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Surgical treatment of cervical vertebral hemangioma associated with adjacent cervical spondylotic myelopathy
The Spine Journal 13 (2013) 1774–1779
Clinical Study
Surgical treatment of cervical vertebral hemangioma associated with adjacent cervical spondylotic myelopathy Ying-jie Hao, MD*, Lei Yu, MD, Yan Zhang, MD, Li-min Wang, MD, Jia-zhen Li, MD Department of Orthopaedics, The First Affiliated Hospital, Zhengzhou University, No.1, Eastern Jianshe Road, Zhengzhou 450052, China Received 13 November 2012; accepted 4 May 2013
Abstract
BACKGROUND CONTEXT: Symptoms may vary from simple vertebral pain to progressive neurologic deficit because of cervical vertebral hemangioma associated with adjacent cervical spondylotic myelopathy (CVHAWACSM). Often resistant to conservative medical treatment, surgery has been the treatment of choice for these patients, but the optimal surgical strategy for CVHAWACSM has not been defined. PURPOSE: This study aimed to investigate the methods and efficacy in the treatment of CVHAWACSM. STUDY DESIGN: Retrospective review of patients enrolled in prospective randomized trial. PATIENT SAMPLE: Procedure was performed in 18 patients (11 men and 7 women) with CVHAWACSM, who were enrolled between January 2006 and September 2011. OUTCOME MEASURES: Radiographic examinations were carried out to assess total filling of polymethylmethacrylate in the vertebral body, fusion rates, implant failure, and general complications. The recovery of neurologic function and neck and shoulder pain relief were measured based on the Japanese Orthopedic Association (JOA) and the visual analog scale (VAS) scores. METHODS: Eighteen patients had single vertebral hemangioma, including one case at C3, three at C4, six at C5, five at C6, and three at C7. The X-ray films showed a typical ‘‘palisade’’ change. According to the clinical and imaging features, there were 12 cases of Type II and 6 of Type IV cervical hemangioma. Standard anterior cervical decompression and fusion with a stand-alone polyetheretherketone cage (filled with autologous cancellous iliac bone) was performed, followed by vertebroplasty. Clinical and radiologic follow-ups were performed. RESULTS: The mean follow-up was 24.1 months, with a range of 18 to 36 months. The symptoms of all 18 patients were improved, by varying degrees, and the lesion vertebra did not show anterior bone cement leakage or injuries in the spinal cord and nerves. The forming vertebra did not show fracture or collapse, and there was no recurrence of the hemangioma. During the follow-up, there was no implant loosening, displacement, or breakage. The JOA and the VAS scores were significantly recovered at 3 months after the operation and in the last follow-up, compared with the preoperative level (p!.05). The JOA scores in the last follow-up showed 13 excellent, 4 good, 1 fair, and 0 poor cases. CONCLUSIONS: This procedure seems to be a safe efficient method to treat symptomatic CVHAWACSM. It seems to serve the purpose of providing vertebral augmentation, cord decompression, and rigid fusion at the same sitting. Although the present outcomes are promising, long-term follow-up studies with larger patient numbers are required to confirm this effect. Ó 2013 Elsevier Inc. All rights reserved.
Keywords:
Vertebral hemangioma; Cervical spondylotic myelopathy; Vertebroplasty; ACDF; PEEK
FDA device/drug status: Not applicable. Author disclosures: Y-jH: Nothing to disclose. LY: Nothing to disclose. YZ: Nothing to disclose. L-mW: Nothing to disclose. J-zL: Nothing to disclose. 1529-9430/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2013.05.048
* Corresponding author. Department of Orthopaedics, The First Affiliated Hospital, Zhengzhou University, No. 1, Eastern Jianshe Road, Zhengzhou 450052, China. Tel.: (86) 371-67967206; fax: (86) 37166970906. E-mail address: [email protected] (Y.-jie Hao)
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Introduction Vertebral hemangioma, one of the benign diseases, does not require treatment if the patient has no obvious symptoms. It has been suggested that only 0.9% to 1.2% of patients with vertebral hemangioma who show the symptoms of local pain, spinal activity limitation, compression of the nerve or the spinal cord, and even paraplegia need to be treated [1–4]. Moreover, there have been even fewer cases of vertebral hemangioma combined with cervical spondylotic myelopathy for which the conservative medical treatment approach failed to gain ideal efficacy, requiring surgical excision [5–9]. Surgical excision therapy has been, for many years, the treatment of vertebral hemangiomas and cervical spondylotic myelopathy, which have been burdened with many complications related to intraoperative or postoperative bleeding and large trauma; furthermore, the procedure was difficult [10–12]. In this report, we reviewed data on 18 patients with cervical vertebral hemangioma associated with adjacent cervical spondylotic myelopathy (CVHAWACSM) admitted to our hospital during the 2006 to 2011 period. These patients were treated with the combined therapy of ACDF with a stand-alone polyetheretherketone (PEEK) cage and vertebroplasty. The aim of this work is to illustrate the efficacy and safety of this surgery in the treatment of patients with CVHAWACSM.
Context Occasionally, when performing an ACDF, a vertebral body with a symptomatic (or asymptomatic) hemangioma is encountered. The authors present their experience using vertebroplasty for this condition. Contribution In this case series of 18 patients, the authors report good results with no complications associated with the treatment of the hemangioma. Implications One important role for case-series reports is to present novel treatment options for uncommon problems. The authors’ methods might be helpful for others encountering similar patients.
interbody osteophytes were also detected. The spiral CT scan revealed reduced vertebra density, thickening of the residual vertical trabeculae, and an enlarged medullary cavity. The vertebra sinusoid was dilated to a mesh-like or honeycomb morphology, with the cross-section showing ‘‘matches-beam’’ changes. All patients showed an intact
Patients and methods General information The 18 patients (11 men and 7 women) had an average age of 44.3 years (32–70 years) and an average disease course of 16.7 months (10–30 months). All patients had single vertebral hemangioma, including one case at C3, three at C4, six at C5, five at C6, and three at C7. Moreover, the cervical disc herniation caused adjacent single intervertebral herniation in all patients. The clinical symptoms included cervical and shoulder refractory pain, which was more severe than the pain solely caused by cervical spondylotic myelopathy, and varying degrees of limb weakness, unsteady walking, limb numbness, and muscle atrophy. The examination results showed constrained cervical motion, obvious paravertebral or spinous tenderness, nerve root traction, inordinate limb sensation, dyskinesia, muscle strength loss, hypermyotonia, tender hyperreflexia, positive Hoffmann reflex, and positive Babinski reflex. Three patients showed patellar clonus and ankle clonus. All patients received examinations with cervical X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) (Fig. 1). The X-ray examination revealed that the damaged vertebra usually showed a typical ‘‘palisade’’ morphology [13], such as reduced bone mineral density, cortical thinning, and residual trabeculae thickening. Moreover, the cervical physiological curve became straight or even showed recurvation. Intervertebral stenosis and posterior cervical
Fig. 1. A 70-year-old woman with C5 vertebral hemangioma (Type IV) combined with C5–6 intervertebral disc herniation. Preoperative magnetic resonance imaging revealed high-intensity signal in the C5 vertebra and spinal cord compression in the C5–6 vertebra.
