title: Management of pediatric single-level vertebral hemangiomas presenting with myelopathy by three-pronged approach (ethanol embolization, laminectomy, and instrumentation): a single-institute experience.
abstract: OBJECTIVE
  Pediatric vertebral hemangiomas (VH) are exceedingly rare benign and highly vascular tumours of the spine. There are no guidelines available for management of these patients in literature. Purpose of this study is to evaluate the role of intraoperative ethanol embolization, surgical decompression, and instrumented fusion in pediatric symptomatic VH with single-level involvement.
  
  
  METHODS
  Surgery consisted of intraoperative bilateral pedicular absolute alcohol injection and laminectomy at the level of pathology followed by a short-/long-segment instrumented fusion using pedicle screws and rod. Seven patients (mean age 14 ± 2.4 years, range 10-17 years, five females and two males) (age < 18 years) who were treated using this technique at our institute since March 2008 to December 2013 were enrolled in this retrospective study. Demographical, clinical, radiological, operative details, and postoperative events were retrieved from hospital records. During follow-up visits, clinical status and imaging were recorded. Outcome assessed with clinical and neurological outcome score of American Spinal Injury Association (ASIA) Impairment Scale.
  
  
  RESULTS
  Duration of symptoms ranged from 3 to 60 months (mean, 14.7 ± 20.4 months). Clinical features include myelopathy with motor and sensory involvement in all (five were paraplegic), back pain in two patients, and bladder involvement in two patients. The preoperative American Spinal Injury Association (ASIA) Impairment Scale (AIS) were B in five patients and C and D in one patient each. All had pan vertebral body VH with severe cord compression in the thoracic region on imaging study. Mean duration of surgery was 248.6 ± 60 minutes (range 195-310 min) and blood loss was 535 ml (range 200-1500 ml). Immediate embolization was achieved in all patients, which allowed laminectomy and soft tissue hemangioma removal relatively easy. Post surgery, at mean follow-up of 45.3 (±23.2) months (range 1-78 months), all patients showed improvement in power (sphincter improvement in two patients). ASIA were E in six patients and D in one patient at the last follow-up.
  
  
  CONCLUSIONS
  The present study is the largest series of pediatric symptomatic VH. This procedure is a safe, efficient method to treat symptomatic pediatric VH with severe cord compression. It seems to serve the purpose of providing embolization, cord decompression, rigid fusion at the same sitting without adding new morbidity, and preventing excessive blood loss.
authors.affiliation: Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Pankaj Kumar
authors.initials: PK
authors.lastname: Singh
authors.affiliation: Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India. saratpchandra3@gmail.com.
authors.forename: P Sarat
authors.initials: PS
authors.lastname: Chandra
authors.affiliation: Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Gaurang
authors.initials: G
authors.lastname: Vaghani
authors.affiliation: Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Dattaraj Paramanand
authors.initials: DP
authors.lastname: Savarkar
authors.affiliation: Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Kanwaljeet
authors.initials: K
authors.lastname: Garg
authors.affiliation: Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Rajender
authors.initials: R
authors.lastname: Kumar
authors.affiliation: Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Shashant Sharad
authors.initials: SS
authors.lastname: Kale
authors.affiliation: Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Bhawani Shankar
authors.initials: BS
authors.lastname: Sharma
mesh_terms: D000293:Adolescent; D002648:Child; D019299:Decompression, Surgical; D004621:Embolization, Therapeutic / Q000379:methods*; D000431:Ethanol / Q000627:therapeutic use*; D005260:Female; D006391:Hemangioma / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D007796:Laminectomy / Q000379:methods*; D008297:Male; D012189:Retrospective Studies; D012997:Solvents / Q000627:therapeutic use*; D013117:Spinal Cord Compression / Q000209:etiology / Q000628:therapy*; D013123:Spinal Fusion / Q000379:methods*; D013125:Spinal Neoplasms / Q000150:complications / Q000175:diagnosis / Q000628:therapy*
chemical_list: D012997:Solvents; D000431:Ethanol
keywords: Alcohol embolization; Cord compression; Instrumented fusion; Pediatric vertebral hemangioma