Correspondence

Treatment of Vertebral Hemangioma by Intralesional Injection of Absolute Ethanol

N Engl J Med 1996; 334:1340May 16, 1996

Article

To the Editor:

Two years ago (Aug. 25, 1994, issue),1 we reported on two patients who had relief of spinal cord compression after the direct injection of ethanol into a vertebral hemangioma. The improvement in their condition has been maintained for over three years. However, in a larger series of seven patients there have been two instances of vertebral compression fracture, a complication not seen in our initial two patients.

The first patient was a 66-year-old woman with paraparesis who had moderate back pain while pulling weeds in her garden four months after the injection of ethanol into a hemangioma of the T12 vertebra. The second patient was a 45-year-old man who had a recurrence of pain in the back and right lower extremity while lifting weights four weeks after his L3 vertebral hemangioma was injected with ethanol. Spinal roentgenograms showed compression fractures of the injected vertebrae in both patients. The pain did not improve with bed rest or spinal bracing. Both patients underwent removal of the vertebral body, internal stabilization, and interbody fusion. The vertebral bodies bled sparingly during their removal. Focal osteonecrosis was present in the pathological specimens. The patients' symptoms improved after surgery.

The first patient had received 40 ml of ethanol. The second patient required an injection of 50 ml to eliminate backflow of blood into the needle. In both patients magnetic resonance imaging with contrast material showed evidence of broad devascularization of the treated vertebral bodies. The unaffected patients, in contrast, had received injections of 6 to 12 ml and had devascularization of only the hemangioma. Both compression fractures occurred relatively soon (one to four months) after treatment. On the other hand, the five unaffected patients have been followed for 7 to 46 months (mean, 24) and have maintained their neurologic improvement. Although spontaneous compression fractures occur in 6 to 16 percent of patients with symptomatic vertebral hemangiomas,2 the injection of more than 12 ml of ethanol may predispose patients to this complication.

To preclude open surgery, intralesional ethanol treatment must destroy the vertebral hemangioma and preserve vertebral integrity. In two of our seven patients, ethanol devascularized the vertebral body and caused osteonecrosis and compression fracture. Removal of the affected vertebral body, an accepted treatment for symptomatic hemangioma, was required, although ethanol-induced devascularization of the vertebral hemangioma greatly reduced the operative blood loss usually associated with this surgery.3 Additional experience with the infusion of small doses of ethanol into the hemangioma will determine whether this approach can consistently eradicate vertebral hemangiomas without increasing the risk of compression fracture.

John D. Heiss, M.D.
John L. Doppman, M.D.
Edward H. Oldfield, M.D.
National Institutes of Health, Bethesda, MD 20892

3 References

1. 1

   Heiss JD, Doppman JL, Oldfield EH. Relief of spinal cord compression from vertebral hemangioma by intralesional injection of absolute ethanol. N Engl J Med 1994;331:508-511
   Full Text | Web of Science | Medline

2. 2

   Vertebral hemangiomas with neurologic symptomsNeurochirurgie 1989;35:264-265
   Web of Science

3. 3

   Graham JJ, Yang WC. Vertebral hemangioma with compression fracture and paraparesis treated with preoperative embolization and vertebral resection. Spine 1984;9:97-101
   CrossRef | Web of Science | Medline

Citing Articles (9)

Citing Articles

1. 1

   Oren N. Gottfried, Andrew T. Dailey, Meic H. Schmidt. (2008) Adjunct and Minimally Invasive Techniques for the Diagnosis and Treatment of Vertebral Tumors. Neurosurgery Clinics of North America 19:1, 125-138
   CrossRef

2. 2

   Masahiro Kawanishi, Akira Morimoto, Yasuaki Okuda, Daisuke Satoh, Nahoko Matsuda, Yutaka Itoh, Hajime Handa, Keiji Shimoyama. (2005) Intralesional Injection of Absolute Alcohol Into Symptomatic Vertebral Hemangiomas. Neurosurgery Quarterly 15:2, 75-78
   CrossRef

3. 3

   Masahiro Kawanishi, Akira Morimoto, Yasuaki Okuda, Daisuke Satoh, Nahoko Matsuda, Yutaka Itoh, Hajime Handa, Keiji Shimoyama. (2005) Percutaneous Sclerotherapy of Symptomatic Vertebral Hemangiomas: Case Report and Review of the Literature. Spinal Surgery 19:2, 145-151
   CrossRef

4. 4

   Remi Nader, Brent T. Alford, Haring J. W. Nauta, Wayne Crow, Eric Vansonnenberg, Alexander G. Hadjipavlou. (2002) Preoperative embolization and intraoperative cryocoagulation as adjuncts in resection of hypervascular lesions of the thoracolumbar spine. Journal of Neurosurgery: Spine 97:3, 294-300
   CrossRef

5. 5

   Björn Gunterberg. (2001) Point of View. Spine 26:14, 1581-1582
   CrossRef

6. 6

   Thomas Niemeyer, John McClellan, John Webb, Tim Jaspan, Norlisah Ramli. (1999) Brown-Sequard Syndrome After Management of Vertebral Hemangioma With Intralesional Alcohol. Spine 24:17, 1845
   CrossRef

7. 7

   Russell R. Lonser, John D. Heiss, Edward H. Oldfield. (1998) Tumor devascularization by intratumoral ethanol injection during surgery. Journal of Neurosurgery 88:5, 923-924
   CrossRef

8. 8

   Jacques E. Dion. (1998) Neurointerventional Approaches in the Evaluation and Treatment of Spinal Lesions. Journal of Vascular and Interventional Radiology 9:1, 88-90
   CrossRef

9. 9

   &NA;. (1996) Alcohol. Reactions Weekly &NA;:602, 5
   CrossRef