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Fig. 2. Lateral X-ray at 3 months after operation. The C5 vertebra showed ideal morphology without collapse, and the bone cement diffusion was also ideal. The Solis cage was well positioned without loosening, displacement, or breakage.
PEEK cage (Solis; Stryker Spine, Allendale, NJ, USA) filled with cancellous bone obtained from the anterior iliac crest through a minimal incision. The heights of the cage were 6, 7, 8, and 9 mm in 8, 28, 8, and 3 segments, respectively. The anteroposterior diameters of the cage were 12 and 14 mm in 21 and 26 segments, respectively. After the cervical vertebra with the hemangioma was determined using C-arm X-ray, a puncture needle was inserted into the vertebra through the center of the anterior vertebral surface to one-third the distance to the vertebra (the specimens of Type IV patients with hemangioma were collected and examined). Polymethylmethacrylate bone cement was injected into the vertebra with lateral fluoroscopy applied to prevent leakage. The needle should be continuously rotated to promote sealing. After injection, the puncture needle was extracted to the cortical bone. The needle core was inserted, and the needle was rotated to prevent fixation. The needle was fully extracted before the cement solidified. The incision was rinsed and sutured, and a drainage tube was placed in the incision for 1 to 2 days. Hormones, dehydration agents, and antibiotics were applied for 1 to 2 days. Postoperative review was performed every 3 months, including physical examination, Japanese Orthopedic Association (JOA) score, visual analog scale (VAS) score, cervical radiograph (Figs. 2 and 3), and CT (Fig. 4), to monitor the distribution of bone cement in the vertebra and the internal fixation.
posterior vertebral wall without spinal hemangioma invasion. The MRI examination of the sagittal T1-weighted imaging revealed that the damaged vertebra usually showed mixed high-intensity signals, and low-intensity signals were distributed in the cleft between the high-intensity zones. All seven vertebral segments showed even high-intensity signals at the levels of T1-weighted imaging and T2-weighted imaging. In the meanwhile, a cervical intervertebral disc represented by intermediate signals had invaded into the vertebra and compressed the dura and spinal cord. A total of 18 patients showed proliferating and degenerative osteophytes, represented by low-intensity signals, in the posterior vertebral edge. According to the clinical and imaging features, there were 12 cases of Type II and 6 of Type IV cervical hemangioma [5,6]. Surgical procedure After anesthesia, the patient took a supine position with neck thrown back. The surgical site was exposed via a standard anterior approach, and microscopic anterior cervical discectomy was performed. Cartilage was removed with care to avoid damaging the cortical bone of the vertebral end plates. The posterior longitudinal ligament was opened, and decompression was carried out. The appropriate cage size was then determined under fluoroscopy guidance. Anterior cervical fusion was performed using a stand-alone
Fig. 3. Front X-ray at 3 months after operation. The C5 vertebra showed normal morphology, and the Solis cage was appropriately and stably positioned.
Y.-jie Hao et al. / The Spine Journal 13 (2013) 1774–1779
Fig. 4. The spiral computed tomography scan, at 12 months after operation, revealed the Solis cage with good position. Solid fusion was achieved between C5 and C6 at 12-month follow-up.
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(60–90 minutes), the average intraoperative bleeding was 45 mL (20–100 mL), and the average cement amount was 2.2 mL per vertebra (1.5–3.2 mL). All patients received an 18- to 36-month follow-up (mean value 24.1 months). The recovery of neurologic function and neck and shoulder pain relief were measured based on the JOA and the VAS scores. The symptoms of nerve compression and neck and shoulder pain were improved for all 18 patients, by varying degrees. Imaging examination revealed that the formed vertebrae had no fracture or collapse, and there was no hemangioma recurrence. Moreover, the Solis cage was well localized without loosening, shifting, or rupture. At 3 to 4 months after the operation (mean value 3.8 months), the spiral CT scan revealed that all fusion segments had bone healing without implant collapse or cervical instability. At 3 months after the operation and in the last follow-up, the JOA scores were similar (pO.05) and were significantly improved compared with the preoperative level (p!.05). In the last follow-up, the patients, including 13 very good, 4 good, and 1 okay cases, had an improvement rate of 58.5%620.8%. The VAS scores at 3 months after the operation and in the last follow-up were similar (pO.05) and were significantly improved compared with the preoperative level (p!.05). The improvement rate of the last follow-up was 45.3%618.0%. All these results are shown in Table.
Evaluation of efficacy The VAS score was evaluated before and at 3 months after the operation and in the last follow-up, to monitor the pain relief of the patient. The improvement rate of the last follow-up was calculated as follows: improvement rate5(preoperative VAS score postoperative VAS score)/ (10 postoperative VAS score)100%. The JOA score was evaluated before and at 3 months after the operation and in the last follow-up, to determine the improvement rate of the cervical cord function of the patient. The improvement rate of the cervical cord function was calculated as follows: improvement rate5(postoperative JOA score preoperative JOA score)/(17 preoperative JOA score)100%. The grade was as follows: very good, 75% or more; good, 50% to 74%; ok, 25% to 49%; and poor, 0% to 24%. Statistical analysis Data were presented as means6standard deviations. The results were analyzed using Student t test with SPSS statistical software, version 11.5 (SPSS, Chicago, IL, USA); p!.05 was considered statistically significant.
Results All patients were successfully treated with surgery, without injury in the spinal cord or nerve, and the incision healed well. The average surgery time was 75 minutes
Discussion Because of the combined symptoms of neck and shoulder pain, cervical spondylosis is often misdiagnosed. Routine X-ray examination may not be able to find the tiny lesions within the vertebra. Although spiral CT scan can overcome this difficulty, it has a limited scan range for soft tissues. Nevertheless, MRI has a broad imaging range, which is sufficient to not only determine the location of the hemangioma but also indicate the degree of spinal cord compression, and thus can be used to determine the surgical plan and prognosis. According to the clinical and imaging features, cervical hemangioma can be classified into four types: Type I, hemangioma without obvious symptoms or vicious imaging performance; Type II, hemangioma shows severe back pain without vicious imaging performance; Type III, hemangioma has vicious imaging performance but without obvious symptoms; and Type IV, hemangioma Table Comparison of JOA and VAS scores between pre- and postoperation (n512, means6standard deviations) Time
JOA score
VAS score
Before operation Three months after operation Last follow-up
7.662.1 13.162.7* 13.663.0*
5.962.1 2.860.8* 2.560.6*
JOA, Japanese Orthopedic Association; VAS, visual analog scale. * Compared with the preoperative value, p!.05.
