Background: Aggressive vertebral hemangioma is rare, and its management can be very challenging. Methods: In this report, we present the case of a 30-year-old female with a normal twin pregnancy. She had been complaining of midthoracic pain after the seventh month of pregnancy with no other symptoms. Normal delivery was done under spinal anesthesia, but the patient's back pain worsened after the delivery, and she left the hospital on Day 4 with the onset of an unsteady gait. She was seen in the spinal clinic on Day 14, referred by her gynecologist, with a paraparetic presentation that was rapidly worsening. Urgent magnetic resonance imaging (MRI) was done and revealed aggressive hemangioma of T6 with kyphosis and significant cord compression. Results: The patient was admitted and was operated the following morning. Posterior decompression with fixation from T4 to T8 and kyphosis correction was done. Samples from the vertebrae were sent to the lab for pathology analysis, and the results confirmed the diagnosis of vertebral hemangioma. She could walk on Day 1 with progressive neurological recovery, but distal junctional kyphosis in the form of a ''chance fracture'' of T8 occurred at 2 months and was treated conservatively. She showed a satisfactory clinical and radiological result at 2 years with no recurrence. Conclusions: Literature is sparse on the management of vertebral hemangioma in the context of pregnancy and postpartum, with only case reports, and its presentation as a kyphotic fracture is extremely rare. The current case shows how, in the context of delivery, a benign procedure such as spinal anesthesia should be done with extreme caution, as it may play a role in aggravating an undiagnosed aggressive hemangioma; rapid management after the onset of paraparetic symptoms enables a full neurological recovery, but close monitoring later on with regular MRI is mandatory for detection of any recurrence.
The lesion is classically juxta-articular at the end of long bones in the age group of 20-40 years with the mean age of 32 years. On the hand, it tends to present earlier with a mean age at presentation of 22 years (that is less than the average occurrence age of conventional GCT). [3,4] The most common location for GCTs is the distal femur and the proximal tibia, which together constitute 55% of cases. Other locations include the distal radius (10%-12%), sacrum (4%-9%), proximal humerus (4%-8%), proximal femur (4%), and less frequently, the vertebral bodies (2.5%). [5] However, its occurrence in the bones of the hands is an infrequent entity, accounting for only 2% of all GCTs, [5,6] and it is even rarer in the phalanges of the hands. Biscaglia reported a 0.9% occurrence in the hands in their review of 900 cases. [7] Averill reported an incidence of 2% GCT in the hands out of 1228 cases. [4] In a review by Patel et al. of 2400 cases, fifty cases (2%) were in the phalanges of the hand. [8] Athanasian, in his data over 50 years from the Mayo Clinic, had just five patients with GCT in the phalanges. [9] From a collection of series, in Turcott's report, of 1299, only 11 (0.84%) cases occurred in the phalanges. [5] We report on two patients with GCT-B of the phalanges. The first case presented with GCT-B in the proximal phalanx of the thumb and the second case with the tumor in the proximal phalanx of the index finger. In both patients, the lesions were radiologically Campanacci III. They were treated by total resection of the involved phalanx and nonbiological reconstruction using a Kirschner (K) wire and cement spacer. Both patients remained disease-free at 9 and 7 years, respectively, post index procedure. A literature review and management options for this rare presentation site in GCT-B are discussed.
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