A novel surgical technique for aggressive vertebral hemangiomas

Canbay, Suat; Kayalar, Ali Erhan; Gel, Gulce; Sabuncuoğlu, Hakan

doi:10.1016/j.neucir.2018.08.003

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Reporte de caso" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1120 "Ancho" => 1750 "Tamanyo" => 539214 ] ] "descripcion" => array:1 [ "en" => "(A)–(B) Intraoperative photographs showing a tumor located just below spinal artery that is covered by a thin layer of connective tissue belonging to leptomeninges. (C)–(D) Tissue dissection revealed a heterogeneous cystic tumor compressing the spinal cord. (E) Complete resection of the spinal cord tumor. 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"identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ali Erhan" "apellidos" => "Kayalar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Gulce" "apellidos" => "Gel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Hakan" "apellidos" => "Sabuncuoğlu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Liv Hospital, Ankara, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Dr. Abdurrahman Yurtaslanı Onkoloji Hastanesi, Ankara, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Ankara, Turkey" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Ufuk Üniversitesi Tıp Fakültesi Dr. Rıdvan Ege Hastanesi, Ankara, Turkey" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Una nueva técnica quirúrgica para hemangiomas vertebrales agresivos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 752 "Ancho" => 2000 "Tamanyo" => 87979 ] ] "descripcion" => array:1 [ "en" => "A preoperative sagittal computed tomography (CT) image of the patient's T11 vertebra shows osseous expansion of the vertebral body. An axial CT image of T11 shows the trabecular structure and the lytic areas within the vertebral body and posterior elements of the vertebra." ] ] ] "textoCompleto" => "IntroductionVertebral hemangiomas are the most common primary benign neoplasms of vertebral bodies. These tumors occur more often in females than in males (ratio 2:1), and the incidence is 10–12%.<a class="elsevierStyleCrossRef" href="#bib0160">1</a> Most vertebral hemangiomas are asymptomatic and diagnosed incidentally,<a class="elsevierStyleCrossRef" href="#bib0165">2</a> and only 0.9–1.2% are symptomatic.<a class="elsevierStyleCrossRef" href="#bib0170">3</a> The symptoms start insidiously and only become apparent.when the tumor-like material or associated vascular structures press on the spinal cord or other neural tissues.Aggressive vertebral hemangiomas are characterized by significant osseous expansion, extraosseous extension, and more vascular stroma than non-aggressive types. Approximately 45% of these aggressive neoplasms are associated with neurological deficits, and the others present with pain alone.<a class="elsevierStyleCrossRefs" href="#bib0175">4,5</a> Histologically, these lesions feature fully developed adult blood vessels with slow-flowing, dilated venous channels that are covered in fat and infiltrate the medullary cavity.<a class="elsevierStyleCrossRefs" href="#bib0185">6–8</a> Pathologically, two types of aggressive vertebral hemangiomas have been described: cavernous and capillary. The cavernous type is most common.<a class="elsevierStyleCrossRef" href="#bib0200">9</a>We describe the case of a 19-year-old man who presented with thoracic back pain. Various imaging modalities were applied to reach the diagnosis of aggressive vertebral hemangioma. We administered radiofrequency ablation combined with vertebroplasty using an autograft, and decompression. Herein we report this case, including the novel surgical technique used to treat the tumor, and we review the relevant literature.Case reportA 19-year-old male presented with thoracic back pain. A computed tomography scan and subsequent magnetic resonance imaging demonstrated an aggressive vertebral hemangioma centered within the T11 vertebral body. The tumor had destroyed the vertebral body and posterior elements (i.e., the pedicles, laminae, transverse processes and facet joints), and soft-tissue components of the mass were observed in the epidural space (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Except for back pain, the patient's physical and neurologic examination findings were normal.