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has both vicious imaging performance and obvious symptoms [5,6]. Type IV can be further divided into two clinical subtypes, one with the acute symptoms of spinal cord and nerve compression (IVa) and the other with the progressive symptoms of spinal cord and nerve compression (IVb). Several options are currently available for the management of symptomatic vertebral hemangioma. The treatment modalities include surgical decompression [14–19], endovascular embolization (more recently using onyx) [20], injection of vertebroplasty cement, absolute alcohol, or methylmethacrylate into the vertebral body [6,12,15,16,21–26], and radiotherapy only [27–30]. The nonsurgical modalities have mainly emerged because of the highly vascular nature of the tumor with the threat of mortality owing to exsanguination during surgery and the difficulty in approaching and totally excising the tumor with its associated morbidity. Pastushyn et al. [31] reported 6% mortality in their surgical group. All these were because of exsanguination during attempts to remove large soft-tissue tumors in the ventral part of the vertebral body. Although more recent series show a considerable improvement in morbidity and mortality [3,12,15,16,18], surgery is still fraught with risks and dangers, even if performed by highly skilled surgeons. As for surgery of cervical myelopathy, anterior cervical decompression and fusion (ACDF) has been performed as the gold standard for the treatment of degenerative cervical disc disease. ACDF using an intervertebral cage has become a popular alternative to prevent the complications of the classic method using an autologous tricortical iliac bone graft [32–35] and anterior cervical plating, including screw loosening, screw breakage, screw migration, and soft-tissue injuries [36,37]. ACDF using an intervertebral cage is credited with promoting instant stability, restoration of the neural foraminal height, and interbody fusion by providing an environment for bone growth [38–40]. In the present study, we investigated 18 patients, including 11 men and 7 women, with an average age of 44.3 years (32–70 years) and an average disease course of 16.7 months (10–30 months). All patients showed obvious neck and shoulder pain, which was more severe than the pain solely caused by cervical spondylosis. Moreover, these patients also showed other symptoms, to varying degrees, including limb weakness, unsteady walking, limb numbness, and muscle atrophy. All these patients had CVHAWACSM, which required us to treat the adjacent lesion vertebra when performing the discectomy and fusion. If the patients were treated with anterior cervical discectomy and decompression, the plate fixation would increase the bleeding of the lesion vertebra, which might result in surgical failure. However, if the patients were first treated with vertebroplasty, the plate would be difficult to place. At the other hand, without dealing with the lesion vertebra, the cage would probably be inserted into the lesion vertebra. All these possibilities made it difficult to treat the patients with surgery. To treat the 18 patients, we applied ACDF with a standalone PEEK cage combined with vertebroplasty. This
combined therapy has several advantages. All operations could be performed in one small incision, which led to a low-level bleeding of, on average, 45 mL (20–100 mL). The surgical cost was reduced. The PEEK cage (Solis; Stryker Spine) can be firmly fixed in the intervertebral space by its fangs on both sides, which in turn can avoid plate insertion and reduce the bleeding and surgery time. With the help of the 3-month postoperative external fixation, the bone fusion time was only 3.8 months, as revealed by follow-up examinations. Compared with the conventional combined treatment approach of totally excising the tumor, decompression, and instrumentation, our surgical procedure operated on a smaller number of fusion vertebrae and thus had a reduced risk of adjacent disc degeneration and other complications. During the surgical process, the surgeon should pay close attention to several points. First, the decompression should be complete, and the osteophytes and degenerative intervertebral discs should be removed till the Luschka joint, especially for the posterior longitudinal ligament in the depression space. Second, based on the lesions and surrounding soft tissues, the puncture should be designed to have the shortest distance and minimal injury. Repetitive punctures should be avoided. With the help of fluoroscopy, the puncture needle should be slowly inserted to one-third the distance from the vertebra [41,42]. Third, the viscosity of the bone cement would significantly affect its diffusion in the vertebra. A too low viscosity can increase the risk of cement leakage though the diffusion can be enhanced. Hence, the bone cement should be injected in the drawing stage [41,43,44], and the injection amount should be controlled. This is because a high amount of cement could cause more complications, whereas not enhancing the analgesic effects [42,45].
Conclusions ACDF with a stand-alone PEEK cage combined with vertebroplasty seems to be a useful (100% improvement in our series) technique in symptomatic CVHAWACSM. It may provide the advantage of reducing the complications of totally excising the tumor by vertebroplasty, allowing immediate recovery because of surgical decompression and preventing pathologic fractures. However, a larger study with a longer follow-up may be required to justify this. References [1] Blankstein A, Spiegelmann R, Shacked I, et al. Hemangioma of the thoracic spine involving multiple adjacent levels: case report. Paraplegia 1988;26:186–91. [2] Dagi TF, Schmidek HH. Vascular tumors of the spine. In: Sundaresan N, Schmidek HH, Schiller AL, Rosenthal DI, eds. Tumors of the spine: diagnosis and clinical management. Philadelphia, PA: W.B. Saunders Co., 1990:181–91. [3] Fox MW, Onofrio BM. The natural history and management of symptomatic and asymptomatic vertebral hemangiomas. J Neurosurg 1993;78:36–45.
