Spinal hemangioma is a benign tumor affecting one, rarely several vertebrae. It is one of the most common neoplasms of the spine. Not prone to malignant degeneration. In most cases, it is asymptomatic. Less often causes pain syndrome. It can cause pathological fractures of the spine, accompanied by compression of the spinal cord or nerve roots. The diagnosis is made on the basis of the clinical picture, the results of radiography, CT and MRI. Treatment is operative, usually alcoholization or embolization of a hemangioma is used, or vertebroplasty is performed.
ICD 10
D16.6
General information
Spinal hemangioma is a widespread benign tumor of vascular origin. According to various data, it occurs in 1.5-11% of the population, women suffer more often than men. Spinal hemangioma accounts for 1-1.5% of the total number of benign neoplasms of the skeleton. It ranks first among bone hemangiomas. It is not prone to malignancy, malignant degeneration is observed in less than 1% of patients.
More than 80% of spinal hemangiomas are localized in the thoracic region, most often the VI thoracic vertebra suffers. The second place in prevalence is occupied by lumbar hemangiomas. Sacral and cervical lesions are detected in 1% of patients. As a rule, a hemangioma is found in one vertebra, multiple neoplasms affecting 2-5 vertebrae are less often diagnosed. Spinal hemangiomas are treated by specialists in the field of vertebrology, neurology and clinical oncology.
Causes
Experts believe that the main cause of this pathology is a genetic predisposition. This hypothesis is supported by a five–fold increase in the risk of developing spinal hemangiomas in the presence of close relatives who suffered from hemangiomas of various localization (including extravertebral ones). Other risk factors include tissue hypoxia, high estrogen levels and traumatic spinal injuries.
Pathogenesis
According to researchers, spinal hemangioma develops as follows: congenital inferiority of the vessel wall located in a particular vertebra, combined with increased stress, injuries and other factors, causes recurrent hemorrhages. Blood clots form in the area of hemorrhages, and then osteoclasts (cells that destroy bone tissue) are activated. In place of the destroyed bone tissue, new vessels with an incomplete wall grow. The hemangioma of the spine increases in volume. Subsequently, the walls of these vessels also rupture, new hemorrhages occur, the process repeats. When a significant part of the bone is destroyed, the support of the damaged vertebra is disrupted, it becomes more vulnerable to mechanical influences. The probability of developing a pathological fracture increases.
Classification
Taking into account the features of the histological structure , there are four types of spinal hemangiomas:
- Capillary – formed by a multitude of intertwining capillaries. The capillary layers are separated by layers of fatty and fibrous tissue.
- Racematous – consist of larger veins or arteries.
- Cavernous – are an accumulation of a large number of cavities of various sizes and shapes. The walls of the cavities consist of thin layers of connective tissue covered with endothelium. The cavities communicate with each other.
- Mixed – have features of capillary, racematous and cavernous hemangiomas.
Taking into account the localization and volume of the lesion, there are five types of spinal hemangiomas:
- Type 1 – the hemangioma extends to the entire vertebra.
- Type 2 – only the vertebral body suffers.
- Type 3 – only the rear half-ring is affected.
- Type 4 – the body and part of the posterior semicircle suffer.
- Type 5 – hemangioma is located epidurally.
Symptoms
The tumor is often asymptomatic and becomes an accidental finding during examination due to other diseases or injuries. In 10-15% of patients with spinal hemangioma, local pain in the vertebral region or paravertebral zone is detected. The pain is usually dull, aching, increasing at night and after physical exertion. The cause of pain syndrome in spinal hemangioma is irritation of the pain receptors of the periosteum and the posterior longitudinal ligament.
Some patients show symptoms of irritation of the spinal cord and nerve roots due to the pressure of the soft tissue component of the hemangioma located in the epidural space. In 3-4% of cases, aggressive growth of spinal hemangioma is noted, leading to a significant decrease in bone strength and the development of pathological fractures. Possible sensitivity disorders, paresis, paralysis and disorders of the pelvic organs caused by the accumulation of blood in the extradural space.
Taking into account clinical and radiological symptoms, there are four types of spinal hemangiomas: asymptomatic non-aggressive (without clinical and radiological signs of aggressiveness), symptomatic non-aggressive (with clinical manifestations, but without radiological signs of aggressiveness), asymptomatic aggressive (asymptomatic, but with radiological signs of aggressiveness), symptomatic aggressive (with clinical and radiological signs of aggressiveness).
