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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Vertebral hemangiomas are the most common primary benign neoplasms of vertebral bodies&#46; These tumors occur more often in females than in males &#40;ratio 2&#58;1&#41;&#44; and the incidence is 10&#8211;12&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a> Most vertebral hemangiomas are asymptomatic and diagnosed incidentally&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">2</span></a> and only 0&#46;9&#8211;1&#46;2&#37; are symptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> The symptoms start insidiously and only become apparent&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">when the tumor-like material or associated vascular structures press on the spinal cord or other neural tissues&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Aggressive vertebral hemangiomas are characterized by significant osseous expansion&#44; 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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        "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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Case Report
A novel surgical technique for aggressive vertebral hemangiomas
Una nueva técnica quirúrgica para hemangiomas vertebrales agresivos
Suat Canbaya,
Autor para correspondencia
suatcanbay@hotmail.com

Corresponding author.
, Ali Erhan Kayalarb, Gulce Gelc, Hakan Sabuncuoğlud
a Liv Hospital, Ankara, Turkey
b Dr. Abdurrahman Yurtaslanı Onkoloji Hastanesi, Ankara, Turkey
c Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Ankara, Turkey
d Ufuk Üniversitesi Tıp Fakültesi Dr. Rıdvan Ege Hastanesi, Ankara, Turkey
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Vertebral hemangiomas are the most common primary benign neoplasms of vertebral bodies&#46; These tumors occur more often in females than in males &#40;ratio 2&#58;1&#41;&#44; and the incidence is 10&#8211;12&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a> Most vertebral hemangiomas are asymptomatic and diagnosed incidentally&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">2</span></a> and only 0&#46;9&#8211;1&#46;2&#37; are symptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> The symptoms start insidiously and only become apparent&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">when the tumor-like material or associated vascular structures press on the spinal cord or other neural tissues&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Aggressive vertebral hemangiomas are characterized by significant osseous expansion&#44; 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="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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ISSN: 11301473
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