Y.-jie Hao et al. / The Spine Journal 13 (2013) 1774–1779 [4] Acosta FL Jr, Dowd CF, Chin C, et al. Current treatment strategies and outcomes in the management of symptomatic vertebral hemangiomas. Neurosurgery 2006;58:287–95. [5] Murugan L, Samson RS, Chandy MJ. Management of symptomatic vertebral hemangiomas: review of 13 patients. Neurol India 2002;50:300–5. [6] Bas T, Aparisi F, Bas JL. Efficacy and safety of ethanol injections in 18 cases of vertebral hemangioma. Spine 2001;26:1577–82. [7] Aebli N, Krebs J, Schwenke D, et al. Pressurization of vertebral bodies during vertebroplasty causes cardiovascular complications: an experimental study in sheep. Spine 2003;28:1513–20. [8] Kaufmann TJ, Trout AT, Kallmes DF. The effects of cement volume on clinical outcomes of percutaneous vertebroplasty. AJNR Am J Neuroradiol 2006;27:1933–7. [9] Jho HD. Posterolateral approach for anteriorly located cervical spine tumors: technical note. Minim Invasive Neurosurg 1998;41:204–8. [10] Hao J, Hu Z. Percutaneous cement vertebroplasty in the treatment of symptomatic vertebral hemangiomas. Pain Physician 2012;15:43–9. [11] Boschi V, Pogorelic Z, Gulan G, et al. Management of cement vertebroplasty in the treatment of vertebral hemangioma. Scand J Surg 2011;100:120–4. [12] Guarnieri G, Ambrosanio G, Vassallo P, et al. Vertebroplasty as treatment of aggressive and symptomatic vertebral hemangiomas: up to 4 years of follow-up. Neuroradiology 2009;51:471–6. [13] Kelekis AD, Martin JB, Somon T, et al. Radicular pain after vertebroplasty: compression or irritation of the nerve root? Initial experience with the ‘‘cooling system’’. Spine 2003;28:E265–9. [14] Feuerman T, Dwan PS, Young RF. Vertebrectomy for treatment of vertebral hemangioma without preoperative embolization. Case report. J Neurosurg 1986;65:404–6. [15] Hemmy DC. Vertebral hemangiomas. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. New York, NY: McGraw-Hill, 1996:1827–9. [16] Acosta FL Jr, Sanai N, Chi JH, et al. Comprehensive management of symptomatic and aggressive vertebral hemangiomas. Neurosurg Clin N Am 2008;19:17–29. [17] Shah KC, Chacko AG. Extensive vertebral haemangioma with cord compression in two patients: review of the literature. Br J Neurosurg 2004;18:250–2. [18] Nguyen JP, Djindjian M, Gaston A, et al. Vertebral hemangiomas presenting with neurologic symptoms. Surg Neurol 1987;27:391–7. [19] Blecher R, Smorgick Y, Anekstein Y, et al. Management of symptomatic vertebral hemangioma: follow-up of 6 patients. J Spinal Disord Tech 2011;24:196–201. [20] Hurley MC, Gross BA, Surdell D, et al. Preoperative Onyx embolization of aggressive vertebral hemangiomas. AJNR Am J Neuroradiol 2008;29:1095–7. [21] Ide C, Gangi A, Rimmelin A, et al. Vertebral haemangiomas with spinal cord compression: the place of preoperative percutaneous vertebroplasty with methyl methacrylate. Neuroradiology 1996;38: 585–9. [22] Jayakumar PN, Vasudev MK, Srikanth SG. Symptomatic vertebral haemangioma: endovascular treatment of 12 patients. Spinal Cord 1997;35:624–8. [23] Jones JO, Bruel BM, Vattam SR. Management of painful vertebral hemangiomas with kyphoplasty: a report of two cases and a literature review. Pain Physician 2009;12:E297–303. [24] Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine 2000;25:923–8.
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[25] Doppman JL, Oldfield EH, Heiss JD. Symptomatic vertebral hemangiomas: treatment by means of direct intralesional injection of ethanol. Radiology 2000;214:341–8. [26] Gabal AM. Percutaneous technique for sclerotherapy of vertebral hemangioma compressing spinal cord. Cardiovasc Intervent Radiol 2002;25:494–500. [27] Scheller K, Eckert AW, Scheller C. A huge infiltrating squamous cell carcinoma of the neck 46 years after radiotherapy of a haemangioma. J Dermatol Case Rep 2010;4:22–4. [28] Miszczyk L, Tukiendorf A. Radiotherapy of painful vertebral hemangiomas: the single center retrospective analysis of 137 cases. Int J Radiat Oncol Biol Phys 2012;82:e173–80. [29] Aich RK, Deb AR, Banerjee A, et al. Symptomatic vertebral hemangioma: treatment with radiotherapy. J Cancer Res Ther 2010;6:199–203. [30] Beyzadeoglu M, Dirican B, Oysul K, et al. Evaluation of radiation carcinogenesis risk in vertebral hemangioma treated by radiotherapy. Neoplasma 2002;49:338–41. [31] Pastushyn AI, Slin’ko EI, Mirzoyeva GM. Vertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients. Surg Neurol 1998;50:535–47. [32] Silber JS, Anderson DG, Daffner SD, et al. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine 2003;28:134–9. [33] Siddiqui AA, Jackowski A. Cage versus tricortical graft for cervical interbody fusion: a prospective randomised study. J Bone Joint Surg Br 2003;85:1019–25. [34] Vavruch L, Hedlund R, Javid D, et al. A prospective randomized comparison between the cloward procedure and a carbon fiber cage in the cervical spine: a clinical and radiologic study. Spine 2002;27: 1694–701. [35] Shad A, Leach JC, Teddy PJ, Cadoux-Hudson TA. Use of the Solis cage and local autologous bone graft for anterior cervical discectomy and fusion: early technical experience. J Neurosurg Spine 2005;2: 116–22. [36] Gaudinez RF, English GM, Gebhard JS, et al. Esophageal perforations after anterior cervical surgery. J Spinal Disord 2000;13:77–84. [37] Yang JJ, Yu CH, Chang BS, et al. Subsidence and nonunion after anterior cervical interbody fusion using a stand-alone polyetheretherketone (PEEK) cage. Clin Orthop Surg 2011;3:16–23. [38] Steffen T, Tsantrizos A, Fruth I, Aebi M. Cages: designs and concepts. Eur Spine J 2000;9(1 Suppl):S89–94. [39] Bartels RH, Donk RD, Feuth T. Subsidence of stand-alone cervical carbon fiber cages. Neurosurgery 2006;58:502–8. [40] Bartels RH, Donk R, van Azn RD. Height of cervical foramina after anterior discectomy and implantation of a carbon fiber cage. J Neurosurg 2001;95(1 Suppl):40–2. [41] Eckel TS, Olan W. Vertebroplasty and vertebral augmentation techniques. Tech Vasc Interv Radiol 2009;12:44–50. [42] Heran MK, Legiehn GM, Munk PL. Current concepts and techniques in percutaneous vertebroplasty. Orthop Clin North Am 2006;37: 409–34. [43] Guglielmi G, Andreula C, Muto M, Gilula LA. Percutaneous vertebroplasty: indications, contraindications, technique, and complications. Acta Radiol 2005;46:256–68. [44] Peh WC, Gilula LA. Percutaneous vertebroplasty: indications, contraindications, and technique. Br J Radiol 2003;76:69–75. [45] Ambrosanio G, Lavanga A, Vassallo P, et al. Vertebroplasty in the treatment of spine disease. Interv Neuroradiol 2005;11:309–23.