Radiological signs of aggressiveness of spinal hemangiomas include localization in the interval between the III and IX thoracic vertebrae, damage to the whole body, fuzzy edges and expansion of the cortical layer, expansion of the tumor to the root of the arch. During CT and MRI of aggressive neoplasms, irregularly shaped cells and soft-tissue formations are found in the epidural space. The presence of three or more of the listed signs is considered as evidence of aggressiveness of spinal hemangioma.
Diagnostics
The diagnosis of spinal hemangioma is established by the results of an examination by an oncologist, neurologist and vertebrologist based on clinical symptoms and the results of radiological studies.
- Spine x-ray. Structural rearrangement of the vertebra in a vacuum-like, columnar or mesh variant is revealed. With a vacuum-like variant, the hemangioma of the spine is viewed in the form of oval rarefaction zones bounded by the rims of sclerotically compacted bone. With the columnar variant, “columns” are found in the image – bone partitions that are clearly visible against the background of the rarefaction area. In the mesh variant, the X-ray picture of the spinal hemangioma resembles a fine-meshed sponge.
- Tomography of the spine. To clarify the nature and extent of damage to bone structures and soft tissues, after radiography, the patient is referred for CT or MRI of the spine. According to MRI data, a hyper- or isointensive speckled signal is determined on T1- and T2-weighted images. According to the results of CT of the spine, a formation with a cellular structure resembling a honeycomb is revealed.
Treatment
Various techniques are used in the treatment of neoplasia, including surgical operations, radiation therapy, alcoholization, embolization and percutaneous puncture vertebroplasty.
- Resection of the vertebra. The classic technique used in the treatment of spinal hemangioma since the 30s of the last century is surgical removal of altered soft tissues and resection of affected areas of bone. Nowadays, it has a very narrow range of applications due to insufficient effectiveness and high risk of profuse bleeding from vessels or cavities of neoplasm. It is indicated for compression of the spinal cord and nerve roots.
- Radiation therapy. As a result of irradiation, the tumor vessels subside, the soft-tissue component undergoes fibrous degeneration, and the affected bone tissue, penetrated by capillaries or large vessels, remains unchanged. The technique is more effective and less dangerous compared to surgical intervention. Currently, it is rarely used because of the high radiation load and the high probability of developing neurological disorders.
- Alcoholization of spinal hemangioma. A relatively new technique developed at the end of the XX century. Alcohol injected into the cavity of the neoplasm causes vascular thrombosis and destruction of the endothelium, as a result of which the tumor decreases in size. Despite the good immediate results, this method of treating spinal hemangioma has not been widely used due to the large number of complications in the long-term period. According to the specialists who developed the technique, there is a fairly high probability of pathological fractures. Other researchers indicate that after alcoholization of spinal hemangioma, paravertebral abscesses and myelopathy with Brown-Sekara syndrome may develop (spastic paralysis and impaired deep sensitivity in one half of the body, combined with a decrease in temperature and pain sensitivity in the other half of the body).
- Immobilization of spinal hemangioma. It has been used since the late 60s of the last century. Currently, two methods of embolization are used – transvasal and selective. In the first case, emboli are injected into nearby vessels, in the second – directly into the area of neoplasm. Transvasal embolization of spinal hemangioma is less effective, because after the procedure, small feeding vessels remain, which can subsequently increase and nourish the tumor, which causes its recurrence.
- Percutaneous puncture vertebroplasty. It is considered the most effective and safe method of treating spinal hemangioma. In the process of vertebroplasty, bone cement is injected into the tumor area. To fill the hemangioma of the spine located in the thoracic vertebra, about 4 ml of cement is required, in the lumbar vertebra – 6-7 ml of cement. The vessels or cavities of the tumor are damaged, squeezed and destroyed. The cavity of the hemangioma of the spine is filled with a material that ensures the integrity and high strength of the vertebra. Thus, at the same time it is possible to eliminate the neoplasm and prevent the development of pathological fractures. Percutaneous puncture vertebroplasty belongs to the category of minimally invasive surgical interventions. Patients are activated just a few hours after the end of the operation. Pain reduction is noted already in the first day.
Prognosis and prevention
The prognosis is favorable. Usually, spinal hemangioma is asymptomatic. The outcome of percutaneous puncture vertebroplasty is satisfactory in most cases, the probability of complications ranges from 1-10%, a significant part of complications occurs during surgery (general hyperthermia and pain during cement injection) and does not entail long-term consequences. Malignant degeneration of spinal hemangioma is extremely rare. Prevention has not been developed.