ABSTRACT
Purpose: We studied the clinico-radiological features and treatment outcomes of patients with aggressive spinal haemangiomas. Methods: We undertook a retrospective review of 24 patients with aggressive spinal haemangiomas managed at our centre from 2004 to 2016. The cohort was divided into two groups. Group1 included patients managed from 2004 to 2009 while Group 2 was those treated between 2010 and 2016. Clinicoradiological features and treatment outcomes were studied. Results: Back pain (24/24) and myelopathy (18/24) were the most common presenting complaints. Over 80% (20/24) of patients, had involvement of the thoracic spine and more than 50% (13/24) had severe spasticity, being Nurick grade 4&5 at presentation. The various treatment modalities used were laminectomy with or without instrumented posterior fusion (10/24), corpectomy with instrumented fusion (10/24) and alcohol injection alone (4/24). Patients who were treated with surgery had significant clinical improvement at follow-up in both groups. Patients who underwent alcohol injection did not have any improvement in symptoms at follow-up. There was a change in our strategy in the later part of the series from a two staged anterior and posterior approach to a single staged posterior-only approach to address vertebral body disease with preoperative angioembolization. Conclusion: Haemangiomas are benign lesions with locally aggressive behavior in some cases. Results of conservative approaches such as alcohol injection in management of these lesions are discouraging. Aggressive surgical decompression combined with preoperative adjuncts such as angioembolization with or without stabilization reduces intra operative blood loss and results in good neurological recovery even in patients with severe myelopathy.
ABSTRACT
INTRODUCTION: The course of the vertebral artery after exiting from the C1 foramen transversarium and prior to entering the dura lends itself to compression in C1-2 instability. However, atlantoaxial dislocation presenting with vertebrobasilar insufficiency and posterior circulation stroke (PCS) is rare. METHODS: In this retrospective study, we identified 96 patients with PCS who had complete radiological data. Ten (10.4%) patients had craniovertebral junction (CVJ) anomalies, of which six underwent surgery and four were managed conservatively. The clinical and functional outcomes were measured in the two groups. RESULTS: Left-sided strokes were seen in 7/10 patients, the majority of whom had left dominant vertebral arteries. The mean age at presentation in those with CVJ anomalies was 27.2 ± 12.8 years that was significantly lower than those without CVJ anomalies, 52.2 ± 14.5 years (p ≤ 0.001). The etiologies of PCS in those < 50 years were CVJ anomalies (30%), atherosclerosis (30%) and vasculitis (27%); however, the overwhelming majority of strokes in the > 50 year age group was atherosclerosis (91%). Postoperatively, there were no recurrent strokes in the operated patients, who also obtained significant clinical improvement on the modified Rankin Scale, Nurick Scale and modified McCormick Scale as compared to those who did not undergo surgery. CONCLUSION: Early diagnosis and surgical treatment of CVJ instability prevent recurrent strokes and improve outcomes in patients with PCS. Physicians and spine surgeons need to be sensitized regarding CVJ anomalies as a cause of PCS enabling early diagnosis with dynamic imaging particularly in the younger age group. These slides can be retrieved under Electronic Supplementary Material.
