Management of cement vertebroplasty in the treatment of vertebral hemangioma

Transcription

1 Scandinavian Journal of Surgery 100: , 2011 Management of cement vertebroplasty in the treatment of vertebral hemangioma V. Boschi 1, Z. Pogorelić, G. Gulan 3, Z. Perko 1, L. Grandić 1, V. Radonić 1 1 Department of Surgery, University Hospital Split and Split University School of Medicine, Split, Croatia 2 Department of Pediatric Surgery, University Hospital Split and Split University School of Medicine, Split, Croatia 3 Orthopedic Clinic Lovran, Lovran, Croatia ABSTRACT Background: The vertebral hemangiomas are benign vascular lesions occurring in spine. Although uncommon, symptomatic vertebral hemangiomas can be painful and can limit daily activities. A number of methods have been used in the treatment of symptomatic and aggressive vertebral hemangioma, but none of them is optimal. Treatment with cement vertebroplasty showed very good results. This study aims to illustrate the validity of the treatment with cement vertebroplasty in patients with painful vertebral hemangiomas. Patients and Methods: From January 2000 to January 2007, 24 patients were treated by percutaneous vertebroplasty because of hemangioma: 16 thoracic, 8 lumbar. There were 11 males and 13 females. The average age at the time of surgery was 48 years. All the patients complained of a pain syndrome resistant to continuing medication. All patients underwent X-ray examination, CT-scan and MR of the involved level preoperatively. A unipedicular approach under fluoroscopic guidance has been performed in all patients. All procedures have been carried out under the local anesthesia. The mean follow-up was 5.8 years. Results: In all the patients a successful outcome has been observed with a complete resolution of pain symptom. Extravertebral vascular cement leakage has been observed in 3 patients, without any clinical radicular syndrome onset due to the epidural diffusion. Clinical and radiological follow-up showed stability of the treatment and absence of pain in all patients. Conclusion: Percutaneous treatment with vertebroplasty for symptomatic vertebral hemangiomas is a valuable, less-invasive, and a quick method that allows a complete and enduring resolution of the painful vertebral symptoms without findings of the vertebral body s fracture. Key words: Vertebroplasty; vertebral hemangioma; percutaneous technique; pain; cement vertebroplasty; spine Correspondence: Zenon PogoreliÍc, M.D. Department of Pediatric Surgery University Hospital Split, SpinvciÍceva Split, Croatia zenon@vip.hr

2 Treatment of vertebral hemangioma 121 INTRODUCTION Vertebral body hemangiomas are the most common slow-growing, non-painful benign tumors of the spine (1). They represent about 2 3% of all spinal tumors and they are usually found in about 11% of all vertebral autopsies (2). Most of them remain clinically silent, in about 0.9 to 1.2% of patients they are presented with pain symptomatology (1, 2). In symptomatic hemangiomas the most common symptom is pain, rarely they are presented with neurological deficit due to hypertrophy of the posterior cortex of the vertebral body. Compression fractures or hemorrhages are very rare (3). They are usually detected at the fourth or fifth life decade and are twice more often in women than in men (1, 4). They are clinically subdivided into three main categories: the most common asymptomatic hemangioma, the compressive vertebral hemangioma and the rare symptomatic hemangioma (5). We can microscopically differentiate several types of hemangiomas: capillary, cavernous, arteriovenous and venous with the first two groups being the most prevalent in osseous tissue (3). Vertebral hemangiomas are usually detected on the plain X-ray. Plain X-ray films show coarse vertical striations partially or completely involving vertebral body. The diagnosis is confirmed by a CT scan or MRI findings. On the CT scan, hemangioma is presented with a characteristic polka dot appearance. Extraosseous, para-vertebra and epidural extension can also be visualized, while in MRI it is detectable in both T1 and T2 sequences with T2 being the most diagnostic (2, 5, 6). In the past, vertebral hemangiomas were treated by radiotherapy, vascular embolization, surgery, intralesional injection of ethanol or a combined therapy (2, 4, 7). Nowadays, percutaneous vertebroplasty