1.king saud university, riyadh,saudi arabia 2.consultant of orthopedic and spine surgery,spine...
TRANSCRIPT
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?