This document summarizes the case of a 43-year-old man admitted with back pain for 2 months and weakness in both lower limbs for 1 month. MRI and angiography revealed a hemangioma in his D5 vertebra. Hemangiomas are benign bone tumors that typically occur in the thoracic spine and can cause pain and neurological issues like paraparesis. Surgical excision was performed after preoperative embolization to reduce blood flow to the tumor. Vertebral hemangiomas can enlarge during pregnancy and resolve after delivery but recur in subsequent pregnancies.

1. DR. P. JOHN
PAUL

2. INTERESTING CASE
OF
VERTEBRAL BODY
HEMANGIOMA

3. 43 year old gentleman admitted with
c/o back pain for past 2 months
c/o weakness of both lower limbs for the
past 1 month

4. Patient was apparently normal before 2
months
He developed pain in the upper back
H/o band like constricting pain below the
level of nipple present
H/o pain radiating to both lower limbs
H/o night pains present and the pain is not
relieved by drugs
H/o painful restriction during movements of
the body
H/o increase in pain after strenuous work and
relieved by taking rest

5. H/o difficulty in getting up from lying posture
H/o difficulty in getting up from squatting
position
H/o buckling of knees and tripping of toes
present
H/o slippage of slippers for past 1 month
No H/o difficulty is raising the head off the
pillow
No H/o difficulty in breathing

6. H/o decreased sensation below the nipple level
for the past 1 month
Not able to feel the clothes on the body
Not able to feel hot and cold water running down
his abdomen and lower limbs
Not able to perceive mosquito bite below the
nipple level
H/o heaviness of both lower limbs present
H/o of numbness over both lower limbs present

7. No H/o swaying or dysarthria
No H/o bladder or bowel disturbances
No H/o abnormal curvature of the spine
No H/o suggestive of higher mental function
disturbances
No history of cranial nerve disturbances

8. Past History :
H/o lumbar disc surgery done 10 years
before
Not a known DM / HT / TB pt
No H/o any prolonged drug intake
Personal History :
Takes mixed diet
Family History :
No other family member is affected by
similar complaints

9. Patient Conscious
Oriented
MMSE 30 / 30
Speech normal
Right handed individual
Vitals stable
Cranial nerve examination normal
Bulk normal in all 4 limbs
Tone increased in both lower limbs

10. Power
Limb Joint Movement Right Left
Upper
limb
Shoulder Flexion 5 5
Extension 5 5
Abduction 5 5
Adduction 5 5
Elbow Fexion 5 5
Extension 5 5
Wrist Flexion 5 5
Extension 5 5
Hand grip 100 % 100 %

11. Limb Joint Movement Right Left
Lower
Limb
Hip Flexion 4 4
Extension 4 + 4+
Adduction 4 + 4 +
Abduction 4 4
Knee Flexion 4 - 4
Extension 4 + 4 +
Lower limb Ankle Dorsiflexio
n
4 4
Plantar
flexion
4- 4 -

12. Plantar extensor on both sides
DTR bilateral knee jerk brisk
No cerebellar signs
No autonomic signs
No signs of meningeal irritation
No signs of raised ICT

13. MRI IMAGES

25. PRE OP SELECTIVE D 5
ANGIOGRAM
LEFT SIDE

26. PRE OP SELECTIVE D 5
ANGIOGRAM
RIGHT SIDE

27. INTRA OPERATIVE
PICTURES

33. VERTEBRAL BODY HEMANGIOMA
Hemangiomas are true benign neoplasms of
the bone
They may occasionally be hamartomatous in nature ,
the incidence is 2 to 12 %
They tend to occur in the third decade of life with a
slight female preponderance
They may be associated with Klippel-Trenaunay-
Weber Syndrome
When the hemangiomas are multiple , they may cause
consumptive coagulopathy

34. D 5 VERTEBRAL BODY
HEMANGIOMA

35. CLINICAL PRESENTATION :
Usually present with pain
Thoracic spine is more commonly involved
Neurological compromise is also seen in the
form of Para paresis
But pathological fracture of bones is not
common

36. These tumors characteristically enlarge
during the third trimester of pregnancy
They resolve following delivery
But recur in subsequent pregnancies

37. PATHOLOGY
The lesion arises from the periosteum or the
marrow spaces producing a honey comb
bloody mass .
These tumors are usually supplied by the
intercostal arteries .
They may be capillary or cavernous
hemangiomas .
The lesion is functionally an arteriovenous
shunt .

38. DIFFERENTIAL DIAGNOSIS :
1. Tuberculosis of the spine
2. Osteoid osteoma
3. Pagets disease
4. Secondaries

39. RADIOLOGICAL CHARECTERS :
1. Vertical striated appearance of the
vertebral bodies due to ossification around
areas of hemangioma ( Honey Comb
appearance )

40. On CT these lesions give the appearance of
“ polka dots ” .
Vertebral body is involved than the posterior
elements
Contiguous multiple vertebral involvement
can occur
ANGIOGRAPHY :
These lesions demonstrate extensive tumor
blush

41. HONEY COMB
APPEARANCE

42. POLKA DOT APPEARANCE

43. MODES OF SPINAL CORD COMPRESSION
1. Fracture of the vertebral body
2. Soft tissue outgrowth of the vertebral
hemangioma causing compression
3. Steal phenomenon and ischemia of the cord

44. MODES OF SPINAL CORD
COMPRESSION

45. PREOP EMBOLIZATION
If surgery is planned , embolization is
performed
Risk of ischemia of the cord is there if more
than three vascular pedicles are embolised
After embolization radical excision is done

46. RADIOTHERAPY :
Recommended dose is 30 to 40 cGy in a
single course over 6 to 8 weeks
It is often used when complete surgical
excision has not been done
STABILISATION :
If there is spinal instability , spinal
stabilization is done

47. If vertebral hemangiomas are detected
during pregnancy ,
Treatment should be undertaken after
delivery , even if the symptoms subside after
delivery
Vertebral hemangiomas recur in subsequent
pregnancies

48. THANK YOU