and balloon kyphoplasty are extensively used in the treatment of painful vertebral hemangiomas. In a case of the pathological fractures most authors used kyphoplasty, and in painful hemangiomas vertebroplasty is the most used method (1, 4). Recently, there are new reports on the results of the percutaneous vertebroplasty in treating the vertebral hemangiomas, but unfortunately, literature data are mostly limited to case reports and small series of patients. In this report, we reviewed data of 24 patients with painful vertebral hemangioma treated by percutaneous vertebroplasty. The purpose of this study was to assess the efficacy and safety of percutaneous cement vertebroplasty in the vertebral hemangioma treatment. PATIENTS AND METHODS From January 2000 to January 2007, the clinical cases and radiographic records were reviewed retrospectively for 24 patients treated for the painful vertebral hemangioma by percutaneous cement vertebroplasty in the Department of Surgery, University Hospital Split, Croatia. There were 11 males (45.8%) and 13 females (54.2%). The age range was 36 to 54 years (mean 48 years). In 16 patients hemangiomas were located in the thoracic spine and in 8 patients in the lumbar spine. The vertebral body was affected in all cases, there were no tumor spreading in the pedicle. All patients presented with the localized pain in a static or physical effort in the level of hemangioma. All patients underwent X-ray examination, CT-scan and MR of the affected level preoperatively. There were no compression fractures or neurological deficits in patients. Before the operation each patient completed visual numerical scales rating their average back pain (0 10). Under local anesthesia and fluoroscopic guidance percutaneous vertebroplasty was performed by a right transpedicular approach. The tip of a needle (Vertebroplasty needle kit, Synthes, GmbH, Switzerland) enters the pedicle surface at its superior and lateral edge, at an angle to bring the needle tip in a midline position within the vertebral body. Vertebroplastic TM cement (De Puy AcroMed, Inc. Raynham, MA, USA) was injected into the vertebral body under fluoroscopic guidance. The injection continued as long as there was no evidence of epidural or foraminal leakage and venous run-off. The injection was terminated when the adequate vertebral filling was obtained. An average amount of injected cement was 4.8 ml (range ml) for each level. The patients were followed-up at 1, 6, 12 months postoperatively, and then examined once a year. The mean followup was 5.8 years (range years). Patients were controlled by X-ray, CT-scan and MR immediately, two months and three years after the operation. RESULTS The average operation time was 22 minutes (range minutes). Twenty-four hours after the surgery all the patients got up. Neither violation of the pedicle wall and neurological complications nor cement leakage into epidural or foraminal region was found. We followed-up for the existence of the pain after surgery in all patients. In 8 patients, immediately after operation, there was no longer any pain in the level of hemangioma (lumbar spine localization). In 10 patients the pain disappeared 5 6 days after operation and at 6 patients after 2 weeks (thoracic spine localization). Following the postoperative period of the next 4 9 years we did not record the pain recurrence in the level of hemangioma. Two patients reported pain in lumbosacral region below the level of hemangioma as a result of degenerative changes in that region. The average extent of pain severity decreased from 8.40 preoperatively to 0.85 one month postoperatively (P < 0.001). Venous leakage of the cement during the vertebroplasty occurred in 3 patients, and cement injection was stopped immediately. No clinical symptoms appeared. In these patients the area of hemangioma was not completely filled with cement, but the pain disappeared. Control CT-scan after the surgery showed partial presence of the hemangioma, but 2 months later on control CT-scan a sclerosation of the residue hemangioma was clearly seen. Three years after procedure CT-scan and MR found a complete disappearance of hemangioma in the place where there was no cement and creating of a new spongious bone. There were no structural or degenerative vertebral changes on MR and CT-scan three years after the surgery in other 21 patients.

