Combined treatment of hypervascular spinal tumors. Our experience
Objective – to increase the feasibility and safety of surgical treatment and to achieve better clinical outcome in patients with hypervascular spine tumors by combining managed endovascular embolization followed by surgery.
Materials and methods. We enrolled 10 patients (6 men and 4 women, the average age was 57 years) with hypervascular spinal tumors who underwent examination and treatment at SO «Scientific-Practical Center of Endovascular Neuroradiology of NAMS of Ukraine» during the period from 2015 to 2019. Five patients have aggressive vertebral hemangiomas (L1, L2, Th12, Th 7, Th 6) and 5 patients have metastases of renal cell carcinoma of the vertebrae (Th4, Th10, Th12, L3) were included. Medical history and neurological status were evaluated, but in all cases the clinical diagnosis was made according to MRI and spine CT. In addition, all patients underwent selective spinal angiography via transfemoral access at the level of the lesion and in at least two adjacent levels. All patients underwent endovascular embolization of the tumor as the first step and open surgery in the volume of biopsy, decompression, and stabilization of the spine in the second stage. The volume of blood loss in ml was estimated by the anesthesiologist.
Results. According to the localization of the lesions, spinal angiography showed a high accumulation of contrast fluid in its structure, compared to surrounding tissues, in all cases. This is evidence of the presence of a hypervascular lesion. All patients underwent the combination treatment – preventive endovascular embolization followed by surgery. In 9 cases embolization was performed 24–36 hours before surgery. Due to the patient’s somatic condition, open surgery was delayed once by 5 days. The total embolization of the tumor vasculature in 7 cases was achieved, with a subtotal embolization in 3 cases. Partial embolization was performed in one case of aggressive hemangioma when the afferent was involved in the blood supply of the spinal artery. Reversible deeper neurologic deficits following embolization in 4 cases was observed. Two patients noticed the reduction of the pain immediately after embolization. Mean intraoperative blood loss was 500 ml during the second stage of treatment. Blood loss was 600 ml in the case of delayed surgery. In all cases, the control of bleeding didn’t interrupt adequate decompression and transpedicular stabilization if it was required, and none of the surgical stages were delayed or canceled because of bleeding. Residual bleeding persisted from the venous system and tumor-related tissues.
Conclusions. Preoperative embolization of hypervascularized tumors is a safe and effective method to reduce perioperative hemorrhage, which in turn leads to the reduction of the duration of surgery, improves the visualization of the surgical field, allows the performance of all steps of open surgery and achieve a positive clinical result. The mean blood loss was lower compared to procedures without preoperative embolization, according to published papers on surgery of hypervascular spinal tumors. Embolic agents (mixture of Histoacryl and Lipiodol and polyvinyl alcohol (PVA)) have shown high efficacy to control arterial bleeding, with residual bleeding from the venous system.
Boland PJ, Lane JM, Sundaresan N. Metastatic disease of the spine. Clin Orthop Relat Res. 1982 Sep;(169):95-102. https://doi.org/10.1097/00003086-198209000-00012. PubMed PMID: 7105592.
Shi HB, Suh DC, Lee HK, Lim SM, Kim DH, Choi CG et al. Preoperative transarterial embolization of spinal tumor: embolization techniques and results. Am J Neuroradiol. 1999;20(10):2009-15. PubMed PMID: 10588136. Available from: https://pdfs.semanticscholar.org/233f/31a91e7d92b9c03e141ea9330897051c4737.pdf.
Junghanns H, Schmorl G. The Human Spine in Health and Disease. 2nd ed. New York: Grune & Stratton; 1971. 504 p.
Dang L, Liu C, Yang SM, Jiang L, Liu ZJ, Liu XG et al. Aggressive vertebral hemangioma of the thoracic spine without typical radiological appearance. Eur Spine J. 2012 Oct; 21(10):1994-9. doi: 10.1007/s00586-012-2349-1. Epub 2012 Jun 26. PubMed PMID: 22732826; PubMed Central PMCID: PMC3463694.
Nguyen JP, Djindjian M, Gaston A, Gherardi R, Benhaiem N, Caron JP et al. Vertebral hemangiomas presenting with neurologic symptoms. Surg Neurol. 1987 Apr;27(4):391-7. doi: 10.1016/0090-3019(87)90020-6. PubMed PMID: 3824146.
Vasudeva VS, Chi JH, Groff MW. Surgical treatment of aggressive vertebral hemangiomas. Neurosurg Focus. 2016 Aug;41(2):E7. doi: 10.3171/2016.5.FOCUS16169. Review. PubMed PMID: 27476849.
Olerud C, Jónsson H Jr, Löfberg AM, Lörelius LE, Sjöström L. Embolization of spinal metastases reduces peroperative blood loss. 21 patients operated on for renal cell carcinoma. Acta Orthop Scand. 1993 Feb;64(1):9-12. doi: 10.3109/17453679308994517. PubMed PMID: 8451959.
Smith TP, Koci T, Mehringer CM, Tsai FY, Fraser KW, Dowd CF et al. Transarterial embolization of vertebral hemangioma. J Vasc Interv Radiol. 1993 Sep-Oct;4(5):681-5. doi: 10.1016/s1051-0443(93)71948-x. PubMed PMID: 8219564.
King GJ, Kostuik JP, McBroom RJ, Richardson W. Surgical management of metastatic renal carcinoma of the spine. Spine (Phila Pa 1976). 1991 Mar;16(3):265-71. doi: 10.1097/00007632-199103000-00003. PubMed PMID: 1709305.
Al-Hadithy N, Gikas P, Perera J, Aston W, Pollock R, Skinner J et al. Pre-operative embolization of primary and secondary bone tumours is safe and effective: a retrospective study. World J Oncol. 2011 Dec; 2(6): 319-22. doi: 10.4021/wjon389w. PMID: 29147270; PMCID: PMC5649719.
Shi HB, Suh DC, Lee HK, Lim SM, Kim DH, Choi CG et al. Preoperative transarterial embolization of spinal tumor: embolization techniques and results. Am J Neuroradiol. 1999 Nov-Dec;20(10):2009-15. PubMed PMID: 10588136. https://pdfs.semanticscholar.org/233f/31a91e7d92b9c03e141ea9330897051c4737.pdf.
Manke C, Bretschneider T, Lenhart M, Strotzer M, Neumann C, Gmeinwieser J, et al. Spinal metastases from renal cell carcinoma: effect of preoperative particle embolization on intraoperative blood loss. Am J Neuroradiol. 2001 May;22(5):997-1003. PubMed PMID: 11337348. http://www.ajnr.org/content/22/5/997.
Smith TP, Koci T, Mehringer CM, Tsai FY, Fraser KW, Dowd CF et al. Transarterial embolization of vertebral hemangioma. J Vasc Interv Radiol. 1993 Sep-Oct;4(5):681-5. doi:10.1016/s1051-0443(93)71948-x. PubMed PMID: 8219564.
Yohan Robinson J, Sheta R, Salci K, Willander J. Blood loss in surgery for aggressive vertebral haemangioma with and without embolisation. Asian Spine J. 2015 Jun; 9(3): 483-91. doi: 10.4184/asj.2015.9.3.483. PMID: 26097668; PMCID: PMC4472601.
Abstract views: 97 PDF Downloads: 44