Pain pattern in multiple vertebral hemangiomas involving non-adjacent levels: report of two cases

Abstract

IntroductionHemangioma is a benign tumor consisting of blood vessels. There are two types: generalized and localized. In the generalized type there is involvement of multiple organs such as the liver, skin and bone [7]. Localized hemangiomas are the most common. In the skeleton, the most common site is the spine, followed by the skull and pelvis. Hemangiomas are often asymptomatic and discovered accidentally, but they may cause back pain or spinal cord compression in some cases. Radiographic and CT evidence of the hemangioma are characteristic. Multiple lesions of the spine are rather uncommon. Management of the patient depends on the severity of the symptoms, and may be either conservative or surgical.We present the cases of two patients with multiple hemangiomas of the spine involving multiple non-adjacent vertebrae and we comment on the possible clinical significance of their presentation. Case reports Case 1A 68-year-old man initially presented at the outpatient clinic because of persistent low back-pain. Radiographs revealed hemangiomas of the L3 and L4 vertebrae (Fig. 1). Conventional radiographs of the upper spine were normal. The patient was treated by conservative means. He was given non-steroidal anti-inflammatory drugs (NSAID) and a course of physiotherapy, and he was soon symptom free. At a follow up examination 1 year later, he was symptom free and was discharged. He was advised to attend annual follow-up examinations but did not.The patient came back to the clinic 15 years later complaining of suffering acute back pain localized in the area of T8-T10 during the previous 3 months. Common pain-killers gave him no relief. On examination, there was no evidence of neurologic involvement,

Symptomatic Expansile Vertebral Hemangioma Causing Conus Medullaris Compression

“…Multiple vertebral hemangiomas may present with different clinical characteristics over a long period. 10 Plain film radiographic findings of hemangioma are characteristic. Typical radiographic findings include coarse axial contrast-enhanced T1-weighted image (B) reveal continued complete replacement of the marrow at the L1 lumbar vertebra and a moderate-sized persistent epidural mass, only slightly diminished compared with the earlier examination.…”

Extraosseous Extension of Vertebral Hemangioma From Posterior Elements of Vertebra, a Rare Feature of Vertebral Hemangioma and Spinal Cord Compression

“…The incidence of symptomatic hemangioma is unknown. 5 Fox and Onofrio reported that 35 of 59 patients with vertebral hemangioma (59%) were asymptomatic; that 13 (22%) had only local pain, and that 11 (19%) exhibited abnormal neurologic findings. 9 Neurologic impairment from vertebral hemangioma results from a variety of mechanisms, including the following: compression fracture of the involved vertebra; sudden hemorrhage into the extradural space; subperiosteal growth of the tumor creating an extradural mass producing compression; spinal cord ischemia caused by steal phenomenon 11,12 ; hypertrophy of the posterior cortex of the vertebral body or enlargement of the lamina and facets as a result of the angiomatous invasion 6,[11][12][13][14][15][16] and compression from anomalous vessels draining or feeding the lesion.…”

“…Also methacrylate may leak into spinal canal and this may produce spinal cord or nerve damage and pulmonary embolism. 5,19 Percutaneous intralesional injection of ethanol or a sclerosing substance is used for decreasing size of hemangioma. 6 Critical to the effectiveness of this method is the requirement that the ethanol be injected into the vascular space of the hemangioma and not leak out.…”

“…5 One mechanism is epidural extension of the lesion. 6 This rare feature of hemangioma causes cord and nerve compression.…”

Vertebral Hemangiomas and Their Correlation With Other Pathologies

“…1,4,18,23,24 Notably, intervertebral disc lesions are painful, 25 and pain supposedly related to VHs has been found to closely resemble symptoms of disc lesions. 26 It is thus possible that back pain in cases of VHs is due to the co-occurrence with disc lesions.…”