Unusual Cause of Back Pain in an Adolescent Patient: A Case Report and Natural History of Aggressive Vertebral Hemangioma in Children

Abstract

Back pain is an unusual complaint in children as compared to the adult population but is more likely to be pathological. We present a longitudinal study of an 11-year-old patient who presented with a vertebral hemangioma which remained stable for a period of about 20 months followed by aggressive growth resulting in spinal cord compression. This is only the fourth reported case of aggressive vertebral hemangioma in children; however, we document for the first time the evolution of this lesion demonstrating a period of stability followed by aggressive growth of the lesion. We discuss the imaging differential diagnosis which includes asymptomatic vertebral hemangioma and malignant lesions. We also discuss different treatment options available and their complications. In our patient, among the risk factors for an aggressive hemangioma, female gender and involvement of posterior elements were positive. However, the natural history of this lesion is not well known in children. We need to study vertebral hemangioma further especially in children to understand the natural course and help identify lesions which have aggressive potential and prevent spinal cord compression. This will also help to manage the lesion earlier with less aggressive therapies such as embolization and ethanol injection rather than surgery. Key words: back pain, pediatrics, vertebral hemangioma

Aggressive vertebral hemangiomas in asymptomatic patients: A review

“…Only 4 of 89 articles met the inclusion criteria for this the study [Table 2]. [2,3,5,6] Patients undergoing surgery, embolizations, or radiotherapy, were excluded from the study.…”

“…Of the four initially asymptomatic patients, two later required emergent surgery within an average follow-up period of 28 months. [3,6] DISCUSSION e natural history for aggressive hemangiomas was described by four authors and involved just four patients.…”

“…Jha and Choudhary described the natural history of an 11-year-old female with back pain, due to a T12 vertebral hemangioma treated with bracing alone. [3] However, within 20 months, she developed spinal cord compression warranting surgical decompression [Table 2]. [3] In a third case, Pretell-Mazzini et al described a 13-yearold female with low back pain and an aggressive L1 hemangioma; suddenly, 3 years later, she acutely presented with a cauda equina syndrome requiring emergency surgery [Table 2].…”

“…[3] However, within 20 months, she developed spinal cord compression warranting surgical decompression [Table 2]. [3] In a third case, Pretell-Mazzini et al described a 13-yearold female with low back pain and an aggressive L1 hemangioma; suddenly, 3 years later, she acutely presented with a cauda equina syndrome requiring emergency surgery [Table 2]. [5] In the fourth case (e.g., 4th study), Uzunaslan et al described using propranolol to treat T5 aggressive hemangioma.…”

Symptomatic and aggressive vertebral hemangiomas in children: features of modern interpretation and treatment tactics

“…Для уточнения локализации, распространенности, наличия экстравер-тебрального распространения используют КТ и МРТ. На МРТ гемангиома классически демонстрирует высокую интенсивность сигнала на T1и Т2-взвешенных последовательностях [19]. Атипичная гемангиома проявляется на КТ остеолизисом позвонка в сочетании с гипертрофией сохранившихся костных трабекул, экстравертебральное распространение -параоссальным mass-эффектом на МРТ и крайне редко -патологическим переломом позвонка [20].…”