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Surgery was performed. There were no complications during or after the operation, and the patient's back pain resolved completely during the postsurgical period. He continued to do well and there were no clinical or radiographic signs of recurrence at his 6-month follow-up visit. Also, repeat computed tomography and magnetic resonance imaging at that time showed successful ossification of the T11 vertebra body graft, with no spinal cord compression or kyphosis (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Surgical techniqueThe patient was placed on the operating table in prone position under general anesthesia. Intraoperative neuromonitoring was used to monitor the integrity of the nervous system and neurological functions. The levels of the T9 and L1 vertebral bodies were confirmed by fluoroscopy. A midline skin incision was made from the area of T9 to L1 and the skin and subcutaneous tissue were dissected. The fascia was then dissected and the paravertebral muscles were stripped bilaterally. Laminectomies were performed to achieve decompression while preserving the facet junctions. To address the midline tension band breakdown caused by the laminectomies, posterior stabilization was achieved by placing monoaxial pedicle screws between the T10 and T12 vertebral bodies. We also stabilized the T11 vertebra in effort to prevent extreme pressure on that structure. Next, fluoroscopy guidance was used to select suitable entry points for working cannulae in the T11 vertebral pedicles. At the beginning of the operation, there was acute bleeding inside these cannulae. The trabecular structure of the T11 vertebral body was then broken down using a STAR™ Tumor Ablation System (Merit Medical, USA) and radiofrequency ablation was performed. First, the ablation probe was placed into the T11 vertebral body under fluoroscopic guidance. We waited until the distal end of the probe temperature reached 50°C (122°F) and ensured that the proximal end of the ablation probe temperature did not exceed 42°C (107°F). Radiofrequency ablation was then performed on the T11 vertebral body for 8min. This process decreased the bleeding. Next, 5mL of FLOSEAL (Baxter, USA) was injected into the T11 vertebral body via the working cannulae and the bleeding eventually stopped. A spongious bone graft was harvested from the posterior superior region of the right iliac bone, and was cut into small pieces. Five to six milliliters of this autograft material was placed inside the vertebral body bilaterally via the working cannulae, and was packed in place. Once this step was complete, T11 laminectomies were performed to decompress the spinal canal and the facet joints were preserved. The stabilization system was then completed with placement of the rods. No abnormalities were observed on neuromonitoring throughout the surgery, and no blood transfusion was required.DiscussionThe literature describes multiple treatment options for aggressive vertebral hemangiomas, including embolization, ethanol injection, radiotherapy, vertebroplasty, decompression surgery, and en bloc or gross total resection. Few studies have compared these treatment modalities; therefore, there is no consensus on a preferred strategy. One systematic study that included 51 patients with aggressive vertebral hemangiomas affirmed the benefits of embolization; the results indicated significantly less blood loss in the group that received preoperative embolization compared to the control group.<a class="elsevierStyleCrossRef" href="#bib0205">10</a> In another study, Cotton et al. found that preoperative embolization and vertebroplasty can be used together to reduce blood loss even further during the operation.<a class="elsevierStyleCrossRef" href="#bib0210">11</a>Embolization treatment for aggressive vertebral hemangiomas is performed by identifying the tumor's main arterial supply via an endovascular approach, and then injecting occlusive materials.According to the literature, embolization is insufficient because the tumor's feeder vessels and their branches extend throughout the affected area. Also, it is important to consider the type of embolization materials that are used. Some materials can cause excessive embolization, which can occlude the spinal feeder vessels leaving the patient with neurological deficits.Another method is to inject ethyl alcohol into the affected vertebral body to embolize and control bleeding; however, a few articles have noted negative side effects of this, such as the potential for alcohol to enter undesired areas and cause neurological deficits. Even though injecting ethyl alcohol has been effective at alleviating neurological symptoms in patients with aggressive vertebral hemangiomas, there are few data on rate of recurrence. Potential complications with this treatment are osteonecrosis, vertebral collapse, transient neurological, deterioration, spinal cord injury, hemodynamic instability and asystole.<a class="elsevierStyleCrossRefs" href="#bib0170">3,12–17</a> This method can also promote osteoporosis.Vertebroplasty with polymethylmethacrylate (PMM) cement is another treatment option for vertebral hemangiomas that was first described in the late 1980s.