Sacroplasty for Symptomatic Sacral Hemangioma: A Novel Treatment Approach

Summary

Painful vertebral body hemangiomas have been successfully treated with vertebroplasty and kyphoplasty. Sacral hemangiomas are uncommon and as such painful sacral hemangiomas are rare entities. We report what we believe is only the second successful treatment of a painful sacral hemangioma with CT-guided sacroplasty.

A 56-year-old woman with a history of right-sided total hip arthroplasty and lipoma excision presented to her orthopedic surgeon with persistent right-sided low back pain which radiated into her buttock and right groin and hindered her ability to walk and perform her activities of daily living. MRIs of the thoracic spine, lumbar spine and pelvis showed numerous lesions with imaging characteristics consistent with multiple hemangiomas including a 2.2×2.1 cm lesion involving the right sacrum adjacent to the right S1 neural foramen. Conservative measures including rest, physical therapy, oral analgesics and right-sided sacroiliac joint steroid injection did not provide significant relief. Given her lack of improvement and the fact that her pain localized to the right sacrum, the patient underwent CT-guided sacroplasty for treatment of a painful right sacral hemangioma. Under CT fluoroscopic guidance, a 10 gauge introducer needle was advanced through the soft tissues of the back to the margin of the lesion. Biopsy was then performed and after appropriate preparation, cement was then introduced through the needle using a separate cement filler cannula. Appropriate filling of the right sacral hemangioma was visualized using intermittent CT fluoroscopy. After injection of approximately 2.5 cc of cement, it was felt that there was near complete filling of the right sacral hemangioma. With satisfactory achievement of cement filling, the procedure was terminated. Pathology from biopsy taken at the time of the procedure was consistent with hemangioma.

Image-guided sacroplasty with well-defined endpoints is an effective, minimally invasive and safe procedure. Patients with painful sacral hemangiomas can be treated with this technique with no significant complications.

Introduction

Vertebral body hemangiomas represent 2-3% of all spinal tumors and most commonly occur in the lower thoracic and lumbar regions ¹. Although the majority remain clinically silent, they can become symptomatic in about 0.9-1.2% of patients with pain being the most common presentation ². Symptomatic hemangiomas are most often encountered in the thoracic spine and unless the lesion extends into the neural foramen, pain is usually localized to the back ³. Percutaneous treatment with vertebroplasty or kyphoplasty has been shown to be a minimally invasive and effective treatment of painful vertebral hemangiomas ^4-6. Multiple hemangiomas are seen in 25-30% of patients, but sacral involvement is uncommon ⁷. Given that painful sacral hemangiomas are rare entities, experience with sacroplasty as a potential treatment option is very limited ^8-10. We report what we believe is only the second successful treatment of a painful sacral hemangioma with CT-guided sacroplasty.

Case Report

A 56-year-old woman presented to her orthopedic surgeon with severe right-sided hip pain for which she underwent right-sided total hip arthroplasty. She did well post-operatively until approximately six months later when she complained of pain in the region of her right posterior superior iliac spine. On imaging, she was found to have a subcutaneous mass in this region which was surgically excised and confirmed at pathology as lipoma with foci of fat necrosis.

Although her pain somewhat improved, over the next several months she began complaining of right-sided low back pain which radiated into her buttock and right groin. The pain hindered her ability to walk and perform her activities of daily living. She denied significant radiation of pain down the right lower extremity and there were no associated sensory or motor neuropathic symptoms. On physical examination, her pain localized to the right sacrum. MRIs of the thoracic spine, lumbar spine and pelvis were performed and showed numerous lesions with imaging characteristics consistent with multiple hemangiomas. Specifically, the lesions demonstrated increased T1 and T2 signal and contrast enhancement. Note was made of a 2.2×2.1 cm lesion involving the right sacrum adjacent to the right S1 neural foramen (Figures 1 and 2). Conservative measures including rest, physical therapy, oral analgesics and right-sided sacroiliac (SI) joint steroid injection did not provide significant relief. Given her lack of improvement and the fact that her pain localized to the right sacrum, the patient was referred for consideration of sacroplasty as treatment of a painful right sacral hemangioma.

Figure 1.

Sagittal T1-weighted images of the thoracic and lumbar spine demonstrating numerous T1 bright lesions involving the vertebral bodies consistent with hemangiomas.

Figure 2.

Axial T1 and T2-weighted images of the sacrum demonstrating right sacral hemangioma adjacent to the right S1 neural foramen.

Technical Note

CT-guided sacroplasty was performed by the lead author (VA). A single slice CT scanner was utilized (GE Medical Systems, Milwaukee, WI, USA) equipped with CT/i Smart View/Smart Prep. CT fluoroscopy was controlled by an integrated foot switch and hand-held controller with the scanning plane highlighted with a laser marker light. The quick check technique was used wherein a single section CT fluoroscopic spot view is obtained (24 cm FOV, 3 mm slice thickness, 120kV, 60 mA and 512×512 image matrix reconstruction).

