1.King Saud university, Riyadh,Saudi Arabia 2.Consultant of orthopedic and spine surgery,Spine surgery department,National neuroscience institute,King.

Case report

Thoracic vertebral hemangioma causing lower limb spastic paresis

Tariq ALOTAIBI¹

Mohammed alfawareh.MD²

1.King Saud university, Riyadh ,Saudi Arabia2.Consultant of orthopedic and spine surgery ,Spine surgery department ,National neuroscience institute ,King Fahad medical city

What is vertebral hemangioma? Slow growing intraosseous vascular tumor

Benign in origin

Histologically, it has 3 types: capillary, cavernous and Mixed

Causing local compression if aggressive (rare)

Introduction The most common benign vertebral tumor

Incidental finding on autopsy

Asymptomatic in adult

Symptomatic in children with few cases reported

Rarely symptomatic in adult (0.9-1.2)

McAllister VL, Kendall BE, Bull JW. Symptomatic vertebral hemangiomas. Brain. 1975;98 (1): 71-80.Murugan L, Samson RS, Chandy MJ (2002) Management of symptomatic vertebral hemangiomas: review of 13 patients Neurol India 50(3):300–305

Thoracic vertebral hemangioma are more common

More likely to be symptomatic

Incidence about 10-12%

Aich RK, Deb AR, Banerjee A, Karim R, Gupta P (2010) Symptomatic vertebral hemangioma: treatment with radiotherapy. J Cancer Res Ther 6:199–203 Nassar SI, Hanbali FS, Haddad MC, Fahl MH (1998) Thoracic vertebral hemangioma with extradural extension and spinal cord compression. Case report. Clin Imaging 22(1):65–68

Case report

Eighteen years old

Male

One month history of radiating mid thoracic back pain

lower limb weakness

Decreasing sensation in both lower legs

Physical Examination Lower limbs power was decreased; 3/5 all over

Exaggerated deep tendon reflexes, with bilateral sustained clonus

Sensation was impaired below T 10, there was bilateral spasticity and Babinski sign

Radiological Imaging

X ray

Plain x-ray of the spine showed the lesion at T8 with vertical trabeculation

(jail bar appearance)

There is mild scoliotic deformity with convexity toward the right side

CT scan

CT without contrast showed diffuse T8 body coarse trabeculation referred as

(corduroy cloth) sign

Axial view

There is an expansion of the body and laminas causing spinal stenosis Trabiculation seen as (polka dot sign.)

Tumor was extending to both pedicles, laminas and the base of the transverse processes bilaterally

MRI

T8 extensive high signal intensity body lesion on T2 , T1 and stained with contrast

Tumor extending to the neuronal canal causing mass effect over spinal cord at that level

Management

Decompression and fixation from T5 through T 10 on an emergency bases

Permanent biopsy samples reported as blood vessels proliferation and dilated spaces with no malignant cells consistent with Hemangioma

Post-op Uneventful post-op recovery

Spasticity; improved over time

Power; returning to normal

Rehabilitation Patient was referred to rehabilitation and recovered near

complete after 6 weeks of extensive physiotherapy and rehabilitation

Discharged walking independently

Minimal weakness and near normal sensations

Discussion Most vertebral hemangiomas are asymptomatic which require no treatment

The most common presenting symptom is back pain

Radiological diagnosis (CT is the gold standard )

Spastic para-paresis in our case reflects an aggressive hemangioma, which can result in permanent paraplegia if not managed appropriately

Hiari A, Nawaiseh B, Jaber H (1998) Magnetic resonance imaging in the diagnosis of vertebral haemangiomas. East Mediterr Health J 4(1):149–155

Laredo JD, Reizine D, Bard M, Merland JJ. Vertebral hemangiomas: radiologic evaluation. Radiology. 1986;161(1):183–9.

Conclusion Young age back pain!

Rare but can present with sever symptoms

Full recovery if managed appropriately

Needs high index of suspension, malignant?