Background: Vertebral body (VH) hemangiomas with myelopathy are difficult to manage.
Objective: The authors describe their technique of symptomatic vertebral body hemangiomas (VH) with absolute alcohol (ethyl alcohol) describe the long-term outcomes and do a literature review
Methods: Surgery consisted of intra-operative bilateral pedicular absolute alcohol (<1% hydrated ethyl alcohol) injection, laminectomy and cord decompression at the level of pathology followed by a short segment instrumented fusion using pedicle screws. Patients treated included symptomatic VH with cord compression with myelopathy. The following were excluded: pathological fractures and/or deformity or multi-level pathologies.
Results: 38 patients (Mean 24.9+12.2, range: 10-68 years, 20 females). Clinical features included myelopathy all (5 paraplegic), sphincter involvement (13) and mid back/lower pain (7). Pre-operative American Spinal Injury Association (ASIA) scores: A (8), B (13), C (6), D (10) and E (1). Majority had single vertebral involvement (35), 3 multiple levels. Six underwent surgery earlier (1 alcohol embolization here). Mean surgical time: 122+38 min, average blood: 260+80 cc. Mean amount of absolute alcohol injected: 14+5.2 cc. (2 requiring 20 and 25 cc). Immediate embolization achieved in all, allowing laminectomy and soft-tissue hemangioma removal easily. Post-surgery, 1 patient had transient deterioration, rest all patients improved (sphincters improved in 9) at a follow up ranging 28-103 months (mean 47.6+22.3). Follow-up ASIA scores: E (28), D (6), B (3) and C (1). All patients showed evidence of bone sclerosis and relief of cord compression on follow-up imaging.
Conclusion: This is largest study in literature showing excellent improvement, low re-operation rates following ethanol embolization and short segment fixation.
Keywords: Vertebral hemangioma, Absolute alcohol, Ethanol, Pedicle screw fixation, Outcomes
Vertebral hemangiomas (VH) are among most common lesions of the vertebral column, but can become very challenging to treat when they start becoming symptomatic by causing cord compression [1-5]. They are more common in females with overall incidence of these lesions is about 10% in normal population [1-8]. Single vertebral involvement occurs most commonly, although two level involvements is not so uncommon even though involvement of more number of levels is exceedingly uncommon [1,3-7,9,10]. Till date, whatever surgical techniques described have been very difficult, let it either complete vertebrectomy [10-17], injection of various “cement” like material [18-48] and even radiotherapy [49-52]. Complete vertebrectomy is extremely difficult and associated with high morbidity and mortality due to blood loss and degree of surgical exposure. Likewise, injection of various embolizing and ‘cement’ like material would only temporarily reduce the vascularity with obvious risk of recurrence.
Ethanol embolization [53-62] through a per-cutaneous route was shown to be effective but was associated with a high incidence of pathological factures and also transient neurological deterioration. The authors demonstrated a unique technique in 2011 [63,64], which consists of intra-operative ethanol embolization combined with short segment fixation. This and subsequent publications [63-65] and have demonstrated high degree of safety, efficacy and feasibility of this procedure.
CLINICAL MATERIALS AND METHODS
The main indications of this procedure include vertebral hemangiomas with myelopathy. We do not use it in cases with pathological fractures, deformity, Von Hippel disease or patients with severe systemic illnesses (e.g. hypertension or diabetes). The surgical technique has been described in details in the earlier papers [63-65]. However briefly, the technique consists of exposure of the affected vertebrae along with one level above and below. Instrumented fixation (pedicle screws) was then performed one level above and below. After this, absolute alcohol (1% ethyl alcohol) is injected into either pedicle (using fluoroscopy or neuronavigation) of the affected vertebrae using 14-16 gauges Jamshide needle. The presence of VH is confirmed by rapid oozing or gushing of venous blood from the cannulas. We generally prefer using 6-7 cc of absolute alcohol in either side. This is introduced with slow increments of 0.5 cc with careful monitoring of hemodynamic status.