In brief, the patient was placed prone on the CT table and scout CT images of the lower lumbar spine and sacrum were obtained at 3 mm slice thickness. Given the close proximity of the right sacral hemangioma to the right S1 neural foramen, a right S1 nerve root injection was initially performed under CT guidance with a 25-gauge spinal needle. A total of 2 cc 0.25% preservative free bupivacaine and 80 mg Depo-Medrol was slowly hand-injected adjacent to the right S1 nerve root without complication. A suitable trajectory to the known hemangioma involving the right superior aspect of the right sacral ala was then identified. Superficial and deep anesthesia was obtained with 5 cc preservative-free bupivacaine. Using intermittent CT fluoroscopy for guidance, a 10 gauge introducer needle was advanced through the soft tissues of the back to the margin of the lesion (Figure 3). The stylet was removed and an 11 gauge bone biopsy needle set introduced. Using negative pressure, a small core of bone measuring approximately 1 cm as well as a small amount (1 cc) of bloody material was obtained and sent for pathology. After appropriate preparation, polymethylmethacrylate (PMMA) was then introduced through the needle using a separate cement filler cannula (Figure 4). Appropriate filling of the right sacral hemangioma was visualized using intermittent CT fluoroscopy. After injection of approximately 2.5 cc PMMA, it was felt that there was near complete filling of the right sacral hemangioma (Figure 5). With satisfactory achievement of cement filling, the procedure was terminated. The needle was removed and hemostasis obtained. The procedure was performed under conscious sedation with intravenous Versed and Fentanyl.

Figure 3.

Screen save from CT-guided sacroplasty demonstrating the 10 gauge introducer needle at the margin of the right sacral hemangioma prior to biopsy.

Figure 4.

Screen saves from CT-guided sacroplasty demonstrating polymethylmethacrylate injection using a separate cement filler cannula.

Figure 5.

Post-procedure CT image showing near complete filling of the right sacral hemangioma with no extravasation of cement.

Results

The patient tolerated the procedure and there were no cardiovascular or neurologic complications after approximately three hours of monitoring. Immediate post-procedure CT through the region of interest showed near complete cement filling of the right sacral hemangioma. There was no extravasation of PMMA; specifically there was no evidence of leakage into the right S1 neural foramen or spinal canal. No significant hematoma was noted at or underlying the procedure site.

Shortly after the procedure, the patient noted a significant relief of her right-sided pain. At discharge, she was able to ambulate without difficulty and was neurologically intact. At one and three month follow-up visits, the patient has remained significantly pain-free. Pathology results from biopsy taken at the time of the procedure were consistent with hemangioma.

Discussion

Hemangiomas are common benign vascular tumors of the spine found in approximately 11% of all vertebral autopsies ¹. Hemangiomas consist of bony trabeculae separating endothelial lined vascular spaces. Some bony trabeculae are thinned whereas others are thickened leading to the typical polka dot appearance on axial CT. On MR imaging, osseous hemangiomas are usually T1 and T2 bright with variable enhancement pattern. The bright signal is attributed to fat within the lesions. Vertebral hemangiomas are rarely painful however they can become symptomatic in particular when there is neural arch expansion, vertebral body enlargement or direct compression of the thecal sac or nerve roots ^11-13. The majority of patients with symptomatic vertebral hemangiomas present with pain ². When conservative therapies fail, vertebroplasty and kyphoplasty have been shown to be effective and less invasive techniques to treat painful vertebral hemangiomas compared with open surgical treatment, transarterial embolization or lytic therapies ^5,6. Multiple hemangiomas are encountered in about one third of patients with spinal hemangiomas, but sacral involvement is uncommon ⁷. As such painful sacral hemangiomas are rare entities and as a result experience with sacroplasty as potential treatment option is very limited ^8-10.

To our knowledge, there is only one previous case report of successful treatment of a symptomatic sacral hemangioma using sacroplasty ¹⁴. The principles are the same as in treatment of symptomatic vertebral hemangiomas using vertebroplasty and kyphoplasty. Heat generated by exothermic reaction during PMMA hardening helps to destroy tumoral tissue producing pain relief. Our patient experienced near complete pain relief after the procedure and was able to ambulate without difficulty, similar to the results reported by Atalay et al. ¹⁴ Percutaneous sacroplasty has already been shown to be an effective alternative to traditional medical therapy for sacral insufficiency fractures ¹⁵. The use of CT fluoroscopy allows more accurate needle placement and potentially improved assessment of cement extrusion compared with conventional fluoroscopy. Contraindications to this procedure include bleeding disorders, unstable fracture and infection. Complications are infrequent and include venous intravasation with pulmonary embolism, infection and cement migration into and compromise of the neural foramen ¹⁵.

Conclusion

Percutaneous image-guided sacroplasty is a simple, effective and minimally invasive treatment option for symptomatic sacral hemangiomas. The principles are the same as in treatment of symptomatic vertebral hemangiomas using vertebroplasty and kyphoplasty. Image-guided sacroplasty can eliminate the need for long-term narcotics and is an effective alternative to open surgical management, transarterial embolization or lytic therapies.