Decompression surgery with intraoperative vertebroplasty: A reduced invasiveness treatment strategy for aggressive vertebral hemangiomas

Decompression surgery with intraoperative vertebroplasty: A reduced invasiveness treatment strategy for aggressive vertebral hemangiomas | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Decompression surgery with intraoperative vertebroplasty: A reduced invasiveness treatment strategy for aggressive vertebral hemangiomas Ben Wang, Jiasheng Chen, Ruomu Qu, Xiang Li, Yanchao Tang, Panpan Hu, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6529168/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Aggressive vertebral hemangiomas (VHs) are rare benign tumors but can cause neurological deficits. Currently, the optimal treatment strategy for aggressive VHs remains controversial. The purpose of study is to evaluate the safety and efficacy of decompression surgery with intraoperative vertebroplasty for the treatment of aggressive VHs. Methods A total of 85 aggressive VH patients with neurological deficits who underwent decompression surgery with intraoperative vertebroplasty between January 2010 and May 2024 were included in this study. Clinical data such as patient demographics, symptoms, neurological function, pain levels, radiologic features, surgical information, pathology, and perioperative complications, were recorded and analyzed. Enneking staging was determined based on radiological findings. Neurological function and pain levels were assessed using the Frankel grade and the Visual Analogue Scale (VAS), respectively. The minimum follow-up duration was 12 months. Results The average age of 85 patients (49 male and 36 female) was 51.1 ± 14.3 (21–77) years. Lesions were located in the cervical spine in 1 case, the thoracic spine in 67 cases, and the lumbar spine in 17 cases. All surgery procedures were completed successfully with an average surgery duration of 168.2 ± 83.3 (90–500) minutes and an average blood loss of 670.1 ± 674.8 (50–2500) ml. Preoperative embolization significantly reduced intraoperative blood loss (P < 0.01). Postoperatively, the pain levels of patients were significantly alleviated (P < 0.01). The average follow-up duration was 76.1 ± 55.1 (12–182) months and all patients remained alive at the final follow-up. Recurrence was observed in eight patients, one of whom underwent surgery combined with radiotherapy, while the remaining seven received radiotherapy alone, and at the last follow-up, these patients were symptom-free. Adequate and satisfactory intraoperative filling of bone cement could reduce the risk of recurrence (P < 0.01). Conclusions Decompression surgery with intraoperative vertebroplasty can effectively reduce blood loss, alleviate neurological symptoms and reduce the risk of recurrence, and is a safe and effective approach in the management of aggressive VHs. Aggressive vertebral hemangioma Intraoperative vertebroplasty Decompression surgery Radiotherapy Surgical strategy Figures Figure 1 Figure 2 Figure 3 Introduction Vertebral hemangiomas (VHs) represent the most common benign spinal lesions and are often identified incidentally during routine spinal radiographic examinations in patients presenting with back or neck pain [ 1 , 2 ]. Previous studies have reported that the incidence of VHs ranges between 11% and 26% [ 3 – 5 ]. While the vast majority of VHs are asymptomatic and latent (Enneking stage 1, S1), fewer than 5% of patients exhibit clinical manifestations [ 5 ]. Among symptomatic cases, approximately 45% are aggressive (Enneking stage 3, S3), characterized by rapid growth, extension beyond the vertebral body, and invasion into the paravertebral and/or epidural spaces. These lesions may also compress the spinal cord and/or nerve roots, resulting in pain and neurological deficits [ 6 – 9 ]; therefore, timely treatment is essential. Decompression by laminectomy, while relatively straightforward from a technical perspective, is often insufficient for complete tumor resection and is associated with a relatively high risk of recurrence. To minimize the recurrence rate, the current surgical approaches include total en bloc spondylectomy and intralesional vertebrectomy [ 7 – 10 ]. However, these procedures are technically demanding and highly invasive, posing significant challenges in clinical practice. Our institution previously introduced a surgical technique combining decompression with intraoperative vertebroplasty for the treatment of VHs in 2013 and 2018 [ 5 , 11 ]. This approach not only reduces surgical complexity but also significantly decreases the postoperative recurrence rates. Building upon this basis, we further expand the sample size. To the best of our knowledge, this study represents the largest cohort of aggressive VHs reported to date. Additionally, we extend the follow-up period to further validate the efficacy and safety of this technique. We aim to provide more data and evidence, offering valuable insights and references for the management of aggressive VHs. Materials and