spinal epidural hemangiomas have been reported in the literature , but most of them were cavernous type hemangiomas that enable a preoperative differential diagnosis with relative ease .
the limited number of spinal epidural hemangiomas and few radiological findings make an exact diagnosis difficult prior to surgery .
a high vascularization of spinal epidural hemangiomas may result in an unexpected surgical situation in the case of preoperative misinterpretation . in the current case ,
a 51-year - old woman presented with a 3-week history of lower back pain with right anterior thigh numbness .
the patient had a magnetic resonance imaging ( mri ) at a local hospital which revealed a lesion at the l3 level , located in the ventral epidural space and connected with l3/4 protruded disc material that demonstrated a heterogeneous signal at t2 weighted images and an iso- to low signal at t1 weighted image ( t1-wi ) .
1 ) . based on a presumed diagnosis of a ruptured disc with possible sequestration or granulation tissue formation , the patient underwent surgery .
a right hemilamincetomy of l3 was performed , and a retracting thecal sac revealed a highly engorged vascular structure .
near - infrared indocyanine green videoangiography ( icg - va ) showed a delayed mass filling .
histological examination revealed a vascular lesion composed of small to medium sized veins with irregular calibers , which is consistent with an arteriovenous hemangioma ( fig .
the typical symptoms of epidural lesions other than disc herniation of the lumbar region are low back pain or radiculopathy which are indistinguishable from the clinical symptoms of disc herniation diseases . moreover , spinal epidural hemangiomas are very rare .
also , spinal epidural hemangiomas constitute approximately 4% of all epidural tumors and 12% of all intraspinal hemangiomas4 ) . the differential diagnosis for spinal epidural hemangiomas before surgery included schwannoma , lymphoma , meningioma , angiolipoma , disk herniation , synovial cysts , granulomatous infection , pure epidural hematoma , and extramedullary hematopoiesis9,12 ) .
the cavernous type displays histologically with large number of sinusoidal channels in collagenous tissue7 ) , whereas the arteriovenous type shows with a cluster of abnormal arteries and veins and vessel walls containing elastin , and smooth muscle5 ) .
a complete surgical en bloc removal is the treatment of choice for spinal epidural hemangiomas with mass effect because of the excessive vascularity of hemangioma , piece to piece resection should be avoided6 ) .
an indocyanine green videoangiography can help surgeons understand the vasculature surrounding the mass and facilitate the en bloc removal of the hemangioma .
fluorescence angiography with indocyanine green provides real - time information regarding the patency of vessels .
an icg - va enhances the flow direction delineation capability , flow velocity and sequence of dye filling in different components of complex spinal vascular lesions3 ) . due to the high vascularization of hemangiomas ,
the incomplete surgical removal of a spinal hemagioma because of diffuse bleeding or minimal exposure during disk surgery might result in the persistence of clinical symptoms or recurrence .
reoperation for remnant or recurrent spinal hemangioma is very difficult due to peridural or periradicular adhesion and unclear margins ; as a result , complete resection can not be guaranteed .
therefore , proper preoperative planning and complete resection during the operation is essential . for this ,
but , like this case , an angiography may not always confirm the diagnosis of an artriovenous hemangioma .
clinicians should be aware that an angiography can not provide conclusive evidence of the presence of an antriovenous hemangioma . if spinal epidural hemangiomas are unexpected encountered during surgery , an icg - va can be helpful to diagnose and surgery .
this technique provides accurate information about the flow dynamics through the anatomy of vascular lesions in real time10,11,13,14 ) .
further study is required to recognize and to provide a differential diagnosis of spinal epidural hemangiomas .
if the lesion is like a ruptured disc in mri , we should consider spinal epidural hemangioma as one of differential diagnosis .
 a spinal epidural hemangioma is rare . in this case , 
 a 51 year - old female patient had low back pain and right thigh numbness . 
 she was initially misdiagnosed as having a ruptured disc with possible sequestration of granulation tissue formation due to the limited number of spinal epidural hemangiomas and little - known radiological findings . 
 because there are no effective diagnostic tools to verify the hemangioma , more effort should be put into preoperative imaging tests to avoid misdiagnosis and poor decisions ) . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION