ, Kallmes DF. Unilateral transpedicular percutaneous vertebroplasty: Initial experience. Radiology 2002;222:737-41.  Back to cited text no. 18
19.Tohmeh AG, Mathis JM, Fenton DC, Levine AM, Belkoff SM. Biomechanical efficacy of unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression fractures. Spine (Phila Pa 1976) 1999;24:1772-6.  Back to cited text no. 19
20.Martin JB, Jean B, Sugiu K, San Millán Ruíz D, Piotin M, Murphy K, et al. Vertebroplasty: Clinical experience and followup results. Bone 1999;25:11S-5.  Back to cited text no. 20
21.Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine (Phila Pa 1976) 2000;25:923-8.  Back to cited text no. 21
22.Padovani B, Kasriel O, Brunner P, Peretti-Viton P. Pulmonary embolism caused by acrylic cement: A rare complication of percutaneous vertebroplasty. AJNR Am J Neuroradiol 1999;20:375-7.  Back to cited text no. 22
23.Bandiera S, Gasbarrini A, De Iure F, Cappuccio M, Picci P, Boriani S. Symptomatic vertebral hemangioma: the treatment of 23 cases and a review of literature. Chir Organi Mov 2002;87:1-15.  Back to cited text no. 23

Correspondence Address:
Sibasankar Dalai
OP No: 12, First Floor, Seven Hills Hospital, Rockdale Layout, Visakhapatnam - 530 017, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5413.128759

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