methods This retrospective study was approved by the Peking University Third Hospital Ethics Committee (No. M2017106) and conducted in accordance with the Declaration of Helsinki. Study population We conducted a retrospective review of patients with VHs who underwent decompression surgery with intraoperative vertebroplasty at our institution between January 2010 and May 2024. Following the exclusion of patients with incomplete follow-up records and/or missing clinical data, a total of 85 patients with a confirmed pathologic diagnosis of aggressive VH were included. Clinical data were systematically extracted from patient records and documented using a pre-designed data collection form. The collected variables included patient demographics (age and sex), clinical manifestations (symptoms, pain levels, and neurological function), radiological characteristics, surgical details (approach, duration, and intraoperative blood loss), pathological findings, length of hospital stay, and perioperative complications. Pain levels were quantified using the Visual Analogue Scale (VAS). Neurological function was evaluated according to the Frankel grade. The Enneking stage was determined based on radiological evaluations. Imaging Anteroposterior and lateral spinal radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) were routinely conducted for every patient. The typical radiographic features of aggressive VHs include vertical striations, a honeycomb appearance, a “polka-dot sign” on CT, and/or a salt-and-pepper appearance on MRI [ 12 ]. Preoperative and postoperative CT images were imported into AutoCAD 2020 (AUTODESK Inc., San Rafael, CA) to measure the maximum cross-sectional areas of the lesions and the bone cement. The intraoperative cement filling rate was calculated as the ratio of the bone cement area to the lesion area. A fill rate of ≥ 80% is considered satisfactory. (Figs. 1 A–H, 2 A–H, and 3 A–H) Biopsy Lesions exhibiting atypical imaging features, such as osteolytic vertebral bone destruction, could be challenging to differentiate from malignant vascular tumors or multiple myeloma, increasing the risk of misdiagnosis. In such cases, percutaneous CT-guided biopsy was typically performed to facilitate the accurate diagnosis of VHs [ 12 ]. Treatment protocol Treatment protocol Surgical indications included aggressive VHs combined with neurological deficits. For patients with mild or slowly progressive neurological deficits, radiotherapy was the preferred treatment modality. All surgical procedures were performed by experienced surgeons. Follow-up X-rays were performed at 3 months, 6 months, and 12 months in the first postoperative year and annually thereafter. MRI was conducted at 3 months post-surgery and was repeated annually. At the 3-month follow-up, contrast-enhanced CT was utilized to assess residual lesions; if detected, adjuvant radiotherapy with a dose of 40–50 Gy was recommended to prevent recurrence. In cases where symptoms suggestive of local recurrence emerged, MRI was promptly performed. The minimum follow-up duration for all patients was 12 months. Surgical techniques Patients were positioned prone to expose the surgical site. Following stepwise exposure, the vertebral bodies were visualized, and pedicle screws were inserted. Posterior decompression involved resection of the adjacent cephalic and caudal laminae to expose the dural sac. Bilateral transpedicular cement injection was then performed into the affected vertebral body to induce shrinkage of the vascular malformation. Under fluoroscopic guidance, the cannula tip was advanced to the anterior border of the lesion, ensuring adequate cement distribution within the vertebral body to reduce the volume of the epidural tumor. The cement acts by inducing irreversible sclerosis of venous pools and intralesional thrombosis within the hemangioma. In cases of intravertebral fractures, it also provided internal stabilization of spongy bone trabecular microfractures, enhances spinal structural support, and alleviates back pain. The reduction in blood loss and direct visualization of the adjacent dural sac increased the safety of laminectomy at the lesion site. Additionally, bipolar electrocoagulation was employed to further reduce the epidural mass, achieving adequate decompression. In instances of significant bony compression, additional bony curettage of the vertebral body was performed. Finally, posterolateral fusion was completed using autogenous or artificial bone following instrumentation. Statistical analysis Continuous variables were presented as mean ± SD, while categorical variables were presented in terms of absolute quantity and frequency. Statistical comparisons of continuous variables were performed using the Mann‒Whitney U test or Student’s t test. For categorical variables, the Chi-square test or Fisher’s exact test was employed. A p value of < 0.05 was considered statistically significant. Time-to-event data were defined as the interval from the date of surgery to the occurrence of the corresponding