OUR RESULTS AND LITERATURE REVIEW
We treated till date a total of a total of 38 patients were treated from June 2006 till June 2017 with at least a follow up of 28 months and were included in this study. The mean age was 24.9+13.2 years, (range: 10-68 years, 20 females). Clinical features included myelopathy in all (5 paraplegic), sphincter involvement (13) and mid back/lower pain (7). The pre-operative American Spinal Injury Association (ASIA) scores were A in 8, B in 13, C in 6, D in 10 and E in 1 patient. Majority had single vertebral involvement (35), however 3 patients multiple level involvement. Six underwent surgery earlier. Of these, 1 underwent alcohol embolization at our hospital in 2012. The mean surgical time was 122+38 min, average blood loss being 260+80 cc. The mean amount of absolute alcohol injected was 14+5.2 cc. Two patients required 20 and 25 cc (case 28 and 22 respectively), both having multiple level hemangiomas. Immediate embolization achieved in all, allowing laminectomy and soft-tissue hemangioma removal easily. One patient had transient neurological deterioration. His power deteriorated to 1/5 in both lower limbs. Immediate CT scan showed pedicle screws in place. He was treated with steroids, and within 2 weeks improved to the pre-operative level. His power improved to near normal at 30 months of follow up. One patient had a transient hypotension during surgery. Following copious irrigation with saline, and watchful waiting, this improved. This however did not have any impact on the final clinical outcome.
All patients improved (sphincters also improved in all too various degrees) at a follow up ranging from 28-103 months (mean 47.6+22.3). Follow-up ASIA scores were E in 28, D in 6, B in 5 and C in 1. All patients showed evidence of bone sclerosis and relief of spinal cord compression on follow-up imaging. The Nurick’s grade were I (35 patients) and II (3 patients) at the last follow up. Five patients presented with paraplegia. Of these, one was is term pregnancy (30 weeks). Two improved to ASIA grade B, 2 to ASIA grade E and 1 to grade D. 13 had sphincter involvement, all improved to extent of becoming continent.
Ethanol in earliest times was used to produce angioinfarction of kidneys for uncontrolled hypertension66. While it is a very effective embolizing agent but has the disadvantage of being highly nectotoxic and can have systemic hemodynamic side effects [56,61,62].
Pathologically VH are benign lesions of the bone, usually of dysembryogenetic origin or hamartomatous lesions [67-76]. They can be cavernous, capillary or a mixed type [75,77,78]. Arteriovenous shunting is rare and these have only low flow channels [75,77,78]. Such a pathological architecture provides a relatively safe situation for injection of embolizing agents like ethanol as it would prevent rapid shunting and systemic toxicity (if injected slowly). Presence of low flow fistulas in VH also would prevent rapid ‘wash off’ of ethanol, thus allowing its embolizing and sclerosing action to take place locally.
The current accepted strategies for surgical management of VH include vertebrectomy [10-17] (usually with embolization), injection of ‘cement’ like substances using either vertebroplasty or kyphoplasty [18-48] and radiotherapy [49-52]. The first technique is fraught with high risk, morbidity and mortality (upto 6% in some earlier series ). There are some cases described where this was performed even using total circulatory arrest . In comparison, the latter 2 techniques even though providing much less risk have the short-coming of technically not eradicating the disease.
In 1994, Heiss et al. [54,80,81] published the first report of vertebral hemangiomas treated by percutaneous CT guided injection of absolute alcohol. While this was associated generally with good improvement but was associated with a reports of pathological fractures and transient neurological deterioration. Injection of absolute alcohol causes intralesional thrombosis and destruction of the endothelium that composes the hemangioma. Devascularisation is followed by shrinkage of the lesion and subsequent sclerosis which decompresses the cord and nerve roots [54,80].
VH ethanol embolization has the unique advantage of both providing instant embolization and also being tumoricidal [54-64,66]. This could have been perhaps the reason, why in some cases of per-cutaneous injection of ethanol, the patients developed pathological fractures [54,80,82]. This correlated with the volume of ethanol injected (>40 ml). In such cases, possibly once the tumor was embolized and underwent necrosis by ethanol, the residual bony lattice unable to support the weight of the body collapsed. To counteract this shortcoming, the authors suggested a short segment instrumented fixation [11,63,64].
