Perspective/Short Review: Diagnosis and Treatment of Aggressive Vertebral Hemangiomas and Review of 2 Cases

Background: Although vertebral hemangiomas (VH) are relatively common, aggressive symptomatic VH are rarely reported (i.e. in up to 11% of cases). Multiple other benign and malignant primary bone tumors must be considered in the differential diagnosis. Here, we review the clinical diagnosis and surgical management for aggressive hemangiomas, while also presenting 2 patients with thoracic lesions requiring posterior surgical decompression/fusion, with/without vertebroplasty, embolization, and/or CyberKnife radiosurgery. Methods: The classification system for these tumors ranges from Types I-IV; I Occupy < 50% of a vertebral body (VB), II-Occupy > 50% VB (IIb Thoracolumbar - Symptomatic), III-Occupy 100% VB, and IV-Occupy 100% VB involved plus extension into the pedicles, laminae, spinous process, and epidural space. Results: Radiographically (i.e. X-rays, MR, CT) these lesions originate in the vertebral bodies, but aggressive VH extend into the pedicles, laminae, spinous processes, and epidural space causing both spinal cord/root (i.e., myelopathy/radiculopathy)) compression. Surgical options include anterior, posterior, or circumferential decompressions with/without fusions, percutaneous vertebroplasty, embolization, radiation, and/or chemotherapy. Early treatment maximizes neurological recovery and limits/avoids permanent injury. Conclusion: Aggressive VH are rare lesions that most frequently occur in the thoracic spine. Notably, the subset of Type IV lesions that extend into the pedicles, laminae, spinous processes, and epidural space may cause symptomatic myelopathy/radiculopathy warranting early surgical intervention to optimize neurological outcomes.