event (e.g., recurrence). All the statistical analyses were conducted using SPSS version 21.0 (IBM Corp., Armonk, NY). Results This study included 49 male and 36 female patients, with an average age of 51.1 ± 14.3 years (range: 21–77) (Table 1 ). All 85 patients presented with neurological deficits due to VHs. Four patients (4.7%) exhibited cauda equine syndrome, 16 patients (18.8%) presented with radiculopathy, and 65 cases (76.5%) demonstrated myelopathy (including 4 patients with Frankel B, 9 patients with Frankel C, and 52 patients with Frankel D). Additionally, 57 patients complained of back pain. The average interval from symptom onset to surgical treatment was 8.4 ± 9.6 (0.25–26) months. All surgical procedures were successfully completed. Table 1 Clinical characteristics of 85 patients. Characteristics N (% of total cases) or Mean ± SD (range) Male : Female 49 : 36 Age, (years) 51.1 ± 14.3 (21–77) Tumor location, n (%) Cervical 1 (1.2%) Thoracic 67 (78.8%) Lumbar 17 (20.0%) Neurological deficits Cauda equine syndrome 4 (4.7%) Radiculopathy 16 (18.8%) Myelopathy 65 (76.5%) Typical imaging features 47 Preoperative embolization 14 Hospital stays (days) 9.8 ± 5.4 Surgery duration (minutes) 168.2 ± 83.3 (90–500) Blood loss (ml) 670.1 ± 674.8 (50-2500) Follow-up duration (months) 76.1 ± 55.1 (12–182) Aggressive VHs involved the cervical spine in 1 case, the thoracic spine in 67 cases, and the lumbar spine in 17 cases. Thirteen patients had multiple vertebral lesions with only one vertebra in each patient exhibiting symptomatic Enneking stage 3 (S3) lesions. Among these patients, 4 had hemangiomatous lesions confined to the vertebral bodies, while the remaining patients demonstrated extension into the posterior arch. In all cases, the hemangiomas extended outward from the vertebral body into the spinal canal and/or paravertebral soft tissue. A unilateral pedicle was involved in 17 cases, while bilateral pedicles were affected in the remaining 65 cases. Nerve compression was attributed to soft tumor masses in 57 cases and to a combination of bony compression and soft tumor masses in 28 cases. CT and/or MRI findings of 47 patients were consistent with the typical imaging features of VHs. Among the 38 patients with atypical imaging findings, CT-guided biopsy was performed, with 28 cases (73.7%) confirmed pathologically. The pathological results for the remaining 10 patients were inconclusive with only blood tissues. Decompression surgery with intraoperative vertebroplasty All patients underwent decompression surgery with intraoperative vertebroplasty. The average surgery duration was 168.2 ± 83.3 (90–500) minutes, and the average blood loss was 670.1 ± 674.8 (50–2500) ml. Intraoperative blood transfusion was performed in 29 patients, with an average transfusion volume of 789 ± 669 ml. A total of 14 patients underwent preoperative embolization, and the volume of intraoperative blood loss was 473.3 ± 304.1 ml. In contrast, patients who did not undergo embolization had an average intraoperative blood loss of 721.9 ± 735.7 ml. The difference between the two groups was statistically significant (P < 0.01), demonstrating that preoperative embolization effectively reduces intraoperative blood loss. This finding was consistent with the report by Cotten et al. [ 13 ]. Symptom relief On admission, 33 patients (38.8%) reported mild pain (VAS 1–4), 25 patients (29.4%) experienced moderate pain (VAS 5–6), and 11 patients (12.9%) suffered from severe pain (VAS 7–10). At the three-month postoperative follow-up, complete pain relief was achieved in 13 patients, 55 patients experienced mild pain, and 1 patient reported moderate pain. The average preoperative and postoperative VAS scores were 3.8 ± 2.4 and 1.5 ± 1.1, respectively, indicating a statistically significant improvement in pain levels (P < 0.01). At the final follow-up, 45 patients with preoperative neurological deficits had fully recovered to normal neurological function (Frankel E). The remaining patients demonstrated either improvement or stabilization of their neurological status, with no further deterioration observed. Perioperative complications A total of 19 perioperative complications were documented. Intraoperative complications included three cases of dural tears (3.5%), all of which were successfully repaired. After surgery, eight patients (9.4%) developed unexplained fever, and one patient (1.2%) experienced urinary system infection; these symptoms resolved with intravenous empiric antibiotic therapy. Cerebrospinal fluid (CSF) leakage occurred in three patients (4.5%) and was managed with flat bed rest combined with hypertonic saline infusion. Additionally, four patients (4.8%) experienced electrolyte disturbances that resolved with appropriate symptomatic treatment. Follow-up and recurrence No patients were lost to follow-up, and all remained alive at the final follow-up. One patient reported mild localized numbness and pain at the surgical site, while two patients experienced slight numbness in their lower extremities. The