Clinical Study
Surgical treatment of cervical vertebral hemangioma associated with adjacent cervical spondylotic myelopathy Ying-jie Hao, MD*, Lei Yu, MD, Yan Zhang, MD, Li-min Wang, MD, Jia-zhen Li, MD Department of Orthopaedics, The First Affiliated Hospital, Zhengzhou University, No.1, Eastern Jianshe Road, Zhengzhou 450052, China Received 13 November 2012; accepted 4 May 2013
Abstract
BACKGROUND CONTEXT: Symptoms may vary from simple vertebral pain to progressive neurologic deficit because of cervical vertebral hemangioma associated with adjacent cervical spondylotic myelopathy (CVHAWACSM). Often resistant to conservative medical treatment, surgery has been the treatment of choice for these patients, but the optimal surgical strategy for CVHAWACSM has not been defined. PURPOSE: This study aimed to investigate the methods and efficacy in the treatment of CVHAWACSM. STUDY DESIGN: Retrospective review of patients enrolled in prospective randomized trial. PATIENT SAMPLE: Procedure was performed in 18 patients (11 men and 7 women) with CVHAWACSM, who were enrolled between January 2006 and September 2011. OUTCOME MEASURES: Radiographic examinations were carried out to assess total filling of polymethylmethacrylate in the vertebral body, fusion rates, implant failure, and general complications. The recovery of neurologic function and neck and shoulder pain relief were measured based on the Japanese Orthopedic Association (JOA) and the visual analog scale (VAS) scores. METHODS: Eighteen patients had single vertebral hemangioma, including one case at C3, three at C4, six at C5, five at C6, and three at C7. The X-ray films showed a typical ‘‘palisade’’ change. According to the clinical and imaging features, there were 12 cases of Type II and 6 of Type IV cervical hemangioma. Standard anterior cervical decompression and fusion with a stand-alone polyetheretherketone cage (filled with autologous cancellous iliac bone) was performed, followed by vertebroplasty. Clinical and radiologic follow-ups were performed. RESULTS: The mean follow-up was 24.1 months, with a range of 18 to 36 months. The symptoms of all 18 patients were improved, by varying degrees, and the lesion vertebra did not show anterior bone cement leakage or injuries in the spinal cord and nerves. The forming vertebra did not show fracture or collapse, and there was no recurrence of the hemangioma. During the follow-up, there was no implant loosening, displacement, or breakage. The JOA and the VAS scores were significantly recovered at 3 months after the operation and in the last follow-up, compared with the preoperative level (p!.05). The JOA scores in the last follow-up showed 13 excellent, 4 good, 1 fair, and 0 poor cases. CONCLUSIONS: This procedure seems to be a safe efficient method to treat symptomatic CVHAWACSM. It seems to serve the purpose of providing vertebral augmentation, cord decompression, and rigid fusion at the same sitting. Although the present outcomes are promising, long-term follow-up studies with larger patient numbers are required to confirm this effect. Ó 2013 Elsevier Inc. All rights reserved.
Keywords:
Vertebral hemangioma; Cervical spondylotic myelopathy; Vertebroplasty; ACDF; PEEK
FDA device/drug status: Not applicable. Author disclosures: Y-jH: Nothing to disclose. LY: Nothing to disclose. YZ: Nothing to disclose. L-mW: Nothing to disclose. J-zL: Nothing to disclose. 1529-9430/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2013.05.048
* Corresponding author. Department of Orthopaedics, The First Affiliated Hospital, Zhengzhou University, No. 1, Eastern Jianshe Road, Zhengzhou 450052, China. Tel.: (86) 371-67967206; fax: (86) 37166970906. E-mail address: [email protected] (Y.-jie Hao)
Y.-jie Hao et al. / The Spine Journal 13 (2013) 1774–1779
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Introduction Vertebral hemangioma, one of the benign diseases, does not require treatment if the patient has no obvious symptoms. It has been suggested that only 0.9% to 1.2% of patients with vertebral hemangioma who show the symptoms of local pain, spinal activity limitation, compression of the nerve or the spinal cord, and even paraplegia need to be treated [1–4]. Moreover, there have been even fewer cases of vertebral hemangioma combined with cervical spondylotic myelopathy for which the conservative medical treatment approach failed to gain ideal efficacy, requiring surgical excision [5–9]. Surgical excision therapy has been, for many years, the treatment of vertebral hemangiomas and cervical spondylotic myelopathy, which have been burdened with many complications related to intraoperative or postoperative bleeding and large trauma; furthermore, the procedure was difficult [10–12]. In this report, we reviewed data on 18 patients with cervical vertebral hemangioma associated with adjacent cervical spondylotic myelopathy (CVHAWACSM) admitted to our hospital during the 2006 to 2011 period. These patients were treated with the combined therapy of ACDF with a stand-alone polyetheretherketone (PEEK) cage and vertebroplasty. The aim of this work is to illustrate the efficacy and safety of this surgery in the treatment of patients with CVHAWACSM.
Context Occasionally, when performing an ACDF, a vertebral body with a symptomatic (or asymptomatic) hemangioma is encountered. The authors present their experience using vertebroplasty for this condition. Contribution In this case series of 18 patients, the authors report good results with no complications associated with the treatment of the hemangioma. Implications One important role for case-series reports is to present novel treatment options for uncommon problems. The authors’ methods might be helpful for others encountering similar patients.
interbody osteophytes were also detected. The spiral CT scan revealed reduced vertebra density, thickening of the residual vertical trabeculae, and an enlarged medullary cavity. The vertebra sinusoid was dilated to a mesh-like or honeycomb morphology, with the cross-section showing ‘‘matches-beam’’ changes. All patients showed an intact
Patients and methods General information The 18 patients (11 men and 7 women) had an average age of 44.3 years (32–70 years) and an average disease course of 16.7 months (10–30 months). All patients had single vertebral hemangioma, including one case at C3, three at C4, six at C5, five at C6, and three at C7. Moreover, the cervical disc herniation caused adjacent single intervertebral herniation in all patients. The clinical symptoms included cervical and shoulder refractory pain, which was more severe than the pain solely caused by cervical spondylotic myelopathy, and varying degrees of limb weakness, unsteady walking, limb numbness, and muscle atrophy. The examination results showed constrained cervical motion, obvious paravertebral or spinous tenderness, nerve root traction, inordinate limb sensation, dyskinesia, muscle strength loss, hypermyotonia, tender hyperreflexia, positive Hoffmann reflex, and positive Babinski reflex. Three patients showed patellar clonus and ankle clonus. All patients received examinations with cervical X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) (Fig. 1). The X-ray examination revealed that the damaged vertebra usually showed a typical ‘‘palisade’’ morphology [13], such as reduced bone mineral density, cortical thinning, and residual trabeculae thickening. Moreover, the cervical physiological curve became straight or even showed recurvation. Intervertebral stenosis and posterior cervical
Fig. 1. A 70-year-old woman with C5 vertebral hemangioma (Type IV) combined with C5–6 intervertebral disc herniation. Preoperative magnetic resonance imaging revealed high-intensity signal in the C5 vertebra and spinal cord compression in the C5–6 vertebra.
