we evaluated the outcome of percutaneous vertebroplasty ( pvp ) in the treatment of painful vertebral hemangiomas refractory to medical management .
14 patients ( four thoracic and ten lumbar vertebra ) with painful vertebral hemangiomas presenting with severe back pain for more than 6 months not responding to medical therapy were treated by vertebroplasty .
the pain intensity numeric rating scale ( pi - nrs-11 ) of these patients was in the range of 7 - 10 ( severe pain ) .
after vertebroplasty 8 patients were completely free of pain ( pi nrs score 0 ) while 6 were significantly relieved ( pi - nrs score 1 - 3 ) .
pvp is a safe and effective procedure in patients with painful vertebral hemangiomas refractory to medical management .
vertebral hemangiomas are benign , malformed vascular tumors composed of newly formed blood vessels with normal capillary , venous , or veno - capillary structure and without arterio - venous shunt .
cavernous hemangiomas are composed of large dilated blood vessels closely clustered together and hence they are not separated by normal bone tissue .
capillary hemangiomas are formed of thin walled capillary vessels of various sizes separated by normal bone tissue.1 percutaneous vertebroplasty ( pvp ) is the procedure of injecting bone cement i.e. polymethyl methacrylate ( pmma ) percutaneously into the vertebral body under fluoroscopic guidance .
pvp was developed in france in the late 1980s , principally for treatment of vascular bone lesions such as hemangioma and subsequently found to be useful in treating painful vertebral metastasis and painful osteoporotic vertebral compression.234 after introduction of pvp in north america , the procedure has become increasingly popular during the past decade .
pvp has proven successful in providing dramatic and prompt pain relief in most patients with painful vertebral hemangioma , allowing rapid patient mobilization .
14 patients with vertebral hemangiomas , four had associated vertebral osteoporotic compression fracture , presented between november 2006 and april 2013 , were included in the study .
back pain was diagnosed by the patient 's history , clinical examination and quantified by pain intensity numeric rating scale ( pi - nrs ) [ table 1].5 patients previous medical records and imaging were reviewed . based on the history and clinical findings , relevant imaging including magnetic resonance ( mr ) was done [ figure 1a ] .
the pain intensity nrs ( 0 - 10 ) ( a ) magnetic resonance imaging t2w sagital view showing l4 vertebral hemangioma ( b ) needle position under fluoroscopy ( antero - posterior and lateral view ) , ( c ) lateral view fluoroscopy after vertebroplasty demonstrating good cement filling the mr of the above 14 patients were normal except for vertebral hemangiomas in all and osteoporotic vertebral fractures in four of them .
patients with vertebral hemangiomas with severe back pain for more than 6 months , not responding to medical therapy were included in the study .
all these patients received adequate analgesic therapy with two or more analgesics for more than 6 months .
informed , written consent obtained from all patient undergoing vertebroplasty after explaining the procedure in detail .
all vertebroplasties were performed in the cathlab under high quality fluoroscopic guidance with patient positioned prone .
the entire spine was examined with fluoroscopy in antero - posterior ( ap ) and lateral view and the level of hemangioma was marked with a metallic marker .
the site of entry and the needle track was infiltrated with 10 ml of 2% xylocaine .
the vertebra was approached with an 11 g or 13 g beveled cook bone biopsy needle from the trans - pedicular route .
the needle was progressed into the vertebral body and positioned near the midline , approximately at the junction of the anterior one - third with the posterior two - third .
the patient is asked to report any pain or discomfort especially in the ipsilateral leg during the progression of the needle from the skin to vertebra .
ap and lateral fluoroscopic views confirmed the position of the needle [ figure 1b ] .
the bone cement ( pmma ) is cooled to 4 - 8 centigrade 1 h prior to injection .
the cement is prepared by mixing pmma powder and liquid pmma ( cook medical inc . ,
usa ) and is filled into 1 cc glass syringes then injected into the vertebra through the bone biopsy needle under constant fluoroscopic guidance in lateral view .
as we inject , the cement fills the vertebra backward and we keep injecting till the cement comes to the posterior fourth of the vertebra [ figure 1c ] . keeping a close watch on the movement of the cement is critical to avoid extra vasation either into the venous system , foramina , or other extra vertebral sites .
leakage of cement leads to compression of adjacent structures like spinal nerve roots , spinal cord and may lead to neurological deficits .
we inject around 4 - 7 cc of cement into each vertebra.678 the cement injection is completed within 60 - 90 s as the pmma polymerizes in quick time .
we treated 14 patients of vertebral hemangioma with pvp . among these patients , five were males and nine females .
the average age of patients was 68 years ( range 24 - 79 years ) .
their average pain score was 8.5 ( range 7 - 10 ) [ table 2 ] .
list of patients underwent vertebroplasty after vertebroplasty pain was completely relieved in 8 ( pi - nrs score 0 ) , and significantly relieved in 6 ( pi - nrs score 1 - 3 ) without any complications .
these patients were simultaneously treated with pvp in the same sitting without any complication [ figure 2a  c ] . up to three level vertebras can be safely treated with pvp in the same sitting . as the amount of pmma injected into the vertebra is so small , that even if 3 level pvp does not pose a significant risk.9 ( a ) fluoroscopic view ( lateral ) showing vertebral hemangioma with trabeculations .
