Thoracic Spine Hemangioma

Hemangiomas are benign tumors composed of abnormal blood vessels. They can occur anywhere in the body but most commonly appear on the face, scalp or back. They can also occur in the vertebral bodies in the spine where they are referred to as vertebral hemangiomas. The vertebrae are the boney building blocks that stack one upon another that make up the spine.

What Is Hemangioma In The Thoracic Spine?

Common Symptoms Of Hemangioma In The Thoracic Spine

Most vertebral hemangiomas are asymptomatic and cause no symptoms. Most are diagnosed in people within their 50s with a higher presence in females with a 1:1.5 male to female ratio. Thoracic spine is the most common area of involvement. They can involve a single or multiple vertebrae (3).

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The most common symptoms include:

Back Pain

Back pain can occur in patients with vertebral hemangiomas with varying intensity from mild to moderately severe. The pain is thought to be due to bleeding, boney expansion secondary to tumor growth (4) or compression fracture(5).

It is important to fully evaluate any patient with ongoing back pain with a known thoracic vertebral hemangioma. Other possible causes of back pain include thoracic disc, facet, ligament or costotransverse joint dysfunction which need to be evaluated.

Numbness

If the vertebral hemangioma grows,it can extend beyond the bone and encroach upon the spinal canal with irritation or compression of spinal nerves and or the spinal cord. This nerve compression can result in numbness in the thoracic region or lower extremities.

Weakness

As described above, if the vertebral hemangiomas grows it can extend into the spinal canal with irritation or compression of the spinal cord or nerve roots. This can lead to thoracic and lower extremity weakness.

Causes Of Hemangioma In Thoracic Spine

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The exact cause of thoracic vertebral hemangiomas is not well understood. Possible risk factors include:

• Genetic Factors: some evidence suggests that some patients may have a genetic predisposition.
• Hormonal Factors: Hormones may play a role as thoracic vertebral hemangiomas occur more frequently in women and tend to enlarge during pregnancy. Pregnancy is the one known risk factor for the development of neurologic symptoms (6)
• Trauma: some evidence suggest that trauma may trigger the development of these tumors.

Common Treatments For Thoracic Spine Hemangioma

Vertebral hemangiomas are common benign vascular tumors of the spine. Most are asymptomatic and discovered incidentally.. Only 0.9-1.2 % of all vertebral hemangiomas expand and become symptomatic. Treatment options depend upon the symptoms and their severity.

Treatment options for those patients with thoracic spine hemangiomas include the following.

Observation

Patients with minimal to mild pain can be followed with neurologic and radiographic examinations on a regular basis.

Pain Management

In the absence of any neurologic symptoms or signs of expansion, patients may be managed with oral analgesics, physical therapy, and lifestyle modifications.

Radiation Therapy

An effective treatment option for those patients with pain but no signs of spinal cord compression. Radiation therapy uses high energy radiation to target and shrink the benign tumor thereby reducing pain (7).

Transarterial Embolization

A minimally invasive procedure that aims to reduce the blood flow to the hemangioma(8). This is achieved by advancing a catheter to the blood vessels that supply the hemangioma and then injecting embolic agents that block blood flow.

Surgery

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Reserved for those patients with evidence of spinal cord compression that have not responded to conservative therapy including radiation and embolization. The specific type of surgery will depend upon many factors.

Common surgeries for thoracic spine hemangiomas with evidence of spinal cord compromise include decompressive laminectomy, removal of vertebrae and spinal fusion

• Vertebroplasty or Kyphoplasty: A minimally invasive procedure performed to stabilize the vertebral body and reduce pain. Vertebroplasty involves injecting bone cement into the fractured or weakened vertebra (9), while kyphoplasty involves using a balloon-like device to create space and then filling it with bone cement.

Make Educated Decisions About Your Condition

Hemangiomas are benign tumors composed of abnormal blood vessels. They can occur anywhere in the body including the spine. Vertebral hemangiomas are common benign vascular tumors of the spine. They have a prevalence of 10-12% in the general population. Only 0.9-1.2 % of all vertebral hemangiomas expand and become symptomatic.

Pain and neurologic symptoms such as weakness and numbness are common symptoms. These symptoms are thought to occur due to bleeding, tumor expansion and compression of spinal nerves and in severe cases the spinal cord. The exact cause of thoracic vertebral hemangiomas is not well understood.

Possible risk factors include genetic factors, hormonal factors, and trauma. Treatment when appropriate should always start with conservative therapy. Treatment options in patients with pain and or neurologic symptoms include observation, pain management, radiation, transarterial embolization, vertebroplasty or surgery.

Prolotherapy and PRP injections can treat ligament instability, tendon inflammation and mild cases of spinal nerve irritation in patients with thoracic vertebral hemangiomas.

Other Resources for Thoracic Spine Hemangioma

References:

1. Nakahara M, Nishida K, Kumamoto S, Hijikata Y, Harada K. A case report of spondylectomy with circumference reconstruction for aggressive vertebral hemangioma covering the whole cervical spine (C4) with progressive spinal disorder. Eur Spine J. 2017 May;26(Suppl 1):69-74. doi: 10.1007/s00586-016-4765-0. Epub 2016 Sep 9. PMID: 27613010.
2. Alexander J, Meir A, Vrodos N, Yau YH. Vertebral hemangioma: an important differential in the evaluation of locally aggressive spinal lesions. Spine (Phila Pa 1976). 2010 Aug 15;35(18):E917-20. doi: 10.1097/brs.0b013e3181ddfb24. PMID: 21381257.
3. Gaudino S, Martucci M, Colantonio R, Lozupone E, Visconti E, Leone A, Colosimo C. A systematic approach to vertebral hemangioma. Skeletal Radiol. 2015 Jan;44(1):25-36. doi: 10.1007/s00256-014-2035-y. Epub 2014 Oct 28. PMID: 25348558.
4. Leehey P, Naseem M, Every P, Russell E, Sarwar M. Vertebral hemangioma with compression myelopathy: metrizamide CT demonstration. J Comput Assist Tomogr. 1985 Sep-Oct;9(5):985-6. doi: 10.1097/00004728-198509000-00033. PMID: 4031184.
5. Esparza J, Castro S, Portillo JM, Roger R. Vetebral hemangiomas: spinal angiography and preoperative embolization. Surg Neurol. 1978 Sep;10(3):171-3. PMID: 705602.
6. Lavi E, Jamieson DG, Granat M. Epidural haemangiomas during pregnancy. J Neurol Neurosurg Psychiatry. 1986 Jun;49(6):709-12. doi: 10.1136/jnnp.49.6.709. PMID: 3734828; PMCID: PMC1028857.
7. Faria SL, Schlupp WR, Chiminazzo H Jr. Radiotherapy in the treatment of vertebral hemangiomas. Int J Radiat Oncol Biol Phys. 1985 Feb;11(2):387-90. doi: 10.1016/0360-3016(85)90162-2. PMID: 3972655.
8. Nair AP, Kumar R, Srivastav AK, Sahu RN, Kumar B. Outcome of dorsolumbar vertebral hemangiomas presenting with neuraxial compression. Indian J Orthop. 2012 Sep;46(5):536-41. doi: 10.4103/0019-5413.101033. PMID: 23162146; PMCID: PMC3491787.
9. Narayana R, Pati R, Dalai S. Percutaneous vertebroplasty in painful refractory vertebral hemangiomas. Indian J Orthop. 2014 Mar;48(2):163-7. doi: 10.4103/0019-5413.128759. PMID: 24741138; PMCID: PMC3977372.

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