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Fig. 2. Lateral X-ray at 3 months after operation. The C5 vertebra showed ideal morphology without collapse, and the bone cement diffusion was also ideal. The Solis cage was well positioned without loosening, displacement, or breakage.
PEEK cage (Solis; Stryker Spine, Allendale, NJ, USA) filled with cancellous bone obtained from the anterior iliac crest through a minimal incision. The heights of the cage were 6, 7, 8, and 9 mm in 8, 28, 8, and 3 segments, respectively. The anteroposterior diameters of the cage were 12 and 14 mm in 21 and 26 segments, respectively. After the cervical vertebra with the hemangioma was determined using C-arm X-ray, a puncture needle was inserted into the vertebra through the center of the anterior vertebral surface to one-third the distance to the vertebra (the specimens of Type IV patients with hemangioma were collected and examined). Polymethylmethacrylate bone cement was injected into the vertebra with lateral fluoroscopy applied to prevent leakage. The needle should be continuously rotated to promote sealing. After injection, the puncture needle was extracted to the cortical bone. The needle core was inserted, and the needle was rotated to prevent fixation. The needle was fully extracted before the cement solidified. The incision was rinsed and sutured, and a drainage tube was placed in the incision for 1 to 2 days. Hormones, dehydration agents, and antibiotics were applied for 1 to 2 days. Postoperative review was performed every 3 months, including physical examination, Japanese Orthopedic Association (JOA) score, visual analog scale (VAS) score, cervical radiograph (Figs. 2 and 3), and CT (Fig. 4), to monitor the distribution of bone cement in the vertebra and the internal fixation.
posterior vertebral wall without spinal hemangioma invasion. The MRI examination of the sagittal T1-weighted imaging revealed that the damaged vertebra usually showed mixed high-intensity signals, and low-intensity signals were distributed in the cleft between the high-intensity zones. All seven vertebral segments showed even high-intensity signals at the levels of T1-weighted imaging and T2-weighted imaging. In the meanwhile, a cervical intervertebral disc represented by intermediate signals had invaded into the vertebra and compressed the dura and spinal cord. A total of 18 patients showed proliferating and degenerative osteophytes, represented by low-intensity signals, in the posterior vertebral edge. According to the clinical and imaging features, there were 12 cases of Type II and 6 of Type IV cervical hemangioma [5,6]. Surgical procedure After anesthesia, the patient took a supine position with neck thrown back. The surgical site was exposed via a standard anterior approach, and microscopic anterior cervical discectomy was performed. Cartilage was removed with care to avoid damaging the cortical bone of the vertebral end plates. The posterior longitudinal ligament was opened, and decompression was carried out. The appropriate cage size was then determined under fluoroscopy guidance. Anterior cervical fusion was performed using a stand-alone
Fig. 3. Front X-ray at 3 months after operation. The C5 vertebra showed normal morphology, and the Solis cage was appropriately and stably positioned.
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Fig. 4. The spiral computed tomography scan, at 12 months after operation, revealed the Solis cage with good position. Solid fusion was achieved between C5 and C6 at 12-month follow-up.
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(60–90 minutes), the average intraoperative bleeding was 45 mL (20–100 mL), and the average cement amount was 2.2 mL per vertebra (1.5–3.2 mL). All patients received an 18- to 36-month follow-up (mean value 24.1 months). The recovery of neurologic function and neck and shoulder pain relief were measured based on the JOA and the VAS scores. The symptoms of nerve compression and neck and shoulder pain were improved for all 18 patients, by varying degrees. Imaging examination revealed that the formed vertebrae had no fracture or collapse, and there was no hemangioma recurrence. Moreover, the Solis cage was well localized without loosening, shifting, or rupture. At 3 to 4 months after the operation (mean value 3.8 months), the spiral CT scan revealed that all fusion segments had bone healing without implant collapse or cervical instability. At 3 months after the operation and in the last follow-up, the JOA scores were similar (pO.05) and were significantly improved compared with the preoperative level (p!.05). In the last follow-up, the patients, including 13 very good, 4 good, and 1 okay cases, had an improvement rate of 58.5%620.8%. The VAS scores at 3 months after the operation and in the last follow-up were similar (pO.05) and were significantly improved compared with the preoperative level (p!.05). The improvement rate of the last follow-up was 45.3%618.0%. All these results are shown in Table.
Evaluation of efficacy The VAS score was evaluated before and at 3 months after the operation and in the last follow-up, to monitor the pain relief of the patient. The improvement rate of the last follow-up was calculated as follows: improvement rate5(preoperative VAS score postoperative VAS score)/ (10 postoperative VAS score)100%. The JOA score was evaluated before and at 3 months after the operation and in the last follow-up, to determine the improvement rate of the cervical cord function of the patient. The improvement rate of the cervical cord function was calculated as follows: improvement rate5(postoperative JOA score preoperative JOA score)/(17 preoperative JOA score)100%. The grade was as follows: very good, 75% or more; good, 50% to 74%; ok, 25% to 49%; and poor, 0% to 24%. Statistical analysis Data were presented as means6standard deviations. The results were analyzed using Student t test with SPSS statistical software, version 11.5 (SPSS, Chicago, IL, USA); p!.05 was considered statistically significant.
Results All patients were successfully treated with surgery, without injury in the spinal cord or nerve, and the incision healed well. The average surgery time was 75 minutes
Discussion Because of the combined symptoms of neck and shoulder pain, cervical spondylosis is often misdiagnosed. Routine X-ray examination may not be able to find the tiny lesions within the vertebra. Although spiral CT scan can overcome this difficulty, it has a limited scan range for soft tissues. Nevertheless, MRI has a broad imaging range, which is sufficient to not only determine the location of the hemangioma but also indicate the degree of spinal cord compression, and thus can be used to determine the surgical plan and prognosis. According to the clinical and imaging features, cervical hemangioma can be classified into four types: Type I, hemangioma without obvious symptoms or vicious imaging performance; Type II, hemangioma shows severe back pain without vicious imaging performance; Type III, hemangioma has vicious imaging performance but without obvious symptoms; and Type IV, hemangioma Table Comparison of JOA and VAS scores between pre- and postoperation (n512, means6standard deviations) Time
JOA score
VAS score
Before operation Three months after operation Last follow-up
7.662.1 13.162.7* 13.663.0*
5.962.1 2.860.8* 2.560.6*
JOA, Japanese Orthopedic Association; VAS, visual analog scale. * Compared with the preoperative value, p!.05.