<a class="elsevierStyleCrossRefs" href="#bib0240">17,18</a> This provides hemostatic embolization and supports the anterior spinal column.<a class="elsevierStyleCrossRefs" href="#bib0240">17,19</a> Polymethylmethacrylate can be used to increase the strength of the affected vertebral body; however, due to foreign body side effects, it increases the risk of infection. Furthermore, there is potential for this material to leak into the spinal canal during the operation and cause neurological deficits. In most cases of aggressive vertebral hemangioma, the posterior cortical bone of affected vertebral bodies becomes more fragile, and this makes it easier for PMM to leak into the spinal canal. Also, PMM becomes more rigid than bone once it cures, and this can lead to disease in adjacent segment/s.Radiotherapy is another way to reduce or eliminate soft-tissue pressure on the spinal canal from an aggressive vertebral hemangioma; however, the effects are delayed (approximately 2 months after administration) and radiotherapy does not restore or support vertebral body strength. There is a dose-related effect of radiotherapy for vertebral hemangiomas, and the recommended total dose is 40Gy.<a class="elsevierStyleCrossRefs" href="#bib0240">17,20–23</a> Administering more than this amount can cause osteoporosis, pulmonary radionecrosis, and radiation myelopathy.<a class="elsevierStyleCrossRefs" href="#bib0230">15,20–22</a> It should be noted that the radiographic appearance of aggressive vertebral hemangiomas has not been reported to change after several years, even when radiotherapy is successful.<a class="elsevierStyleCrossRefs" href="#bib0240">17,24,25</a> This indicates that radiotherapy is sufficient for pain control but does not reduce the soft-tissue mass compression on the spinal canal. Consequently, authors have concluded that giving radiation alone may be less effective for patients with aggressive vertebral hemangiomas.<a class="elsevierStyleCrossRefs" href="#bib0185">6,26</a>Surgical decompression and gross-total resection are frequently performed in cases of aggressive vertebral hemangioma.<a class="elsevierStyleCrossRef" href="#bib0290">27</a> Piecemeal gross-total resection and en bloc resection have both been shown to yield good clinical results with minimal possibility of tumor recurrence.<a class="elsevierStyleCrossRefs" href="#bib0290">27,28</a> The vertebral body can be totally removed (i.e., en bloc or piecemeal) or partially removed after surgical decompression, but this operation is extremely aggressive and has more potential complications. If surgery is to be performed on an aggressive vertebral hemangioma, partial corpectomy or decompression is usually recommended.<a class="elsevierStyleCrossRefs" href="#bib0160">1,6,27–30</a> Extensive intraoperative bleeding or postoperative epidural hematoma is a common complication.<a class="elsevierStyleCrossRefs" href="#bib0160">1,30,31</a> Our new surgical technique combines sufficient bleeding control with placement of an autograft to increase vertebral body strength physiologically. This technique avoids several complications that can occur with other treatment techniques, such as adjacent segment disease, osteoporosis and neurological deficits.ConclusionBleeding is an important problem in cases of aggressive vertebral hemangioma. Our new surgical method includes sufficient bleeding control achieved through radiofrequency ablation and use of a hemostatic agent (FLOSEAL). Using an autograft to increase vertebral body strength is more physiologic in patients who have adequate vertebral integrity to support this. As well, this novel method prevents multiple complications that can occur with other treatment methods." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1239285" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1150154" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1239284" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1150153" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Case report" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-05-07" "fechaAceptado" => "2018-08-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1150154" "palabras" => array:4 [ 0 => "Aggressive vertebral hemangioma" 1 => "Hemostatic agent" 2 => "Radiofrequency ablation" 3 => "Autograft" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1150153" "palabras" => array:4 [ 0 => "Hemangioma vertebral agresivo" 1 => "Agente hemostático" 2 => "Ablación por radiofrecuencia" 3 => "Autoinjerto" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Vertebral hemangiomas are relatively