remaining patients were symptom-free. The average follow-up duration was 76.1 ± 55.1 (12–182) months. Recurrence was observed in seven patients (8.2%), with an average recurrence time of 68 (12–108) months postoperatively. One patient underwent a combination of surgery and radiotherapy, while the others were treated with radiotherapy alone. At the last follow-up, all patients had recovered with no neurological symptoms. Bone cement filling effects The average bone cement filling rate of all patients was 87.1% ± 5.1%. We proposed that when the filling rate of bone cement was ≥ 80%, the filling effect was satisfactory. In the recurrence group, the average filling rate was 77.8% ± 5.2%, with 4 patients (33.3%) failing to achieve satisfactory filling, while in patients without recurrence, an average filling rate of 88.0% ± 4.2% was achieved, with unsatisfactory filling observed in 8 patients (10.3%). The recurrence rate was 33.3% (4/12) in patients with unsatisfactory filling, while only 3 cases (4.1%) of recurrence were observed among those with satisfactory filling. The results revealed that satisfactory intraoperative filling could reduce the risk of recurrence (P < 0.01). Discussion VHs were first described in 1867, with the initial radiologic characterization reported in 1926. VHs are a type of benign vascular malformation composed of vascular spaces lined by endothelial cells. The vast majority of VHs are asymptomatic and do not require specific interventions. However, aggressive VHs can cause vertebral body destruction and spinal cord compression, leading to pathologic fractures and neurological deficits, necessitating clinical management [ 14 , 15 ]. Due to its low incidence, there is currently no consensus on the optimal treatment strategy for aggressive VHs. Decompressive laminectomy, while technically straightforward, is often insufficient for complete tumor removal and is associated with a high risk of recurrence. In Pastushyn et al.’s study [ 16 ], 18.6% of patients who underwent laminectomy for VHs experienced recurrence. Complete tumor resection, whether performed intralesional or extralesional, is associated with a lower recurrence rate. In Goldstein et al.’s study [ 7 ], no tumor recurrence was observed in patients with aggressive VHs who underwent en bloc resection. Among the 37 patients who underwent intralesional vertebrectomy, only two experienced recurrence, with a recurrence rate of 5.4%. However, these procedures were characterized by prolonged surgery duration, significant blood loss, and technical complexity [ 5 , 7 – 9 , 17 – 19 ]. In the case of total en bloc spondylectomy reported by Inoue et al. [ 18 ], the surgical duration extended to 565 minutes, with blood loss reaching 4000 ml despite preoperative embolization. Similarly, the average blood loss during intralesional vertebrectomy combined with preoperative embolization was 2100 (800–5000) ml [ 8 ]. Chandra et al. [ 20 ] and Singh et al. [ 21 ] reported that absolute alcohol embolization combined with decompression surgery allowed for relatively low blood loss. However, although this procedure was less technically demanding, it carried a greater risk of complications, such as infection, vertebral collapse and Brown-Séquard syndrome [ 22 , 23 ]. We first introduced the use of decompression surgery with intraoperative vertebroplasty for the treatment of VHs in 2013. This approach achieved vascular shrinkage and obliteration through the sealing effect of bone cement. [ 5 ]. In 2018, we conducted a comparative study between this technique and decompression surgery alone [ 11 ], and our results demonstrated that this technique was a safe, effective and technically undemanding method for reducing blood loss and minimizing postoperative recurrence. Cotten et al. [ 13 ] also highlighted that preoperative embolization combined with vertebroplasty further minimized intraoperative blood loss. Since our team publicized this technique, it has gained widespread recognition and adoption, with several similar and modified approaches subsequently reported in the literature [ 24 – 29 ]. To the best of our knowledge, the sample size of this study represents the largest among the available studies on VHs treatment to date. During the follow-up period, recurrence was observed in seven patients, with a recurrence rate of 8.2%, which is higher than that of complete tumor resection but lower than that of laminectomy alone [ 7 , 16 ]. Compared with complete tumor resection, although this surgical approach had a higher recurrence rate, it offered distinct advantages, including simpler operation, greater safety, shorter surgery duration, and reduced intraoperative blood loss. Furthermore, when combined with postoperative radiotherapy, it could effectively reduce the risk of recurrence. We propose that inadequate filling of VH lesions during surgery is a primary contributing factor to recurrence. If the cement fails to seal all lesion areas, the residual lesions may continue to grow, and the blood supply may be