Systemic complications are another major concern of ethanol injection. Niemeyer et al.  reported a case of Brown-Sequard syndrome following injection of alcohol for VH. This and the cases of transient deterioration described by others [59,82] may have been due to a retrograde leak, which cannot be detected during a percutaneous injection. Such manifestations have been also described in a case that had undergone endovascular embolization of VH83. Migration of microcoil into the sulco-commisural artery has been postulated as the reason for this. MRI done later, demonstrated spinal cord infarct. It is thus possible, that a rapid systemic ‘run off’ of ethanol into the perforators may have caused similar problems of neurological deterioration. The current series has one case of transient deterioration following surgery. The patient had developed severe weakness (1/5) following surgery, which improved to the pre-operative status after 2 weeks. There was another patient, where transient hemodynamic changes were noted during surgery. Apart from these 2 cases, there were no other long-term morbidities. All patients improved in their weakness as a rule. Even the patients with paraplegia improved significantly (3 to ASIA grades >D). In our experience, the incidence of recurrence has been low. Even if the recurrence did take place, a repeat ethanol injection seemed satisfactory in improving symptoms and controlling the disease. We of course cannot comment on longer-term outcomes (>10 years follow up) at this stage.
The mean amount of absolute alcohol injected was 14+5.2 cc. Two patients required 20 and 25 cc, both having multiple level hemangiomas. Interestingly, case 22, which had the maximum amount of ethanol, injected developed transient intraoperative hypotension. This was well within the limits of what has been recommended in the literature. Although it is difficult to comment, it would be safe to conclude that an amount up to 15 cc should be reasonably safe. We feel that more important would be the uses of small increments of 0.5 cc injections during the intra-operative period. We feel that in patients with multiple levels VH, the procedure may be staged.
MRI imaging performed at follow up showed relief of spinal cord compression in all cases. In addition, CT scan demonstrated bone sclerosis and new bone formation. This was a finding, which we found in only 2 cases in our pilot study, but have found consistently in all our cases in the current series. We have not found this finding described in any of the earlier studies even though it may be expected due to 2 reasons: 1) The sclerosing effect of ethanol itself; 2) Necrosis and disintegration of the tumor tissue which now leaves a large space within the bony lattice, providing same for fresh osteogenesis to take place. However, whatever could be the reasons; ethanol embolization provides very good advantage in this aspect over other conventional embolizing agents. Lastly, but not least, it is a highly cost effective technique ($1 for 100 cc of ethanol!). This definitely has had an impact on our patient profile as a significant number of our patients were economically challenged and not covered through insurance .
Intra operative absolute alcohol (<1% hydrated ethanol) combined with surgical decompression of the cord and short segment instrumented fixation seems to be a useful (100% improvement in our series) technique in both single and multiple level vertebral hemangiomas with epidural soft tissue compression of the cord. It may provide the advantage of reducing the complications of ethanol by providing operative visualization, allowing immediate recovery due to surgical decompression and also preventing pathological fractures. In our series of 33 cases with a long term follow up, it has been demonstrated to be safe, effective, and associated with low morbidity. In addition, it has been shown to produce bony sclerosis over a period of time thus strengthening the bone quality. There has been only 1 recurrence in our series, which has been effectively treated with ethanol re-embolization. Based on this, we feel that ethanol embolization and short segment instrumented fixation may be currently one of the best alternatives for treatment of symptomatic vertebral hemangiomas.
We wish to acknowledge all the patients who agreed to be part of this study.
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
1. Acciarri N, Padovani R, Giulioni M, Gaist G (1993). Surgical treatment of spinal cavernous angiomas. J Neurosurg Sci 37: 209-215.
2. Adeolu AA, Oyemolade TA, Salami AA, Adigun TA, Malomo AO, et al. (2015) Features and outcome of surgical management of spinal tumors in a cohort of nigerian patients. World Neurosurg 84: 1090-1094.
3. Baker ND, Klein MJ, Greenspan A, Neuwirth M (1986) Symptomatic vertebral hemangiomas: A report of four cases. Skeletal Radiol 15: 458-463.
4. Bandiera S, Gasbarrini A, De Iure F, Cappuccio M, Picci P, et al. (2002) Symptomatic vertebral hemangioma: The treatment of 23 cases and a review of the literature. Chir Organi Mov 87: 1-15.