common, but those causing spinal cord compression are rare. A 19-year-old male presented with thoracic back pain. The neurologic examination was normal and radiological examinations demonstrated an aggressive vertebral hemangioma centered within the T11 vertebral body. Damaged vertebral bone and soft tissue components of the mass were observed in the epidural space. Surgery was performed using a new technique involving radiofrequency ablation, injection of a hemostatic agent (FLOSEAL, Baxter, USA), and bone autograft placement in the affected vertebral body. There were no complications intra- or postoperatively, and the patient's back pain resolved completely during the postsurgical period. Bleeding is a serious issue in cases of aggressive vertebral hemangioma. This new technique provides improved bleeding control and strengthens the affected vertebra through autograft placement." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los hemangiomas vertebrales son relativamente comunes, pero los que causan la compresión de la médula espinal son raros. Un hombre de 19 años presentó dolor de espalda torácica. El examen neurológico fue normal y los exámenes radiológicos demostraron un hemangioma vertebral agresivo centrado en el cuerpo vertebral T11. Se observaron componentes óseos y vertebrales dañados de la masa en el espacio epidural. La cirugía se realizó utilizando una nueva técnica que incluía ablación por radiofrecuencia, inyección de un agente hemostático (FLOSEAL, Baxter, EE. UU.) Y colocación de autoinjerto de hueso en el cuerpo vertebral afectado. No hubo complicaciones intra y postoperatorias, y el dolor de espalda del paciente se resolvió completamente durante el período posquirúrgico. El sangrado es un problema grave en los casos de hemangioma vertebral agresivo. Esta nueva técnica proporciona un mejor control de la hemorragia y fortalece la vértebra afectada a través de la colocación del autoinjerto." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 752 "Ancho" => 2000 "Tamanyo" => 87979 ] ] "descripcion" => array:1 [ "en" => "A preoperative sagittal computed tomography (CT) image of the patient's T11 vertebra shows osseous expansion of the vertebral body. An axial CT image of T11 shows the trabecular structure and the lytic areas within the vertebral body and posterior elements of the vertebra." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 881 "Ancho" => 2000 "Tamanyo" => 147516 ] ] "descripcion" => array:1 [ "en" => "Fat-suppressed sagittal T2-weighted magnetic resonance images show a diffuse abnormal signal throughout the T11 vertebral body and epidural components." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1108 "Ancho" => 1733 "Tamanyo" => 122908 ] ] "descripcion" => array:1 [ "en" => "A sagittal computed tomography (CT) image at 3 months post-surgery shows the stabilization materials. Axial and sagittal CT images show the autograft within the T11 vertebral body." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 803 "Ancho" => 900 "Tamanyo" => 63205 ] ] "descripcion" => array:1 [ "en" => "Sagittal and axial computed tomography images and magnetic resonance images at 6 months post-surgery reveal the area of new ossification in the T11 vertebral body, no compression of the vertebral body, and no kyphosis. 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extraosseous extension&#44; and more vascular stroma than non-aggressive types&#46; Approximately 45&#37; of these aggressive neoplasms are associated with neurological deficits&#44; and the others present with pain alone&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">4&#44;5</span></a> Histologically&#44; these lesions feature fully developed adult blood vessels with slow-flowing&#44; dilated venous channels that are covered in fat and infiltrate the medullary cavity&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#8211;8</span></a> Pathologically&#44; two types of aggressive vertebral hemangiomas have been described&#58; cavernous and capillary&#46; The cavernous type is most common&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We describe the case of a 19-year-old man who presented with thoracic back pain&#46; Various imaging modalities were applied to reach the diagnosis of aggressive vertebral hemangioma&#46; We administered radiofrequency ablation combined with vertebroplasty using an autograft&#44; and decompression&#46; Herein we report this case&#44; including the novel surgical technique used to treat the tumor&#44; and we review the relevant literature&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 19-year-old male presented with thoracic back pain&#46; A computed tomography scan and subsequent magnetic resonance imaging