Cement vertebroplasty combined with ethanol injection in the treatment of vertebral hemangioma

1136Chin Med j 2007: 120(13 ) 1136-1139Original articleCement vertebroplasty combined with ethanol injection in thetreatment of vertebral hemangiomaCHEN Liang, ZHANG Chun-lin and TANG Tian-siKeywords: lumbar vertebrae; hemangioma; vertebroplasty; ethanol; bone cementsBackground A number of methods have been used in the treatment of symptomatic and aggressive vertebralhemangioma, but none of them is optimal. Vertebral hemangioma treated with cement vertebroplasty or ethanol injectionhe showed relatively good results despite their limitationsMethods Between February 2002 and May 2004, twelve patients with vertebral hemangioma were subjected tocombined cement vertebroplasty and ethanol injection, five of them were men and seven women, and aged from 26 to 54years(mean, 41 years). The following levels of the spine were involved: T9: 1, T10: 3, T12: 2, L1: 1, L2: 2, L3: 2 and L4: 1The clinical results and radiographic records of the patients were assessed after 2 years and 5 months of follow-upResults The average score of back pain significantly decreased from 6.5 before operation to 1.7 one month afteroperation. No severe complications occurred during and after operation. During the period of follow-up, symptoms werenot deteriorated. At the end of follow-up, neither radiographic sign of aggressive destruction nor collapse of the involvedvertebra was observed. Significant improvement in the 12 patients was demonstrated on 7 of 8 SF-36 Health Scaleexcept for mental healthConclusions Cement vertebroplasty combined with ethanol injection as a safe and effective technique is an alternativeto the treatment of patients with vertebral hemangiomaChin Med J2007;120(13):136-1139As a slow-growing lesion, vertebral hemangioma collapse, but may not obliterate the whole lesion(VH) is one of the most common benign tumors of Absolute ethanol can induce thrombosis, edema andthe spine. Most HVs, solitary and asymptomatic, are sclerosis, but vertebral collapse may occure after ethanoloften discovered radiographically by incident. However, injection, which leaves the problem of mechanicallocal pain, radiological aggressiveness and neurologic insufficiency of the involved vertebra unsolved. Thusdeficit sometimes present. According to Deramond et combined cement vertebroplasty and ethanol injection foral, VHs can be classified into four groups. Patientthe treatment of vh is expected to have a better clinicalgroup I have asymptomatic VH without radiologicoutcomeof aggressiveness, and no specific treatment except closefollow-up is required. Patients of other groups need some We treated 12 patients with vertebral hemangioma withkind of intervention. In the past, VH was treated by cement vertebroplasty followed by ethanol injection, andradiotherapy, vascular embolization, surgery, or combined the patients were followed-up for 2 years and 5 monthstherapy. However, no treatment is available for VH on average. The purpose of this study was to assess thewithout side effectsefficacy and safety of this modality for vertebrhemangiomaIn 1987, percutaneous vertebroplasty (Pv)wasintroduced in France by Galibert et al. As a minimallyMETHODSinvasive procedure, this technique offers a therapeuticoption for patients suffering from noninfective, painfuL, Patientsdestructive vertebral lesions, whether benign or malignant, Between February 2002 and May 2004, twelve patientsas well as osteoporotic vertebral fracture. Pv is with symptomatic or aggressive vertebral hemangiomaadvantageous in pain relief and restoration of bone were treated by cement vertebroplasty combined withbiomechanical strength. In 1994, ethanol injection was ethanol injection. The medical and radiographic records ofgiven successfully to two patients with complicatedthe patients, 5 men and 7 women, aged from 26 to 54vertebral hemangioma with cord compression. Recently yeaethanol injection has proved an alternative to the中国煤化 taye. ine votedtreatment of symptomatic vertebral hemangioma. Both DeparCNMH Girs Afiliated Hospital ofcement vertebroplasty and ethanol injection areTang TS)can reinforce the vertebra and decrease the risk of 215006, China(Email: chenliangnal. comChinese Medical Joumal 2007: 120(13 ) 1136-1139levels of the spine included T9: 1, T10; 3, T12: 2, Ll: 1, average (1 year and 6 months-3 years and 9 months)L2: 2, L3: 2 and LA: 1. According to Deramond's Medical Outcome Trust Short-Form 36 (SF-36)classification, seven patients belonged to group 2 and five questionnaire including 8 scales such as physical function,belonged to group 3. The vertebral body was involved in bodily pain and mental health was used for patienteach patient, while the tumor spreaded to the pedicle in 3 based outcome analysis. These data were converted aspatients. Before the operation, each patient was asked to recommended by Ware to a transformed scale of 0 to 100,complete visual numerical scales rating their average the higher score indicating better resultsback pain (0-10), which was coded as 