5. Blankstein A, Spiegelmann R, Shacked I, Schinder E, Chechick A (1988) Hemangioma of the thoracic spine involving multiple adjacent levels: Case report. Paraplegia 26: 186-191.
6. Chang SD, Meisel JA, Hancock SL, Martin DP, McManus M, et al. (1998) Treatment of hemangioblastomas in von Hippel-Lindau disease with linear accelerator-based radiosurgery. Neurosurgery 43: 28-34; discussion 34-25.
7. Esparza J, Castro S, Portillo JM, Roger R (1978) Vetebral hemangiomas: Spinal angiography and preoperative embolization. Surg Neurol 10: 171-173.
8. Pastushyn AI, Slin'ko EI, Mirzoyeva GM (1998) Vertebral hemangiomas: Diagnosis, management, natural history and clinicopathological correlates in 86 patients. Surg Neurol 50: 535-547.
9. Hamel E, Frowein RA, Karimi-Nejad A, Muller W (1984) Tumors of the cervical spine. Nervenarzt 55: 285-292.
10. Hrabalek L, Stary M, Rosik S, Wanek T (2011) Surgery for symptomatic vertebral hemangiomas. Rozhl Chir 90: 264-269.
11. Chandra SP, Ramdurg SR, Kurwale N, Chauhan A, Ansari A, et al. (2014) Extended costotransversectomy to achieve circumferential fusion for pathologies causing thoracic instability. Spine J 14: 2094-2101.
12. Feuerman T, Dwan PS, Young RF (1986) Vertebrectomy for treatment of vertebral hemangioma without preoperative embolization. Case report. J Neurosurg 65: 404-406.
13. Graham JJ, Yang WC (1984) Vertebral hemangioma with compression fracture and paraparesis treated with preoperative embolization and vertebral resection. Spine (Phila Pa 1976) 9: 97-101.
14. Hemmy DC, McGee DM, Armbrust FH, Larson SJ (1977) Resection of a vertebral hemangioma after preoperative embolization. Case report. J Neurosurg 47: 282-285.
15. Hu YG (1990) Tumors of the spine: A clinical study of 80 cases. Zhonghua Wai Ke Za Zhi 28: 392-394; 444.
16. Kravtsov MN, Manukovskii VA, Zharinov GM, Kandyba DV, Tsibirov AA, et al. (2012) Aggressive vertebral hemangiomas: Optimization of management tactics. Zh Vopr Neirokhir Im N N Burdenko 76: 23-31; discussion 31-22.
17. Tarantino R, Donnarumma P, Nigro L, Delfini R (2015) Surgery in extensive vertebral hemangioma: Case report, literature review and a new algorithm proposal. Neurosurg Rev 38: 585-592; discussion 592.
18. Anselmetti GC, Bonaldi G, Carpeggiani P, Manfre L, Masala S, et al. (2011) Vertebral augmentation: 7 years’ experience. Acta Neurochir Suppl 108: 147-161.
19. Atalay B, Caner H, Yilmaz C, Altinors N (2006) Sacral kyphoplasty for relieving pain caused by sacral hemangioma. Spinal Cord 44: 196-199.
20. Boschi V, Pogorelic Z, Gulan G, Perko Z, Grandic L, et al. (2011) Management of cement vertebroplasty in the treatment of vertebral hemangioma. Scand J Surg 100: 120-124.
21. Burton AW, Rhines LD, Mendel E (2005) Vertebroplasty and kyphoplasty: A comprehensive review. Neurosurg Focus 18: e1.
22. Chen LH, Hsieh MK, Liao JC, Lai PL, Niu CC, et al. (2011) Repeated percutaneous vertebroplasty for refracture of cemented vertebrae. Arch Orthop Trauma Surg 131: 927-933.
23. Chiras J, Barragan-Campos HM, Cormier E, Jean B, Rose M, et al. (2007) Vertebroplasty: State of the art. J Radiol 88: 1255-1260.