demonstrated an aggressive vertebral hemangioma centered within the T11 vertebral body&#46; The tumor had destroyed the vertebral body and posterior elements &#40;i&#46;e&#46;&#44; the pedicles&#44; laminae&#44; transverse processes and facet joints&#41;&#44; and soft-tissue components of the mass were observed in the epidural space &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Except for back pain&#44; the patient&#39;s physical and neurologic examination findings were normal&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Surgery was performed&#46; There were no complications during or after the operation&#44; and the patient&#39;s back pain resolved completely during the postsurgical period&#46; He continued to do well and there were no clinical or radiographic signs of recurrence at his 6-month follow-up visit&#46; Also&#44; repeat computed tomography and magnetic resonance imaging at that time showed successful ossification of the T11 vertebra body graft&#44; with no spinal cord compression or kyphosis &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Surgical technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was placed on the operating table in prone position under general anesthesia&#46; Intraoperative neuromonitoring was used to monitor the integrity of the nervous system and neurological functions&#46; The levels of the T9 and L1 vertebral bodies were confirmed by fluoroscopy&#46; A midline skin incision was made from the area of T9 to L1 and the skin and subcutaneous tissue were dissected&#46; The fascia was then dissected and the paravertebral muscles were stripped bilaterally&#46; Laminectomies were performed to achieve decompression while preserving the facet junctions&#46; To address the midline tension band breakdown caused by the laminectomies&#44; posterior stabilization was achieved by placing monoaxial pedicle screws between the T10 and T12 vertebral bodies&#46; We also stabilized the T11 vertebra in effort to prevent extreme pressure on that structure&#46; Next&#44; fluoroscopy guidance was used to select suitable entry points for working cannulae in the T11 vertebral pedicles&#46; At the beginning of the operation&#44; there was acute bleeding inside these cannulae&#46; The trabecular structure of the T11 vertebral body was then broken down using a STAR&#8482; Tumor Ablation System &#40;Merit Medical&#44; USA&#41; and radiofrequency ablation was performed&#46; First&#44; the ablation probe was placed into the T11 vertebral body under fluoroscopic guidance&#46; We waited until the distal end of the probe temperature reached 50<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;122<span class="elsevierStyleHsp" style=""></span>&#176;F&#41; and ensured that the proximal end of the ablation probe temperature did not exceed 42<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;107<span class="elsevierStyleHsp" style=""></span>&#176;F&#41;&#46; Radiofrequency ablation was then performed on the T11 vertebral body for 8<span class="elsevierStyleHsp" style=""></span>min&#46; This process decreased the bleeding&#46; Next&#44; 5<span class="elsevierStyleHsp" style=""></span>mL of FLOSEAL &#40;Baxter&#44; USA&#41; was injected into the T11 vertebral body via the working cannulae and the bleeding eventually stopped&#46; A spongious bone graft was harvested from the posterior superior region of the right iliac bone&#44; and was cut into small pieces&#46; Five to six milliliters of this autograft material was placed inside the vertebral body bilaterally via the working cannulae&#44; and was packed in place&#46; Once this step was complete&#44; T11 laminectomies were performed to decompress the spinal canal and the facet joints were preserved&#46; The stabilization system was then completed with placement of the rods&#46; No abnormalities were observed on neuromonitoring throughout the surgery&#44; and no blood transfusion was required&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The literature describes multiple treatment options for aggressive vertebral hemangiomas&#44; including embolization&#44; ethanol injection&#44; radiotherapy&#44; vertebroplasty&#44; decompression surgery&#44; and <span class="elsevierStyleItalic">en bloc</span> or gross total resection&#46; Few studies have compared these treatment modalities&#59; therefore&#44; there is no consensus on a preferred strategy&#46; One systematic study that included 51 patients with aggressive vertebral hemangiomas affirmed the benefits of embolization&#59; the results indicated significantly less blood loss in the group that received preoperative embolization compared to the control group&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> In another