3 122 V. Boschi, Z. PogoreliÍc, G. Gulan, Z. Perko, L. GrandiÍc, V. RadoniÍc DISCUSSION Hemangiomas represent benign, silent lesions that usually remain undetected. Lesions generally become symptomatic when there is a neural arch expansion, vertebral body enlargement or direct compression of the thecal sac or nerve roots (1, 7, 8). Vertebral hemangiomas with aggressive neurological signs are rare. The predominant position is the thoracic region between T3 and T9 and cervical spine is rarely involved (9). Only one vertebra is affected in 77% of cases of vertebral hemangiomas and multiple location is rare (8, 9). Medullar or radicular compression dominates among other clinical signs. The epidural extension of vertebral hemangioma in the concentric reduction of the spinal canal is the most common (8, 10). Painful vertebral hemangioma can be treated in a number of ways. Surgery can consist of the resection of the vertebral body and the epidural hemangioma associated with an iliac crest or tibial graft; a decompressive laminectomy with transpedicular injection of acrylic cement or its percutaneous injection in order to set the vertebra. Other options include pre-operative embolization that reduces the risk of bleeding, and radiotherapy. All these methods may be used individually or combined. Surgery is indicated in aggressive and painful hemangiomas causing acute neurological compromise but may be complicated by excessive hemorrhage or a consumptive coagulopathy (8, 11). Emergent laminectomy should be performed in all cases of progressive neurological compromise (11). The potential risks of the surgery are intraoperative bleeding and postoperative epidural hematoma. Another problem concerning surgical treatment remains in patients with both anterior and posterior columns involved (7, 11). Fig. 1. CT-scan of the thoracic spine showing polka dot appearance of the vertebra. Radiotherapy has been used since A dose ranging from to rad is indicated even though its fibrous effect on this type of tumor is not clearly proven. Vertebral hemangiomas are radiosensitive and radiation therapy was used successfully in the past. Heyd et al. in their review of 63 patients using radiation therapy revealed complete remission in 57%, partial remission in 32%, and no response in 11% (12). Suparna et al. reported 6 patients treated with radiotherapy because for the vertebral hemangioma. The response to the treatment was assessed in percentage of symptomatic relief. Only one patient had a complete response (100%), good response A B Fig. 2. Radiograph of the thoracic spine two months after percutaneous vertebroplasty. A) Anteroposterior projection. B) Lateral projection.

4 Treatment of vertebral hemangioma 123 (> 50%) was seen in two patients and partial response (< 50%) in three (2). However, this therapy carries the risk of radiation-induced secondary sarcomas or the development of radionecrosis (13). Embolization requires the use of a medullar angiography in order to ensure that the hemangioma is not vascularised by a spinal artery (14). However, it may not be applied as such for aggressive vertebral hemangiomas. Its main purpose is to enable a surgery with the lowest bleeding rate (15). Vertebral hemangiomas treated solely with transarterial embolization failed to improve (16). Acosta et al. reported successful treatment in 4 patients treated with embolization (7, 8). Percutaneous phenol or alcohol injections were also used but had a limited success and were known to cause Brown-Sequard syndrome (16) and pathological fractures (17). Nowadays percutaneous kyphoplasty and vertebroplasty are the most used methods for vertebral hemangioma treatment (18). Percutaneous kyphoplasty has been suggested as an alternate therapy for painful vertebral hemangiomas with short and long-term benefit (1, 18 20). In most of the cases, percutaneous kyphoplasty resolved the patients pain immediately and a few required additional procedures to become painless (1). Percutaneous vertebroplasty is the least invasive procedure that offers a therapeutic option for patients suffering from non-infective, painful, destructive vertebral lesions, as well as osteoporotic vertebral fracture. Percutaneous vertebroplasty has advantages in pain relief and restoration of bone biomechanical strength (4). Vertebroplasty has greatly developed in recent years and has given encouraging results (4, 14, 15, 21 23). It ensures mechanical stability of the vertebra (15). It is so effective that it may be used alone when the haemangioma has caused radicular or spinal pain. Literature is limited to small series and case reports which have demonstrated significant pain relief from symptomatic vertebral hemangiomas with percutaneous vertebroplasty (3, 4, 15, 21 23). Pain relief from vertebral augmentation is not clear but may be related to the stabilization of micro fractures or compression fractures and from an induced chemical lysis of nerve endings within the vertebral body (21, 24). Thermal heating effect of cement may cause destruction of pain