24. Cortet B, Cotten A, Deprez X, Deramond H, Lejeune JP, et al. (1994) Value of vertebroplasty combined with surgical decompression in the treatment of aggressive spinal angioma. Apropos of 3 cases. Rev Rhum Ed Fr 61: 16-22.
25. Dunn J (2002) Percutaneous vertebroplasty in the management of a patient with malignant pain and associated osteolytic compression fractures. Curr Pain Headache Rep 6: 436-443.
26. Durov OV, Shevelev IN, Tissen TP (2004) Vertebroplasty in the treatment of spinal diseases. Zh Vopr Neirokhir Im N N Burdenko 2004: 21-25; discussion 26.
27. Franc J, Lehmann P, Saliou G, Monet P, Kocheida EM, et al. (2010) Vertebroplasty: 10 years clinical and radiological follow-up. J Neuroradiol 37: 211-219.
28. Fuwa S, Numaguchi Y, Kobayashi N, Saida Y (2008) Percutaneous pediculoplasty for vertebral hemangioma involving the neural arch: A case report. Cardiovasc Intervent Radiol 31: 189-192.
29. Gangi A, Kastler BA, Dietemann JL (1994) Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy. AJNR Am J Neuroradiol 15: 83-86.
30. Gepstein R, David R (2002) Vertebroplasty: Percutaneous augmentation of vertebrae. Harefuah 141: 792-794; 858.
31. Hadjipavlou A, Tosounidis T, Gaitanis I, Kakavelakis K, Katonis P (2007) Balloon kyphoplasty as a single or as an adjunct procedure for the management of symptomatic vertebral haemangiomas. J Bone Joint Surg Br 89: 495-502.
32. Hamza S, Meddeb N, Elleuch M, Rajhi H, Chour E, et al. (2003) Vertebroplasty success in a case of aggressive hemangioma. Tunis Med 81: 824-827.
33. Kaso G, Stefanits J, Kover F, Doczi T, Horvath G (2003) Percutaneous transpedicular acrylate vertebroplasty for the treatment of lumbar vertebral hemangioma - Case report. Ideggyogy Sz 56: 41-46.
34. Lewiecki EM (2008) Vertebroplasty and kyphoplasty update. Curr Osteoporos Rep 6: 114-119.
35. Masala S, Fiori R, Massari F, Simonetti G (2003) Vertebroplasty and kyphoplasty: New equipment for malignant vertebral fractures treatment. J Exp Clin Cancer Res 22: 75-79.
36. Masala S, Lunardi P, Fiori R, Liccardo G, Massari F, et al. (2004) Vertebroplasty and kyphoplasty in the treatment of malignant vertebral fractures. J Chemother 16: 30-33.
37. Masala S, Tropepi D, Fiori R, Semprini R, Martorana A, et al. (2004) Kyphoplasty: A new opportunity for rehabilitation of neurologic disabilities. Am J Phys Med Rehabil 83: 810-812.
38. McArthur N, Kasperk C, Baier M, Tanner M, Gritzbach B, et al. (2009) 1150 kyphoplasties over 7 years: Indications, techniques and intraoperative complications. Orthopedics 32: 90.
39. Moore JM, Poonnoose S, McDonald M (2012) Kyphoplasty as a useful technique for complicated hemangiomas. J Clin Neurosci 19: 1291-1293.
40. Moreland DB, Landi MK, Grand W (2001) Vertebroplasty: Techniques to avoid complications. Spine J 1: 66-71.
41. Murphy KJ, Deramond H (2000) Percutaneous vertebroplasty in benign and malignant disease. Neuroimaging Clin N Am 10: 535-545.
42. Muto M, Muto E, Izzo R, Diano AA, Lavanga A, et al. (2005) Vertebroplasty in the treatment of back pain. Radiol Med 109: 208-219.
43. Muto M, Perrotta V, Guarnieri G, Lavanga A, Vassallo P, et al. (2008) Vertebroplasty and kyphoplasty: Friends or foes? Radiol Med 113: 1171-1184.
44. Noez S, Collignon L, Bex V, Sacre F, Crielaard JM (2006) Kyphoplasty for the treatment of painful vertebral hemangioma. Rev Med Liege 61: 91-96.