study&#44; Cotton et al&#46; found that preoperative embolization and vertebroplasty can be used together to reduce blood loss even further during the operation&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Embolization treatment for aggressive vertebral hemangiomas is performed by identifying the tumor&#39;s main arterial supply via an endovascular approach&#44; and then injecting occlusive materials&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">According to the literature&#44; embolization is insufficient because the tumor&#39;s feeder vessels and their branches extend throughout the affected area&#46; Also&#44; it is important to consider the type of embolization materials that are used&#46; Some materials can cause excessive embolization&#44; which can occlude the spinal feeder vessels leaving the patient with neurological deficits&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Another method is to inject ethyl alcohol into the affected vertebral body to embolize and control bleeding&#59; however&#44; a few articles have noted negative side effects of this&#44; such as the potential for alcohol to enter undesired areas and cause neurological deficits&#46; Even though injecting ethyl alcohol has been effective at alleviating neurological symptoms in patients with aggressive vertebral hemangiomas&#44; there are few data on rate of recurrence&#46; Potential complications with this treatment are osteonecrosis&#44; vertebral collapse&#44; transient neurological&#44; deterioration&#44; spinal cord injury&#44; hemodynamic instability and asystole&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">3&#44;12&#8211;17</span></a> This method can also promote osteoporosis&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Vertebroplasty with polymethylmethacrylate &#40;PMM&#41; cement is another treatment option for vertebral hemangiomas that was first described in the late 1980s&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">17&#44;18</span></a> This provides hemostatic embolization and supports the anterior spinal column&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">17&#44;19</span></a> Polymethylmethacrylate can be used to increase the strength of the affected vertebral body&#59; however&#44; due to foreign body side effects&#44; it increases the risk of infection&#46; Furthermore&#44; there is potential for this material to leak into the spinal canal during the operation and cause neurological deficits&#46; In most cases of aggressive vertebral hemangioma&#44; the posterior cortical bone of affected vertebral bodies becomes more fragile&#44; and this makes it easier for PMM to leak into the spinal canal&#46; Also&#44; PMM becomes more rigid than bone once it cures&#44; and this can lead to disease in adjacent segment&#47;s&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Radiotherapy is another way to reduce or eliminate soft-tissue pressure on the spinal canal from an aggressive vertebral hemangioma&#59; however&#44; the effects are delayed &#40;approximately 2 months after administration&#41; and radiotherapy does not restore or support vertebral body strength&#46; There is a dose-related effect of radiotherapy for vertebral hemangiomas&#44; and the recommended total dose is 40<span class="elsevierStyleHsp" style=""></span>Gy&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">17&#44;20&#8211;23</span></a> Administering more than this amount can cause osteoporosis&#44; pulmonary radionecrosis&#44; and radiation myelopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;20&#8211;22</span></a> It should be noted that the radiographic appearance of aggressive vertebral hemangiomas has not been reported to change after several years&#44; even when radiotherapy is successful&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">17&#44;24&#44;25</span></a> This indicates that radiotherapy is sufficient for pain control but does not reduce the soft-tissue mass compression on the spinal canal&#46; Consequently&#44; authors have concluded that giving radiation alone may be less effective for patients with aggressive vertebral hemangiomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;26</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Surgical decompression and gross-total resection are frequently performed in cases of aggressive vertebral hemangioma&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a> Piecemeal gross-total resection and <span class="elsevierStyleItalic">en bloc</span> resection have both been shown to yield good clinical results with minimal possibility of tumor recurrence&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">27&#44;28</span></a> The vertebral body can be totally