Management of pediatric single-level vertebral hemangiomas presenting with myelopathy by three-pronged approach (ethanol embolization, laminectomy, and instrumentation): a single-institute experience

Purpose: Pediatric vertebral hemangiomas (VH) are exceedingly rare benign and highly vascular tumours of the spine. There are no guidelines available for management of these patients in literature. Purpose of this study is to evaluate the role of intraoperative ethanol embolization, surgical decompression, and instrumented fusion in pediatric symptomatic VH with single-level involvement.

Methods: Surgery consisted of intraoperative bilateral pedicular absolute alcohol injection and laminectomy at the level of pathology followed by a short-/long-segment instrumented fusion using pedicle screws and rod. Seven patients (mean age 14 ± 2.4 years, range 10-17 years, five females and two males) (age < 18 years) who were treated using this technique at our institute since March 2008 to December 2013 were enrolled in this retrospective study. Demographical, clinical, radiological, operative details, and postoperative events were retrieved from hospital records. During follow-up visits, clinical status and imaging were recorded. Outcome assessed with clinical and neurological outcome score of American Spinal Injury Association (ASIA) Impairment Scale.

Results: Duration of symptoms ranged from 3 to 60 months (mean, 14.7 ± 20.4 months). Clinical features include myelopathy with motor and sensory involvement in all (five were paraplegic), back pain in two patients, and bladder involvement in two patients. The preoperative American Spinal Injury Association (ASIA) Impairment Scale (AIS) were B in five patients and C and D in one patient each. All had pan vertebral body VH with severe cord compression in the thoracic region on imaging study. Mean duration of surgery was 248.6 ± 60 minutes (range 195-310 min) and blood loss was 535 ml (range 200-1500 ml). Immediate embolization was achieved in all patients, which allowed laminectomy and soft tissue hemangioma removal relatively easy. Post surgery, at mean follow-up of 45.3 (±23.2) months (range 1-78 months), all patients showed improvement in power (sphincter improvement in two patients). ASIA were E in six patients and D in one patient at the last follow-up.

Conclusion: The present study is the largest series of pediatric symptomatic VH. This procedure is a safe, efficient method to treat symptomatic pediatric VH with severe cord compression. It seems to serve the purpose of providing embolization, cord decompression, rigid fusion at the same sitting without adding new morbidity, and preventing excessive blood loss.