45. Nora EH, Christian RC (2006) Visual vignette. Vertebral hemangioma. Endocr Pract 12: 110.
46. Peh WC, Munk PL, Rashid F, Gilula LA (2008) Percutaneous vertebral augmentation: Vertebroplasty, kyphoplasty and skyphoplasty. Radiol Clin North Am 46: 611-635, vii.
47. Provenzano MJ, Murphy KP, Riley LH 3rd (2004) Bone cements: Review of their physiochemical and biochemical properties in percutaneous vertebroplasty. AJNR Am J Neuroradiol 25: 1286-1290.
48. Rauschmann MA, von Stechow D, Thomann KD, Scale D (2004) Complications of vertebroplasty. Orthopade 33: 40-47.
49. Asthana AK, Tandon SC, Pant GC, Srivastava A, Pradhan S (1990) Radiation therapy for symptomatic vertebral hemangioma. Clin Oncol (R Coll Radiol) 2: 159-162.
50. Heyd R, Strassmann G, Filipowicz I, Borowsky K, Martin T, et al. (2001) Radiotherapy in vertebral hemangioma. Rontgenpraxis 53: 208-220.
51. Heyd R, Zamboglou N, Seegenschmiedt MH (2008) Radiotherapy for symptomatic vertebral hemangioma. MMW Fortschr Med 150: 35-37.
52. Yim KL, Sumathi VP, Spooner D (2012) Radiotherapy as an effective primary treatment for epithelioid hemangioendothelioma of the cervical spine. Anticancer Res 32: 4597-4600.
53. Degulmadi D, Brahmajoshyula V, Mayi S, Teegala S (2014) Two-stage surgical management of multilevel symptomatic thoracic haemangioma using ethanol and iliac crest bone graft. Asian Spine J 8: 502-505.
54. Doppman JL, Oldfield EH, Heiss JD (2000) Symptomatic vertebral hemangiomas: Treatment by means of direct intralesional injection of ethanol. Radiology 214: 341-348.
55. Jha B, Choudhary AK (2008) Unusual cause of back pain in an adolescent patient: A case report and natural history of aggressive vertebral hemangioma in children. Pain Physician 11: 687-692.
56. Lonser RR, Heiss JD, Oldfield EH (1998) Tumor devascularization by intratumoral ethanol injection during surgery. Technical note. J Neurosurg 88: 923-924.
57. Murugan L, Samson RS, Chandy MJ (2002) Management of symptomatic vertebral hemangiomas: Review of 13 patients. Neurol India 50: 300-305.
58. Niemeyer T, McClellan J, Webb J, Jaspan T, Ramli N (1999) Brown-Sequard syndrome after management of vertebral hemangioma with intralesional alcohol. A case report. Spine (Phila Pa 1976) 24: 1845-1847.
59. Prabhakar H, Singh GP (2011) Absolute alcohol embolization of symptomatic vertebral hemangiomas may not be absolutely safe during intraoperative period! Neurosurgery 69: E502.
60. Rawat S, Nangia S, Ezhilalan RB, Bansal AK, Ghosh D (2007) Variance in the treatment of vertebral hemangiomas. J Indian Med Assoc 105: 42, 44-45, 48.
61. Sharma D, Jain V, Rath GP (2006) Asystole during percutaneous ethanol injection of symptomatic vertebral haemangioma. Anesth Intensive Care 34: 656-658.
62. Yadav N, Prabhakar H, Singh GP, Bindra A, Ali Z, et al. (2010) Acute hemodynamic instability during alcohol ablation of symptomatic vertebral hemangioma: A prospective study. J Clin Neurosci 17: 810-811.
63. Singh P, Mishra NK, Dash HH, Thyalling RK, Sharma BS, et al. (2011) Treatment of vertebral hemangiomas with absolute alcohol (ethanol) embolization, cord decompression and single level instrumentation: A pilot study. Neurosurgery 68: 78-84; discussion 84.
64. Singh PK, Chandra PS, Vaghani G, Savarkar DP, Garg K, et al. (2016) Management of pediatric single-level vertebral hemangiomas presenting with myelopathy by three-pronged approach (ethanol embolization, laminectomy, and instrumentation): A single-institute experience. Childs Nerv Syst 32: 307-314.
