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J Spinal Disord Tech. 2011 Jun;24(4):268-75. doi: 10.1097/BSD.0b013e3181efe0a4.

Treatment of Enneking stage 3 aggressive vertebral hemangiomas with intralesional spondylectomy: report of 10 cases and review of the literature.

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  • 1Department of Neurological Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.



A retrospective review of consecutive series of Enneking stage 3 vertebral hemangiomas surgically treated at a major tertiary spine tumor center.


To determine the short-term recurrence rates, pain improvement, and operative morbidity of intralesional spondylectomy combined with preoperative embolization for Enneking stage 3 vertebral hemangiomas.


Aggressive vertebral hemangiomas (Enneking stage 3) often involve both the anterior and posterior columns with spinal canal and local soft tissue extension and may present with dramatic bony destruction, spinal instability, and pain accompanied with neurologic compromise. Although the current treatment paradigm for most vertebral hemangiomas is conservative management directed toward symptomatic relief, the subset of patients presenting with this rare variant requires more extensive surgical treatment.


A retrospective clinical review of patients diagnosed with Enneking stage 3 vertebral hemangiomas was conducted at the University of California at San Francisco.


We identified 10 consecutive cases of Enneking stage 3 hemangiomas. Average follow-up was 2.42 years. The most common presentation was pain with or without myelopathy. Three of the 10 cases were recurrences after prior partial resection and reconstruction or cement augmentation. All patients underwent preoperative embolization. Average blood loss despite embolization was 2.1 L (range: 0.8 to 5 L). Average preoperative back pain visual analog scale was 7.2 and postoperative visual analog scale was 3.1 at 6 months. On postoperative imaging, all patients had gross total resection. Six patients had staged posterior/anterior transcavitary approach and 4 patients underwent single stage posterior transpedicular spondylectomy. To date, no patient has required adjuvant radiation therapy for tumor recurrence.


Our results suggest that complete wide resection of aggressive Enneking stage 3 lesions can be safely accomplished with acceptable morbidity and blood loss and significant improvement in pain and neurological status. Partial resection of stage 3 lesions, even with stabilization or vertebroplasty, may lead to early recurrence.

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