reestablished. The complex morphology of hemangiomas (e.g., multilocularity, irregular borders) may further complicate complete filling. Additionally, the viscosity and setting time of the cement, the assessment of the lesion extent, the injection pressure, and the accuracy of the injection location all influence the filling outcomes. To minimize the risk of recurrence, we recommend that the filling rate should not be less than 80%. In our study, the average bone cement filling rate was 87.1% ± 5.1%. Unsatisfactory cement filling was observed in 12 patients, among whom 4 patients experienced postoperative recurrence, with a recurrence rate of 33.3%. However, among the 73 patients with a fill rate of ≥ 80%, only 3 cases of recurrence were observed (4.1%). The results demonstrated that unsatisfactory bone cement filling was significantly positively correlated with the risk of recurrence, and adequate filling significantly reduced recurrence (P 3/5), radiotherapy at a dose of 40–50 Gy, which can alleviate pain and eliminate hemangiomas through vascular necrosis and/or anti-inflammatory effects, is the preferred treatment [ 30 ]. Consequently, radiotherapy is also a viable option for managing some cases of recurrence. In our study, all six patients who experienced recurrence and underwent radiotherapy recovered well and were symptom-free at the final follow-up. Furthermore, adjuvant radiotherapy can be considered when postoperative imaging reveals suboptimal cement filling to reduce the risk of recurrence. Although radiotherapy is associated with potential complications, including radiation necrosis, radiation myelitis, and secondary malignancies, none of these complications were observed in our study. Heyd et al. noted that the risk of radiotherapy-induced secondary malignancies was overemphasized [ 31 ]. Limitations The primary limitations of this study include its retrospective design and the relatively limited sample size from a single center. The nonrandomized nature of the study introduces unavoidable bias and reduces the level of evidence. In the future, multicenter, large-scale, controlled clinical studies are necessary to establish robust management guidelines for patients with VHs. Conclusion In conclusion, our findings demonstrate that decompression surgery with intraoperative vertebroplasty is a safe and effective approach for treating aggressive VHs, significantly reducing intraoperative blood loss and alleviating neurological symptoms. Adequate intraoperative cement filling effectively reduces the risk of recurrence and postoperative radiotherapy is conducive to preventing and treating recurrence. Declarations Author Contribution Ben Wang designed this study. Jiasheng Chen and Ben Wang collected data and follow-up related information, prepared figures and tables, and wrote the main manuscript text. Ruomu Qu and Xiang Li assisted with data collection and manuscript writing. Yanchao Tang, Panpan Hu, Zihe Li, Yan Li, and Hua Zhou assisted with data analysis and figures making. Xiaoguang Liu, Zhongjun Liu and Feng Wei revised the manuscript. All authors contributed to the article and approved the final submitted manuscript. References Kato, K., et al., Vertebral hemangiomas: a review on diagnosis and management. J Orthop Surg Res, 2024. 19(1): p. 310. https://doi.org/10.1186/s13018-024-04799-5 Baudrez, V., C. Galant, and B.C. Vande Berg, Benign vertebral hemangioma: MR-histological correlation. Skeletal Radiol, 2001. 30(8): p. 442-6. https://doi.org/10.1007/s002560100390 Huvos AG. Hemangioma, lymphangioma, angiomatosis/lymphangiomatosis, glomus tumor. Bone tumors: diagnosis, treatment, and prognosis. 2nd ed. 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Int J Radiat Oncol Biol Phys, 2010. 77(1): p. 217-25. https://doi.org/10.1016/j.ijrobp.2009.04.055 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 16 Feb, 2026 Reviews received at journal 14 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviews received at journal 12 Jun, 2025 Reviewers agreed at journal 12 Jun, 2025 Reviewers invited by journal 11 Jun, 2025 Editor assigned by journal 05 May, 2025 Submission checks completed at journal 05 May, 2025 First submitted to journal 25 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6529168","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":470257488,"identity":"c3686b38-4978-4188-b471-56eba415ad01","order_by":0,"name":"Ben Wang","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Ben","middleName":"","lastName":"Wang","suffix":""},{"id":470257489,"identity":"8d202316-c79e-44c8-ac12-e1de6abd6e40","order_by":1,"name":"Jiasheng Chen","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Jiasheng","middleName":"","lastName":"Chen","suffix":""},{"id":470257490,"identity":"6dfbc3a3-315a-4de3-9496-e991d4f6f9d0","order_by":2,"name":"Ruomu Qu","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Ruomu","middleName":"","lastName":"Qu","suffix":""},{"id":470257491,"identity":"c8c0a8ec-128e-421e-97e1-514831b7c90c","order_by":3,"name":"Xiang