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has both vicious imaging performance and obvious symptoms [5,6]. Type IV can be further divided into two clinical subtypes, one with the acute symptoms of spinal cord and nerve compression (IVa) and the other with the progressive symptoms of spinal cord and nerve compression (IVb). Several options are currently available for the management of symptomatic vertebral hemangioma. The treatment modalities include surgical decompression [14–19], endovascular embolization (more recently using onyx) [20], injection of vertebroplasty cement, absolute alcohol, or methylmethacrylate into the vertebral body [6,12,15,16,21–26], and radiotherapy only [27–30]. The nonsurgical modalities have mainly emerged because of the highly vascular nature of the tumor with the threat of mortality owing to exsanguination during surgery and the difficulty in approaching and totally excising the tumor with its associated morbidity. Pastushyn et al. [31] reported 6% mortality in their surgical group. All these were because of exsanguination during attempts to remove large soft-tissue tumors in the ventral part of the vertebral body. Although more recent series show a considerable improvement in morbidity and mortality [3,12,15,16,18], surgery is still fraught with risks and dangers, even if performed by highly skilled surgeons. As for surgery of cervical myelopathy, anterior cervical decompression and fusion (ACDF) has been performed as the gold standard for the treatment of degenerative cervical disc disease. ACDF using an intervertebral cage has become a popular alternative to prevent the complications of the classic method using an autologous tricortical iliac bone graft [32–35] and anterior cervical plating, including screw loosening, screw breakage, screw migration, and soft-tissue injuries [36,37]. ACDF using an intervertebral cage is credited with promoting instant stability, restoration of the neural foraminal height, and interbody fusion by providing an environment for bone growth [38–40]. In the present study, we investigated 18 patients, including 11 men and 7 women, with an average age of 44.3 years (32–70 years) and an average disease course of 16.7 months (10–30 months). All patients showed obvious neck and shoulder pain, which was more severe than the pain solely caused by cervical spondylosis. Moreover, these patients also showed other symptoms, to varying degrees, including limb weakness, unsteady walking, limb numbness, and muscle atrophy. All these patients had CVHAWACSM, which required us to treat the adjacent lesion vertebra when performing the discectomy and fusion. If the patients were treated with anterior cervical discectomy and decompression, the plate fixation would increase the bleeding of the lesion vertebra, which might result in surgical failure. However, if the patients were first treated with vertebroplasty, the plate would be difficult to place. At the other hand, without dealing with the lesion vertebra, the cage would probably be inserted into the lesion vertebra. All these possibilities made it difficult to treat the patients with surgery. To treat the 18 patients, we applied ACDF with a standalone PEEK cage combined with vertebroplasty. This
combined therapy has several advantages. All operations could be performed in one small incision, which led to a low-level bleeding of, on average, 45 mL (20–100 mL). The surgical cost was reduced. The PEEK cage (Solis; Stryker Spine) can be firmly fixed in the intervertebral space by its fangs on both sides, which in turn can avoid plate insertion and reduce the bleeding and surgery time. With the help of the 3-month postoperative external fixation, the bone fusion time was only 3.8 months, as revealed by follow-up examinations. Compared with the conventional combined treatment approach of totally excising the tumor, decompression, and instrumentation, our surgical procedure operated on a smaller number of fusion vertebrae and thus had a reduced risk of adjacent disc degeneration and other complications. During the surgical process, the surgeon should pay close attention to several points. First, the decompression should be complete, and the osteophytes and degenerative intervertebral discs should be removed till the Luschka joint, especially for the posterior longitudinal ligament in the depression space. Second, based on the lesions and surrounding soft tissues, the puncture should be designed to have the shortest distance and minimal injury. Repetitive punctures should be avoided. With the help of fluoroscopy, the puncture needle should be slowly inserted to one-third the distance from the vertebra [41,42]. Third, the viscosity of the bone cement would significantly affect its diffusion in the vertebra. A too low viscosity can increase the risk of cement leakage though the diffusion can be enhanced. Hence, the bone cement should be injected in the drawing stage [41,43,44], and the injection amount should be controlled. This is because a high amount of cement could cause more complications, whereas not enhancing the analgesic effects [42,45].
Conclusions ACDF with a stand-alone PEEK cage combined with vertebroplasty seems to be a useful (100% improvement in our series) technique in symptomatic CVHAWACSM. It may provide the advantage of reducing the complications of totally excising the tumor by vertebroplasty, allowing immediate recovery because of surgical decompression and preventing pathologic fractures. However, a larger study with a longer follow-up may be required to justify this. References [1] Blankstein A, Spiegelmann R, Shacked I, et al. Hemangioma of the thoracic spine involving multiple adjacent levels: case report. Paraplegia 1988;26:186–91. [2] Dagi TF, Schmidek HH. Vascular tumors of the spine. In: Sundaresan N, Schmidek HH, Schiller AL, Rosenthal DI, eds. Tumors of the spine: diagnosis and clinical management. Philadelphia, PA: W.B. Saunders Co., 1990:181–91. [3] Fox MW, Onofrio BM. The natural history and management of symptomatic and asymptomatic vertebral hemangiomas. J Neurosurg 1993;78:36–45.
