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Vascular imaging and endovascular intervcntion in the management of benign vertebral body tumors in children 2005

Interventional Spine

James A Thomas, MD
michele H Johnson , MD, Non ASSR Member
jonathan Grauer , MD, Non ASSR Member
John Strugar , MD, Non ASSR Member

Purpose

To characterize the role of CT angiography, catheter arteriography, and endovascular intervention in the preoperative evaluation and management of benign pediatric vertebral body tumors both as an aid to preoperative planning and to reduce intraoperative blood loss.

Methods & Materials

Retrospective review of three pediatric vertebral body tumors encountered over the last three years where vascular imaging and endovascular techniques were crucial to the patient's surgical management.

Results

A 16 -year-old male presented with neck pain with MR demonstrating an expansile C1 vertebral body lesion. CT guided biopsy revealed osteoblastoma. CTA demonstrated a hypervascular mass and encasement of the vertebral artery. As a result of the CTA, an arteriogram, vertebral test occlusion and permanent left vertebral artery occlusion was performed preoperatively. Total surgical resection was achieved with minimal blood loss. He is disease and symptom free at 3.5 years post treatment.

A 10 year-old female presented with shoulder pain and was diagnosed with scoliosis and an expansile T2 lesion was seen on MRI. CT guided biospsy revealed the solid variant of aneurysmal bone cyst. CTA demonstrated large vessels surrounding T2 with tumoral hypervascularity, indicating the need for preoperative angiography and embolization. Following embolization, total surgical resection was achieved with minimal blood loss. She is disease and symptom free at 1.5 years post treatment..

A 15 male, was diagnosed with an expansile C1 lesion following a football injury. MRI/MRA revealed a mixed signal expansile lesion of the C2 vertebral body with near occlusion of the ipsilateral vertebral artery. CT guided biopsy revealed a benign fibrous lesion. CTA demonstrated significant hypervascularity to the osseous and adjacent soft tissues with near occlusion of the vertebral artery. Angiography revealed intrinsic tumoral neovascularity and a small amount of antegrade vertebral flow. Preoperative particulate embolization and vertebral occlusion were performed and near total surgical resection performed with minimal blood loss. He is disease and symptom free at 3 months post resection.

Conclusion

Many patients will have MRI/MRA following initial presentation, however, we have found that CTA at the time of CT guided biopsy to be an efficient way to assess the bony tumor matrix, the relationship of the bone to adjacent soft tissue structures, and to assess the presence of tumoral neovascularity, as well as the need for preoperative vertebral artery occlusion, in order to reduce blood loss and post surgical neurologic compromise.

Preoperative embolization is useful in those benign vertebral lesions demonstrating enlarged vessels on CTA in order to reduce intraoperative bleeding.

The need for preoperative vertebral artery test occlusion and preoperative permanent occlusion can be preoperatively defined by CT/CTA.

References

Felix S. Chew et. al AJR: 171, November 1998
Michael P. Marks Huy M. Do (Ed) Endovascular and Percutaneous Therapy of the Brain and Spine