65. Chandra SP, Singh P, Kumar R, Agarwal D, Tandon V, et al. (2019) Long-term outcome of treatment of vertebral body hemangiomas with direct ethanol injection and short-segment stabilization. Spine J 19: 131-143.
66. Nanni GS, Hawkins IF Jr, Orak JK (1983) Control of hypertension by ethanol renal ablation. Radiology 148: 51-54.
67. Alexander J, Meir A, Vrodos N, Yau YH (2010) Vertebral hemangioma: An important differential in the evaluation of locally aggressive spinal lesions. Spine (Phila Pa 1976) 35: E917-920.
68. Alobaid A, Bennardo MR, Cenic A, Lach B (2015) Mixed capillary-cavernous extramedullary intradural hemangioma of the spinal cord mimicking meningioma: Case report. Br J Neurosurg 29: 438-439.
69. Barbosa-Silva E, Carvalho GT, Frota Mde O, Sousa AA, Souza CB (2009) Intradural extramedullary hemangioblastoma. Arq Neuropsiquiatr 67: 530-533.
70. Bartels RH, Grotenhuis JA, Van Der Spek JA (1991) Symptomatic vertebral hemangiomas. J Neurosurg Sci 35: 187-192.
71. Bartkowiak E, Bednarczyk J (1964) Cavernous angioma of the spine complicated by compression vertebral fracture. Chir Narzadow Ruchu Ortop Pol 29: 393-396.
72. Carrillo Esper R, O'Farril Anzures R, Berni Betancourt A, Suarez AC (2002) Multiple vertebral hemangiomas. Gac Med Mex 138: 377-378.
73. Fourney DR (2012) Expert's comment concerning Grand Rounds case entitled “Aggressive vertebral hemangioma of the thoracic spine without typical radiological appearance” (Lei Dang, Chen Liu, Shao Min Yang, Liang Jiang, Zhong Jun Liu, Xiao Guang Liu, Hui Shu Yuan, Feng Wei, Miao Yu). Eur Spine J 21: 2000-2002.
74. Fox MW, Onofrio BM (1993) The natural history and management of symptomatic and asymptomatic vertebral hemangiomas. J Neurosurg 78: 36-45.
75. Karikari IO, Nimjee SM, Hodges TR, Cutrell E, Hughes BD, et al. (2015) Impact of tumor histology on resectability and neurological outcome in primary intramedullary spinal cord tumors: A single-center experience with 102 patients. Neurosurgery 76: S4-13.
76. Sadeghi B (1975) Angioma (or hemangioma) of the vertebral body. Brux Med 55: 459-462.
77. Kaloostian PE, Gokaslan ZL (2014) Surgical management of primary tumors of the cervical spine: surgical considerations and avoidance of complications. Neurol Res 36: 557-565.
78. Roessler K, Dietrich W, Haberler C, Goerzer H, Czech T (1999) Multiple spinal “military” hemangioblastomas in von Hippel-Lindau (vHL) disease without cerebellar involvement. A case report and review of the literature. Neurosurg Rev 22: 130-134.
79. McCarthy RE, Lytle JO, Van Devanter S (1993) The use of total circulatory arrest in the surgery of giant hemangioma and Klippel-Trenaunay syndrome in neonates. Clin Orthop Relat Res 1993: 237-242.
80. Heiss JD, Doppman JL, Oldfield EH (1996) Treatment of vertebral hemangioma by intralesional injection of absolute ethanol. N Engl J Med 334: 1340.
81. Heiss JD, Doppman JL, Oldfield EH (1994) Brief report: Relief of spinal cord compression from vertebral hemangioma by intralesional injection of absolute ethanol. N Engl J Med 331: 508-511.
82. Goyal M, Mishra NK, Sharma A, Gaikwad SB, Mohanty BK, et al. (1999) Alcohol ablation of symptomatic vertebral hemangiomas. AJNR Am J Neuroradiol 20: 1091-1096.
83. Fernandez-Torron R, Palma JA, Riverol M, Irimia P, Martinez-Vila E (2012) Brown-sequard syndrome after endovascular embolization of vertebral hemangioma. Spinal Cord 50: 636-637.
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