fibers and death of tumor cells. Experiments have demonstrated that intravertebral body thermocouple temperature at C is the target temperature for killing tumor cells (4). This is why our 3 patients with a partial vertebroplasty had at a later stage complete destruction of the tumor, although tumor was not completely filled with cement. This is confirmed by the fact that the literature does not mention complication in terms of bleeding from hemangioma during vertebroplasty. Guarnieri et al. illustrated the validity of the treatment with vertebroplasty in 24 patients with aggressive or symptomatic vertebral hemangioma with or without epidural extension. In all the patients a successful outcome was noted with a complete resolution of pain symptom. Extra vertebral vascular or distal cement leakage was noted in four patients, without any onset of clinical radicular syndrome due to epidural diffusion. Clinical and radiological follow-up until 4 years showed stability of the treatment and absence of pain (25). Purkayastha et al. reported series of 26 patients treated for the vertebral hemangioma. Most of their patients had pain relief within 48 hours. Only minor side effects were encountered. No patient had any deficit related to the procedure. On follow-up at 3 48 months, all patients had statistically significant improvement in clinical condition (26). Yang et al. concluded that treatment of vertebral hemangioma with percutaneous vertebroplasty is safe and effective with minimal invasion. They treated 7 patients for the vertebral hemangioma, and found good results in all seven cases. Pain was completely relieved in 5 cases and partially relieved in 2 cases. Symptom was also recovered in 2 patients with radiculopathy. No recurrence was found after 1 9 months of postoperative follow-up (27). Cohen et al. reported excellent results in 31 patients treated for vertebral hemangioma and concluded that percutaneous vertebroplasty is relatively simple procedure with a very high rate of success (24). Chen et al. reported 12 patients with vertebral hemangioma treated with cement vertebroplasty and ethanol injection together. They find cement vertebroplasty combined with ethanol injection as a safe and effective technique for the treatment of patients with vertebral hemangioma (4). All presented results are very similar to ours. We reported 3 venous leakages of the cement during vertebroplasty without neurological deficits and with the complete loss of pain in the follow-up. We performed vertebroplasty rather than kyphoplasty, due to the fact that hemangioma of vertebral body without pathological fractures does not destroy the integrity of the vertebra, so there is no need for kyphoplasty. In our patients, the areas of hemangiomas were properly and completely filled with cement without using of balloon. On the other hand vertebroplasty takes less time than kyphoplasty, which is more suitable for the patient. We also recommend less manipulation in the field of hemangioma because of a possible bleeding. Slightly longer recovery of our patients with hemangiomas in the thoracic spine can be explained by the fact that patients with hemangiomas in the thoracic spine preoperatively had more emphasized problems than those with lumbar localization. Indications for percutaneous vertebroplasty are: symptomatic vertebral hemangiomas, painful vertebral body tumors and severe painful osteoporosis with loss of height and/or with compression fractures of vertebral bodies. Contraindications include bleeding disorder, unstable fracture and lack of definable vertebral collapse. The absolute contraindications are hemorrhagic diathesis and infection. The complications in the treatment of vertebral hemangiomas with vertebroplasty include cement pulmonary or renal embolism and transient worsening of pain (28, 29). Nerve root pain from cement leakage can occur and necessitate a treatment (3, 27) but most symptoms are non-neurological, transitory and subclinical, while some patients may experience persis-

5 124 V. Boschi, Z. PogoreliÍc, G. Gulan, Z. Perko, L. GrandiÍc, V. RadoniÍc tent symptoms requiring a surgical extraction (3). There are significantly less complications related to the cement leakage when high viscosity cement is used (30). Very serious complication is infection. Strict sterility during the intervention is obligatory. Temporary pain can occur after the procedure. Patients are usually free of pain after 24 hours and pain is usually proportional to the volume of cement injected. Most of these patients have good packing of the vertebral body with more than 4 ml of cement injected. CONCLUSION Percutaneous vertebroplasty is a simple and minimally invasive technique in treatment of painful hemangiomas of thoracic and lumbar spine without neurological compromise. In the case when there is no pathologic fracture or neurologic deficit and hemangioma is located in the vertebral body, away from the spinal canal, the risk of cement leakage is minimal. 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