0: none, 5moderate and 10: most severe. All patients underwent Statistical analysisX-ray examination and CT of the involved level All data were expressed as mean t standard deviation(SD). Comparison was made by Studen's I test. Theresults were considered significant when a P value wasSurgical procedureless than 0.05For the first 2 patients, we performed aangiography to identify and embolize the feedingRESULTSof the tumor before operation. For the other 10this procedure was abandoned, Percutaneous All patients were operated on via a bipedicular technique,vertebroplasty was performed under local anesthesia by a one side for cement vertebroplasty and the other for ethanolbilateral transpedicular approach (one side for cement injection. The average operation time for each level wavertebroplasty, the opposite side for ethanol injection). 52 minutes(40-80 minutes). Neither violation of the wallThis technique was safe only under high-quality of the pedicle and neurologic complication norfluoroscopic guidance, by which the entire contour of the cementleakage into epidural or foraminal region wpedicle was visualized. The tip of a needle encroached the found. Venous leakage of PMMA during vertebroplastypedicle surface at its superior and lateral edge, withoccurred in 2 patients, and cement injection was stoppedangle to bring the needle tip in a midline position within immediately and no clinical symptoms appearedthe vertebral body. The needle was advanced until its tip Postoperative X-ray film and CT confirmed that cementreached the junction of anterior and middle one-third of filled the opposite side of the vertebral body in 10the vertebral body. Although prior intraosseous patients(Fig ) In the other two patients, only about 3. 8venography was controversial, it was routinely used in ml cement was injected into the vertebral body because ofous venous runoffs. hypotension and oxygen desaturation at cement injectionApproximately 5 ml of neurologically compatible They recovered within 30 minutes by hemodynamicHexabrix omnipaque 300(Nycomed, Princeton, NJ, USA) supportwas injected through the needle to evaluate the venousdrainage and filling characteristics of the vertebral body. Of the 12 patients, 11( 91.7%) noted significantlyDue to significant contrast extravasation in venography, alleviated back pain, and the other one claimed back vuesthis study. Polymethylmethacrylate(PMMA, Stryke- from 6.5 preoperatively to 1.7 one month postoperativelyHowmedica-Osteonics, Kalamazoo, ML, USA)was 5.42, P<0.05). During the period of follow-up,noprepared by mixing barium sulfate powder in a plastic symptoms and radiological signs of bony destructionbowl. When a"toothpaste"consistency was reached, the aggravated in ll patients. One-year follow-up revealedmixture was injected into the vertebral body with a 10 ml that one patient had the onset of pain after a pain-freesyringe under fluoroscopic guidance. The injection was interval, and X-ray film demonstrated a vertebralcontinued as long as there was no evidence of epidural or compression fracture in the adjacent upper level to theforaminal leakage and venous runoff. The injection was treated vertebra. Of the 12 patients, significantterminated when adequate vertebral filling was attained. postoperative improvement was demonstrated on 7 of 8In our study, an average about(5.6+1. 1)ml of cement SF-36 Health Scales except for Mental health(Tablewas injected for each level. We found that cement filledthe vertebral body across the midline from the unilateralDISCUSSIONapproach in 10 of the 12 patients. After the cementvertebroplasty, 5 ml of absolute ethanol was injected via a Vertebral hemangioma is a benign tumor in the spine,14-gauge bone-biopsy needle inserted through the skin which is found in 10%-12% autopsies. Painful andand pedicle into the vertebral body by the same needle aggressive vertebral hemangioma is rare, and can beplacement technique on the opposite side. Finally, the treat中国煤化工 ncluding radiotherapy,patient was kept in supine position for four hours-surgery. Studies haveC Gy of radiotherapy forFollow-up and data collectionvertebral hemangioma, but it is still controversial forThe patients were followed-up at 1, 3, 6, 12 months non-malignant lesions in fear of the inherent risk ofatients were followed-up for 2 years and 5 months on catheterization, embolization of feeding vesse epostoperatively, and then examined once a year. The radionecrosis. With the improvement of vasco138Chin med j2007;12013.:H36-139Fig. A 37-year-old man with severe backreoperative CT of T12 showing vertebral hemangioma involwhole body. B: postoperative CT showing3 of the vertebral body. C, D: anteroposterior and lateral flucafter cement vertebroplasty showing that cementvertebral body across the midline. Ethanol injection on the oppomay be helpful to obliterate the whole lesionTable. Pre- and postoperative scores of 8 SF-36 Health Scales for patients with vertebral hemangioma(n=l2, mean* SD)Role-physics Bodily pain General healhMental healthPreoperative27±1330±1739±1957±2047±1540±1253±162±19value-663vertebral hemangioma has been used to reduce tumor size, frequently described, and the ethanol injection also hasreverse neurological deficit and reduce intraoperative the potential risk of venous runoff. 