Li","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Xiang","middleName":"","lastName":"Li","suffix":""},{"id":470257492,"identity":"49d233a2-2a9e-463f-9fcf-c1d13a3fcdb2","order_by":4,"name":"Yanchao Tang","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Yanchao","middleName":"","lastName":"Tang","suffix":""},{"id":470257493,"identity":"caab1e1b-2d39-4082-94ba-ddc242d8a443","order_by":5,"name":"Panpan Hu","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Panpan","middleName":"","lastName":"Hu","suffix":""},{"id":470257494,"identity":"d9f29e34-568c-412c-9c41-24c28e15f5a6","order_by":6,"name":"Zihe Li","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Zihe","middleName":"","lastName":"Li","suffix":""},{"id":470257495,"identity":"7498bc42-f120-4099-b38e-0ea500175d06","order_by":7,"name":"Yan Li","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Li","suffix":""},{"id":470257496,"identity":"4a270422-c3d9-4736-9e45-5e8675d6003f","order_by":8,"name":"Hua Zhou","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Hua","middleName":"","lastName":"Zhou","suffix":""},{"id":470257497,"identity":"d057b8ac-5d1a-4457-b0d1-09877ab11b70","order_by":9,"name":"Xiaoguang Liu","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Xiaoguang","middleName":"","lastName":"Liu","suffix":""},{"id":470257498,"identity":"6b6d8633-061c-4e42-9473-9798c4dc527c","order_by":10,"name":"Zhongjun Liu","email":"","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":false,"prefix":"","firstName":"Zhongjun","middleName":"","lastName":"Liu","suffix":""},{"id":470257499,"identity":"1c81ce80-498e-42f5-a15d-3cb6ab5f8b15","order_by":11,"name":"Feng Wei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYFACxoYPQFLOgOEAiMdMlJbGGUDSmBQtDIwgLYkbIBwitBgcb25s+LijNn074+k0CYYK68QG9rMH8Gs5c7CxceaZ47k7G85uk2A4k57YwJOXgFeL2Y3E9se8bcdyNxwAamFsO5zYIMFjgF/L/YeNzX/bjqUbgLX8I0bLDcbGZsa2mgSIlgYitNifSWxs7G07YAj0y2aLhGPpxm08Ofi1SLYff9jws61O3lzi7MYbH2qsZfvZz+DXAgWHGRgkDjAwJACZbMSoB4I6Bgb+BiLVjoJRMApGwYgDAMJsUcgObYRyAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Orthopaedics, Peking University Third Hospital, Haidian District","correspondingAuthor":true,"prefix":"","firstName":"Feng","middleName":"","lastName":"Wei","suffix":""}],"badges":[],"createdAt":"2025-04-25 13:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6529168/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6529168/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84819168,"identity":"795329b9-7996-445d-a3da-57893d7e4944","added_by":"auto","created_at":"2025-06-17 15:57:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":564728,"visible":true,"origin":"","legend":"\u003cp\u003eCase 1. A 35-year-old female presented with back pain for one month and cauda equina syndrome for two weeks. Frankel C. (A-D) Sagittal and axial CT and MRI revealed that VHs lesions were located at the T5. (E-H) She underwent decompression surgery and intraoperative vertebroplasty in September 2017. The filling rate of bone cement was measured to be 91.2%. The pain has significantly alleviated. (The preoperative and postoperative VAS scores were 4 and 1, respectively.) During 90 months follow-up, she was symptom-free (Frankel E) and without recurrence.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6529168/v1/302a8478dc4ead4783231c2b.png"},{"id":84817510,"identity":"68fd926e-b50c-4026-8499-9b7c3b107611","added_by":"auto","created_at":"2025-06-17 15:49:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":523941,"visible":true,"origin":"","legend":"\u003cp\u003eCase 2. A 45-year-old female presented with myelopathy and back pain for 11 months. Frankel C. (A-D) Sagittal and axial CT and MRI showed lesions in T8. (E-H) She underwent decompression surgery and intraoperative vertebroplasty in December 2018 and to prevent recurrence, she received radiotherapy 3 months postoperatively. The filling rate of bone cement was measured to be 89.5%. During 75 months follow-up, no recurrence was observed and she was symptom-free.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6529168/v1/758f3438c164ba19840690eb.png"},{"id":84817514,"identity":"bc3c7463-d518-4929-ae6b-afa105091a9c","added_by":"auto","created_at":"2025-06-17 15:49:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":570524,"visible":true,"origin":"","legend":"\u003cp\u003eCase 3. A 64-year-old female presented with L3 radiculopathy and back pain for 3 years. Frankel D. (A-D) Sagittal and axial CT and MRI showed lesions in L3. (E-H) She underwent decompression surgery and intraoperative vertebroplasty in June 2018. The filling rate of bone cement was measured to be 73.9%. In February 2023, the CT scan indicated recurrence of the VHs, and therefore, she underwent radiotherapy. At the last follow-up, she was alive without any symptom and no apparent recurrence was observed.