Y.-jie Hao et al. / The Spine Journal 13 (2013) 1774–1779 [4] Acosta FL Jr, Dowd CF, Chin C, et al. Current treatment strategies and outcomes in the management of symptomatic vertebral hemangiomas. Neurosurgery 2006;58:287–95. [5] Murugan L, Samson RS, Chandy MJ. Management of symptomatic vertebral hemangiomas: review of 13 patients. Neurol India 2002;50:300–5. [6] Bas T, Aparisi F, Bas JL. Efficacy and safety of ethanol injections in 18 cases of vertebral hemangioma. Spine 2001;26:1577–82. [7] Aebli N, Krebs J, Schwenke D, et al. Pressurization of vertebral bodies during vertebroplasty causes cardiovascular complications: an experimental study in sheep. Spine 2003;28:1513–20. [8] Kaufmann TJ, Trout AT, Kallmes DF. The effects of cement volume on clinical outcomes of percutaneous vertebroplasty. AJNR Am J Neuroradiol 2006;27:1933–7. [9] Jho HD. Posterolateral approach for anteriorly located cervical spine tumors: technical note. Minim Invasive Neurosurg 1998;41:204–8. [10] Hao J, Hu Z. Percutaneous cement vertebroplasty in the treatment of symptomatic vertebral hemangiomas. Pain Physician 2012;15:43–9. [11] Boschi V, Pogorelic Z, Gulan G, et al. Management of cement vertebroplasty in the treatment of vertebral hemangioma. Scand J Surg 2011;100:120–4. [12] Guarnieri G, Ambrosanio G, Vassallo P, et al. Vertebroplasty as treatment of aggressive and symptomatic vertebral hemangiomas: up to 4 years of follow-up. Neuroradiology 2009;51:471–6. [13] Kelekis AD, Martin JB, Somon T, et al. Radicular pain after vertebroplasty: compression or irritation of the nerve root? Initial experience with the ‘‘cooling system’’. Spine 2003;28:E265–9. [14] Feuerman T, Dwan PS, Young RF. Vertebrectomy for treatment of vertebral hemangioma without preoperative embolization. Case report. J Neurosurg 1986;65:404–6. [15] Hemmy DC. Vertebral hemangiomas. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. New York, NY: McGraw-Hill, 1996:1827–9. [16] Acosta FL Jr, Sanai N, Chi JH, et al. Comprehensive management of symptomatic and aggressive vertebral hemangiomas. Neurosurg Clin N Am 2008;19:17–29. [17] Shah KC, Chacko AG. Extensive vertebral haemangioma with cord compression in two patients: review of the literature. Br J Neurosurg 2004;18:250–2. [18] Nguyen JP, Djindjian M, Gaston A, et al. Vertebral hemangiomas presenting with neurologic symptoms. Surg Neurol 1987;27:391–7. [19] Blecher R, Smorgick Y, Anekstein Y, et al. Management of symptomatic vertebral hemangioma: follow-up of 6 patients. J Spinal Disord Tech 2011;24:196–201. [20] Hurley MC, Gross BA, Surdell D, et al. Preoperative Onyx embolization of aggressive vertebral hemangiomas. AJNR Am J Neuroradiol 2008;29:1095–7. [21] Ide C, Gangi A, Rimmelin A, et al. Vertebral haemangiomas with spinal cord compression: the place of preoperative percutaneous vertebroplasty with methyl methacrylate. Neuroradiology 1996;38: 585–9. [22] Jayakumar PN, Vasudev MK, Srikanth SG. Symptomatic vertebral haemangioma: endovascular treatment of 12 patients. Spinal Cord 1997;35:624–8. [23] Jones JO, Bruel BM, Vattam SR. Management of painful vertebral hemangiomas with kyphoplasty: a report of two cases and a literature review. Pain Physician 2009;12:E297–303. [24] Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine 2000;25:923–8.
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[25] Doppman JL, Oldfield EH, Heiss JD. Symptomatic vertebral hemangiomas: treatment by means of direct intralesional injection of ethanol. Radiology 2000;214:341–8. [26] Gabal AM. Percutaneous technique for sclerotherapy of vertebral hemangioma compressing spinal cord. Cardiovasc Intervent Radiol 2002;25:494–500. [27] Scheller K, Eckert AW, Scheller C. A huge infiltrating squamous cell carcinoma of the neck 46 years after radiotherapy of a haemangioma. J Dermatol Case Rep 2010;4:22–4. [28] Miszczyk L, Tukiendorf A. Radiotherapy of painful vertebral hemangiomas: the single center retrospective analysis of 137 cases. Int J Radiat Oncol Biol Phys 2012;82:e173–80. [29] Aich RK, Deb AR, Banerjee A, et al. Symptomatic vertebral hemangioma: treatment with radiotherapy. J Cancer Res Ther 2010;6:199–203. [30] Beyzadeoglu M, Dirican B, Oysul K, et al. Evaluation of radiation carcinogenesis risk in vertebral hemangioma treated by radiotherapy. Neoplasma 2002;49:338–41. [31] Pastushyn AI, Slin’ko EI, Mirzoyeva GM. Vertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients. Surg Neurol 1998;50:535–47. [32] Silber JS, Anderson DG, Daffner SD, et al. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine 2003;28:134–9. [33] Siddiqui AA, Jackowski A. Cage versus tricortical graft for cervical interbody fusion: a prospective randomised study. J Bone Joint Surg Br 2003;85:1019–25. [34] Vavruch L, Hedlund R, Javid D, et al. A prospective randomized comparison between the cloward procedure and a carbon fiber cage in the cervical spine: a clinical and radiologic study. Spine 2002;27: 1694–701. [35] Shad A, Leach JC, Teddy PJ, Cadoux-Hudson TA. Use of the Solis cage and local autologous bone graft for anterior cervical discectomy and fusion: early technical experience. J Neurosurg Spine 2005;2: 116–22. [36] Gaudinez RF, English GM, Gebhard JS, et al. Esophageal perforations after anterior cervical surgery. J Spinal Disord 2000;13:77–84. [37] Yang JJ, Yu CH, Chang BS, et al. Subsidence and nonunion after anterior cervical interbody fusion using a stand-alone polyetheretherketone (PEEK) cage. Clin Orthop Surg 2011;3:16–23. [38] Steffen T, Tsantrizos A, Fruth I, Aebi M. Cages: designs and concepts. Eur Spine J 2000;9(1 Suppl):S89–94. [39] Bartels RH, Donk RD, Feuth T. Subsidence of stand-alone cervical carbon fiber cages. Neurosurgery 2006;58:502–8. [40] Bartels RH, Donk R, van Azn RD. Height of cervical foramina after anterior discectomy and implantation of a carbon fiber cage. J Neurosurg 2001;95(1 Suppl):40–2. [41] Eckel TS, Olan W. Vertebroplasty and vertebral augmentation techniques. Tech Vasc Interv Radiol 2009;12:44–50. [42] Heran MK, Legiehn GM, Munk PL. Current concepts and techniques in percutaneous vertebroplasty. Orthop Clin North Am 2006;37: 409–34. [43] Guglielmi G, Andreula C, Muto M, Gilula LA. Percutaneous vertebroplasty: indications, contraindications, technique, and complications. Acta Radiol 2005;46:256–68. [44] Peh WC, Gilula LA. Percutaneous vertebroplasty: indications, contraindications, and technique. Br J Radiol 2003;76:69–75. [45] Ambrosanio G, Lavanga A, Vassallo P, et al. Vertebroplasty in the treatment of spine disease. Interv Neuroradiol 2005;11:309–23.