3.7,. 6-20 To decrease thebleeding, but most authors use embolization as an adjunct risk, we routinely performed intraosseous venographytreatment for transient effect. The potential risks of before cement and ethanol injection. Although McGrawsurgery are intraoperative bleeding and postoperative et al" reported a high predictive value of intraosseousepidural hematoma, another problem concerning surgical venography to cement application in their cases, thetreatment remains in patients with both anterior and attitude towards prior venography are distinctivelyposterior columns involved. Heiss et al reported a different in the United States and Europe. The doubtesuccessful management of spinal cord compression about the effect of this technique lies in the difference incaused by vertebral hemangioma with intralesional flow pattern between PMMa and iodine contrast materialction of alcohol in 1994, and he also pointed out that We believe that venography should be dependent on theno iniection maay be followed by vertebral nature of the disease. In patients with vertebralompression Cement vertebroplasty is well-known for its hemangioma, venography provides information on theability to increase stiffness of the vertebra with route of preferential venous drainage. Although vertebralsteoporosis or fracture. The thermal properties of hemangiomas are vascular in nature, venous flow is notcement in osteoporotic fracture have been debated, but a fast. When the flow is via a large vein, the flow can beheating effect may actually be beneficial in that it causes altered by slight advancement or withdrawal of the needledestruction of pain fibers and death of tumor cells. Since the main venous channels of the vertebral body inExperiments have demonstrated that intravertebral body the equatorial plane, an equatorial position of the needlethermocouple temperature at 60-70C is the target tip should be placed within the vertebral bodymperature for killing tumor cells. Since vertebralhemangioma is characterized by the diminished bone Most of neurologic complications caused by cementdensity, exaggerated vertical striations or honeycombed vertebroplasty or ethanol injection are resulted fromappearance, vascular proliferation and fat deposition of incorrect insertion of the needle. To insert the needlethe vertebra, both tumor and mechanical insufficiency through the pedicle and into the vertebral bodshould be addressed. Hence, cement vertebroplasty successfully, we checked anteroposterior and lateralombined with ethanol injection is feasible for the fluoroscopy three times while the needle tip passingtreatment of vertebral hemangioma. Although we can not through the pedicle. Firstly, when the needle tip reacheddirectly compare the outcome of current study with those the中国煤化工 the pedicle surfaceof cement vertebroplasty or ethanol injection alone, the anneedle tip in a midlineresults of our 12 patients indicated that cement positCNMHGy. Secondly, while theertebroplasty followed by ethanol injection is safe and needle tip reached the midpoint of the pedicle on theeffectivelateral view, it should not go medially beyond the midlineof the cross plane of the pedicle on the anteroposteriorLeakage of PMMA into the perivertebral vein has been view. Finally when the needle tip reached the junction ofChinese Medical Journal 2007: 120(13): 1136-11391139the pedicle and vertebral body, it should not go medially183-189.beyond the medial wall of the pedicle on anteroposterior 10. Bremnes RM, Hauge HN, Sagsveen R. Radiotherapy in theview. The technical challenge of transpedicular approachtreatment of symptomatic vertebral hemangiomas: technicallies in the estimation of the angle that can be takencase report. Neurosurgery 1996: 39: 1054-1058without risk of violating the pedicle wall. Our experience 11. Yang ZY, Zhang L, Chen ZX, Hu HY. Hemangioma ofin the 12 patients using technique mentioned abovevertebral column: A report on twenty-three patientsndicated that this method is safe and effectivespecial reference to functional recovery after radiation therapyActa Radiol Oncol 1985: 24: 129-132At the very beginning, we planned to inject ethanol on 12. Acosta FL Jr, Dowd CE, Chin C, Tihan T, Ames CP, Weinsteinboth sides, followed by bilateral cement vertebroplastyPR. Current treatment strategies and outcomes in theFor fear of ethanol flow and thrombus that may be pushedmanagement of symptomatic vertebral hemangiomaby cement into other untoward sites, cementNeurosurgery 2006: 58: 287-295vertebroplasty was done on one side and followed by 13. Nguyen JP, Djindjian M, Gaston A, Gherardi R, Benhaiem N,ethanol injection on the opposite side in this study. InCaron JP, et al. Vertebral hemangiomas presenting withconclusion, unilateral cement vertebroplasty combinedneurologic symptoms. 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