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6529168/v1/a3c3dd56ce7b0f1c4d5a2702.png"},{"id":84821806,"identity":"71ef3cfe-bac9-4379-b900-ce2f1d63d524","added_by":"auto","created_at":"2025-06-17 16:13:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2913705,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6529168/v1/07e6d3bd-799d-4c28-8e8c-ebef3ba920d5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Decompression surgery with intraoperative vertebroplasty: A reduced invasiveness treatment strategy for aggressive vertebral hemangiomas","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVertebral hemangiomas (VHs) represent the most common benign spinal lesions and are often identified incidentally during routine spinal radiographic examinations in patients presenting with back or neck pain [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Previous studies have reported that the incidence of VHs ranges between 11% and 26% [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While the vast majority of VHs are asymptomatic and latent (Enneking stage 1, S1), fewer than 5% of patients exhibit clinical manifestations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Among symptomatic cases, approximately 45% are aggressive (Enneking stage 3, S3), characterized by rapid growth, extension beyond the vertebral body, and invasion into the paravertebral and/or epidural spaces. These lesions may also compress the spinal cord and/or nerve roots, resulting in pain and neurological deficits [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; therefore, timely treatment is essential.\u003c/p\u003e \u003cp\u003eDecompression by laminectomy, while relatively straightforward from a technical perspective, is often insufficient for complete tumor resection and is associated with a relatively high risk of recurrence. To minimize the recurrence rate, the current surgical approaches include total en bloc spondylectomy and intralesional vertebrectomy [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, these procedures are technically demanding and highly invasive, posing significant challenges in clinical practice.\u003c/p\u003e \u003cp\u003eOur institution previously introduced a surgical technique combining decompression with intraoperative vertebroplasty for the treatment of VHs in 2013 and 2018 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This approach not only reduces surgical complexity but also significantly decreases the postoperative recurrence rates. Building upon this basis, we further expand the sample size. To the best of our knowledge, this study represents the largest cohort of aggressive VHs reported to date. Additionally, we extend the follow-up period to further validate the efficacy and safety of this technique. We aim to provide more data and evidence, offering valuable insights and references for the management of aggressive VHs.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e This retrospective study was approved by the Peking University Third Hospital Ethics Committee (No. M2017106) and conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective review of patients with VHs who underwent decompression surgery with intraoperative vertebroplasty at our institution between January 2010 and May 2024. Following the exclusion of patients with incomplete follow-up records and/or missing clinical data, a total of 85 patients with a confirmed pathologic diagnosis of aggressive VH were included.\u003c/p\u003e \u003cp\u003eClinical data were systematically extracted from patient records and documented using a pre-designed data collection form. The collected variables included patient demographics (age and sex), clinical manifestations (symptoms, pain levels, and neurological function), radiological characteristics, surgical details (approach, duration, and intraoperative blood loss), pathological findings, length of hospital stay, and perioperative complications. Pain levels were quantified using the Visual Analogue Scale (VAS). Neurological function was evaluated according to the Frankel grade. The Enneking stage was determined based on radiological evaluations.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImaging\u003c/h3\u003e\n\u003cp\u003eAnteroposterior and lateral spinal radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) were routinely conducted for every patient. The typical radiographic features of aggressive VHs include vertical striations, a honeycomb appearance, a \u0026ldquo;polka-dot sign\u0026rdquo; on CT, and/or a salt-and-pepper appearance on MRI [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePreoperative and postoperative CT images were imported into AutoCAD 2020 (AUTODESK Inc., San Rafael, CA) to measure the maximum cross-sectional areas of the lesions and the bone cement. The intraoperative cement filling rate was calculated as the ratio of the bone cement area to the lesion area. A fill rate of \u0026ge;\u0026thinsp;80% is considered satisfactory. (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA\u0026ndash;H, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA\u0026ndash;H, and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA\u0026ndash;H)\u003c/p\u003e \n\u003ch3\u003eBiopsy\u003c/h3\u003e\n\u003cp\u003eLesions exhibiting atypical imaging features, such as osteolytic vertebral bone destruction, could be challenging to differentiate from malignant vascular tumors or multiple myeloma, increasing the risk of misdiagnosis. In such cases, percutaneous CT-guided biopsy was typically performed to facilitate the accurate diagnosis of VHs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eTreatment protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eTreatment protocol\u003c/div\u003e \u003cp\u003eSurgical indications included aggressive VHs combined with neurological deficits. For patients with mild or slowly progressive neurological deficits, radiotherapy was the preferred treatment modality. All surgical procedures were performed by experienced surgeons.