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Combined Transoral and Percutaneous Treatment of a Pediatric C2 Aggressive Vertebral Hemangioma 2014

Category Interventional Matteo Bellini
Alfredo Casasco
Daniele Giuseppe Romano
Marco Ferrara
Samuele Cioni
Umberto Arrigucci
Andrea Zandonella
Lucia Monti
Sandra Bracco
Alfonso Cerase
Purpose To report the case of a young patient with aggressive hemangioma of C2 vertebra treated by transoral and percutaneous approach. Materials & Methods A 12-year-old male presented a cervical trauma with neck pain. Preliminary radiographs suspected fracture of C2. Subsequent CT showed a large expansile lesion of vertebral body. Gadolinium-enhanced MRI confirmed these findings, and showed an epidural extension of the lesion suggestive for hemangioma. Seven months later, follow-up MRI revealed significant increase in lesion's volume, with a larger involvement of neural arches and considerable compression of cervical medulla which hod no signal alteration. The patient was neurologically asymptomatic. DSA showed a significant blush of C2 body by cervical branch of left vertebral artery. The patient underwent a surgical biopsy which confirmed vertebral hemangioma. Then, the patient came to our attention sent from the pediatric neurosurgeon. We decided for a combined approach, i.e. transoral and percutaneous, in order to give bone support and to reduce the epidural portion. The combined treatment was performed in two different sessions in around 4 months, to reduce the risk of venous epidural hypertension. Under general anesthesia and fluoroscopic guidance, the first step included a transoral vertebroplasty with 15G needles injecting high viscosity polymethylmethacrylate (PMMA) inside the vertebral body, lateral masses and odontoid process. Then, percutaneous latero-cervical puncture of the posterior neural emiarches was performed in each session: by 18G spinal needles Onyx® 18 was injected under biplane angiographic roadmap, in order to avoid vertebral arteries. Results CT and MRI follow-up showed an optimal filling of C2 vertebral hemangioma, including the most part of vertebral body and odontoid process, and above all left emiarch. There was also a significant reduction of arterial blush. There have been no peri/post-procedural adverse events. Cervical pain disappeared obtaining increase of the degree of rotation and flexion-extension of the neck. Six-month follow-up MRI showed no changes of the volume of hemangioma and of the medulla compression degree. Conclusion Vertebral hemangiomas are common lesions less frequent in the cervical spine, mostly in young patients. Different types of approaches may be performed to treat aggressive vertebral hemangiomas, including irradiation, percutaneous vertebroplasty, intrarterial embolization by particles or ethanol, percutaneous injection of ethanol and surgery. The goals of treatment are to reduce the pain, decompress the spinal cord and nerve roots, stabilize the spine, avoid deformity and stop evolution of the lesion. To the very best of our knowledge, this type of treatment has not been describe in literature before. References G. Guarnieri et al. Vertebroplasty as treatment of aggressive and symptomatic vertebral hemangiomas: up to 4 years of follow-up. Neuroradiology, July 2009