( c ) radiograph post vertebroplasty we had complex situations in two of our patients who underwent trans arterial embolization with poly vinyl particle polyvinyl alcohol ( pva ) prior to vertebroplasty . during
attempted vertebroplasty in one of them , the cement started leaking into the epidural vein without opacifying the vertebra .
the hemangioma was embolized and vertebroplasty was done in the next sitting [ figure 3a  c ] . the other patient presented with pain and paraparesis in her early postpartum period .
she underwent trans - arterial embolization , vertebroplasty followed by laminectomy with a favorable outcome .
( a ) magnetic resonance imaging t2w sagittal view showing l3 vertebral hemangioma and osteoporotic compression fracture of d12 ,
( b ) fluoroscop ic view demonstrating needle position , ( c ) vertebroplasty of l3 hemangioma and osteoporotic d12 vertebra all the patients underwent immediate post procedure ct scan following vertebroplasty to look for cement leak to extra vertebral sites or fracture .
these patients were followed up for 6 - 36 months with an average of 9 months with no recurrence of pain or any other complication .
different series have reported the incidence of vertebral hemangioma to be 10 - 27% based on autopsy series and imaging reviews .
they should be treated conservatively with analgesics and bed rest for at least 6 weeks .
if they do not respond to the above therapies , more aggressive therapies such as surgical decompression , endovascular embolization , radiotherapy and vertebroplasty can be offered .
embolization with pva particle alone is reported to produce usually transient remissions.10 - 12 two patients in this series underwent embolization with pva particles followed by vertebroplasty .
however , during injection of pmma , the bone cement flew off into the epidural venous plexus , suggesting the blood flow to be very high inside the vertebra .
hence , the procedures were abandoned and embolization was done in these patients to reduce excess vascularity .
angiogram may not be performed in all patients of vertebral hemangiomas before vertebroplasty . however , if the bone cement flies off the vertebra during injection due to high flow , the procedure must be abandoned and angio - embolization may be done before reattempting vertebroplasty .
radiation therapy can be used to treat lesions associated with pain.23 they are radiosensitive lesions and respond to administration of 3000 - 4000 cgy .
yang et al.,13 and faria et al.,14 in their study have reported complete reversal of paraplegia of several weeks duration following radiation therapy alone .
radiation therapy as the sole management modality for patients with progressive neurological deficits has however , been controversial .
vertebroplasty has a low rate of clinical complications , but potential complications can be devastating .
incidences of cement leakage are less in hemangioma due to intact cortex compared with osteoporotic fracture
the relevance of this complication will be different in relation to the anatomical structure , which is invaded from the cement .
cement invasion into the vena cava , lungs , heart have been described.1516 these major adverse events only occur in less than 1% of the patients,17 and require immediate management .
pvp can be performed through unipedicular or bipedicular approach . however , in most instances a single injection through one pedicle is all that is required.1819 if there is insufficient filling of the vertebral bodies , a second puncture through the contralateral pedicle may be performed .
a total of 14 patients with vertebral hemangiomas treated by unipedicular pmma injection , pain is completely relieved in 8 cases ( pi - nrs score 0 ) and significantly relieved in 6 cases ( pi - nrs score 1 - 3 ) .
high quality fluoroscopy and operator experience are important to avoid complications like neurologic deficits , fracture of vertebra and rib , hemorrhage , pneumothorax or hemothorax , and pulmonary embolus.202122 we conclude that it is possible to treat painful vertebral hemangioma at single or multiple vertebral levels with or without vertebral collapse in the same sitting with excellent clinical outcome .
 background : painful vertebral hemangiomas are often inadequately managed medically . 
 we evaluated the outcome of percutaneous vertebroplasty ( pvp ) in the treatment of painful vertebral hemangiomas refractory to medical management.materials and methods:14 patients ( four thoracic and ten lumbar vertebra ) with painful vertebral hemangiomas presenting with severe back pain for more than 6 months not responding to medical therapy were treated by vertebroplasty . 
 cross sectional imaging of the spine with magnetic resonance was done . 
 blood investigations were done to exclude coagulopathy excluded . 
 pvp was performed under local anesthesia.results:the pain intensity numeric rating scale ( pi - nrs-11 ) of these patients was in the range of 7 - 10 ( severe pain ) . 
 after vertebroplasty 8 patients were completely free of pain ( pi nrs score 0 ) while 6 were significantly relieved ( pi - nrs score 1 - 3 ) . 
 no complications were observed . 
 two patients with associated radicular pain had good pain relief following pvp . 
 no recurrence was found during 36 months of postoperative followup.conclusion:pvp is a safe and effective procedure in patients with painful vertebral hemangiomas refractory to medical management . 
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