removed &#40;i&#46;e&#46;&#44; <span class="elsevierStyleItalic">en bloc</span> or piecemeal&#41; or partially removed after surgical decompression&#44; but this operation is extremely aggressive and has more potential complications&#46; If surgery is to be performed on an aggressive vertebral hemangioma&#44; partial corpectomy or decompression is usually recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;6&#44;27&#8211;30</span></a> Extensive intraoperative bleeding or postoperative epidural hematoma is a common complication&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;30&#44;31</span></a> Our new surgical technique combines sufficient bleeding control with placement of an autograft to increase vertebral body strength physiologically&#46; This technique avoids several complications that can occur with other treatment techniques&#44; such as adjacent segment disease&#44; osteoporosis and neurological deficits&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Bleeding is an important problem in cases of aggressive vertebral hemangioma&#46; Our new surgical method includes sufficient bleeding control achieved through radiofrequency ablation and use of a hemostatic agent &#40;FLOSEAL&#41;&#46; Using an autograft to increase vertebral body strength is more physiologic in patients who have adequate vertebral integrity to support this&#46; As well&#44; this novel method prevents multiple complications that can occur with other treatment methods&#46;</p></span></span>"
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            1 => "Agente hemost&#225;tico"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Vertebral hemangiomas are relatively common&#44; but those causing spinal cord compression are rare&#46; A 19-year-old male presented with thoracic back pain&#46; The neurologic examination was normal and radiological examinations demonstrated an aggressive vertebral hemangioma centered within the T11 vertebral body&#46; Damaged vertebral bone and soft tissue components of the mass were observed in the epidural space&#46; Surgery was performed using a new technique involving radiofrequency ablation&#44; injection of a hemostatic agent &#40;FLOSEAL&#44; Baxter&#44; USA&#41;&#44; and bone autograft placement in the affected vertebral body&#46; There were no complications intra- or postoperatively&#44; and the patient&#39;s back pain resolved completely during the postsurgical period&#46; Bleeding is a serious issue in cases of aggressive vertebral hemangioma&#46; This new technique provides improved bleeding control and strengthens the affected vertebra through autograft placement&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los hemangiomas vertebrales son relativamente comunes&#44; pero los que causan la compresi&#243;n de la m&#233;dula espinal son raros&#46; Un hombre de 19 a&#241;os present&#243; dolor de espalda tor&#225;cica&#46; El examen neurol&#243;gico fue normal y los ex&#225;menes radiol&#243;gicos demostraron un hemangioma vertebral agresivo centrado en el cuerpo vertebral T11&#46; Se observaron componentes &#243;seos y vertebrales da&#241;ados de la masa en el espacio epidural&#46; La cirug&#237;a se realiz&#243; utilizando una nueva t&#233;cnica que inclu&#237;a ablaci&#243;n por radiofrecuencia&#44; inyecci&#243;n de un agente hemost&#225;tico &#40;FLOSEAL&#44; Baxter&#44; EE&#46; UU&#46;&#41; Y colocaci&#243;n de autoinjerto de hueso en el cuerpo vertebral afectado&#46; No hubo complicaciones intra y postoperatorias&#44; y el dolor de espalda del paciente se resolvi&#243; completamente durante el per&#237;odo posquir&#250;rgico&#46; El sangrado es un problema grave en los casos de hemangioma vertebral agresivo&#46; Esta nueva t&#233;cnica proporciona un mejor control de la hemorragia y fortalece la v&#233;rtebra afectada a trav&#233;s de la colocaci&#243;n del autoinjerto&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A preoperative sagittal computed tomography &#40;CT&#41; image of the patient&#39;s T11 vertebra shows osseous expansion of the vertebral body&#46; An axial CT image of T11 shows the trabecular structure and the lytic areas within the vertebral body and posterior elements of the vertebra&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Fat-suppressed sagittal T2-weighted magnetic resonance images show a diffuse abnormal signal throughout the T11 vertebral body and epidural components&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A sagittal computed tomography &#40;CT&#41; image at 3 months post-surgery shows the stabilization materials&#46; Axial and sagittal CT images show the autograft within the T11 vertebral body&#46;</p>"
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