\u003c/p\u003e\n\u003ch3\u003eFollow-up\u003c/h3\u003e\n\u003cp\u003eX-rays were performed at 3 months, 6 months, and 12 months in the first postoperative year and annually thereafter. MRI was conducted at 3 months post-surgery and was repeated annually. At the 3-month follow-up, contrast-enhanced CT was utilized to assess residual lesions; if detected, adjuvant radiotherapy with a dose of 40\u0026ndash;50 Gy was recommended to prevent recurrence. In cases where symptoms suggestive of local recurrence emerged, MRI was promptly performed. The minimum follow-up duration for all patients was 12 months.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSurgical techniques\u003c/h2\u003e \u003cp\u003ePatients were positioned prone to expose the surgical site. Following stepwise exposure, the vertebral bodies were visualized, and pedicle screws were inserted. Posterior decompression involved resection of the adjacent cephalic and caudal laminae to expose the dural sac. Bilateral transpedicular cement injection was then performed into the affected vertebral body to induce shrinkage of the vascular malformation. Under fluoroscopic guidance, the cannula tip was advanced to the anterior border of the lesion, ensuring adequate cement distribution within the vertebral body to reduce the volume of the epidural tumor. The cement acts by inducing irreversible sclerosis of venous pools and intralesional thrombosis within the hemangioma. In cases of intravertebral fractures, it also provided internal stabilization of spongy bone trabecular microfractures, enhances spinal structural support, and alleviates back pain. The reduction in blood loss and direct visualization of the adjacent dural sac increased the safety of laminectomy at the lesion site. Additionally, bipolar electrocoagulation was employed to further reduce the epidural mass, achieving adequate decompression. In instances of significant bony compression, additional bony curettage of the vertebral body was performed. Finally, posterolateral fusion was completed using autogenous or artificial bone following instrumentation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, while categorical variables were presented in terms of absolute quantity and frequency. Statistical comparisons of continuous variables were performed using the Mann‒Whitney U test or Student\u0026rsquo;s t test. For categorical variables, the Chi-square test or Fisher\u0026rsquo;s exact test was employed. A p value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. Time-to-event data were defined as the interval from the date of surgery to the occurrence of the corresponding event (e.g., recurrence). All the statistical analyses were conducted using SPSS version 21.0 (IBM Corp., Armonk, NY).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study included 49 male and 36 female patients, with an average age of 51.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3 years (range: 21\u0026ndash;77) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All 85 patients presented with neurological deficits due to VHs. Four patients (4.7%) exhibited cauda equine syndrome, 16 patients (18.8%) presented with radiculopathy, and 65 cases (76.5%) demonstrated myelopathy (including 4 patients with Frankel B, 9 patients with Frankel C, and 52 patients with Frankel D). Additionally, 57 patients complained of back pain. The average interval from symptom onset to surgical treatment was 8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6 (0.25\u0026ndash;26) months. All surgical procedures were successfully completed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics of 85 patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (% of total\u003c/p\u003e \u003cp\u003ecases) or Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale : Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 : 36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3 (21\u0026ndash;77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor location, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (78.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurological deficits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCauda equine syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiculopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyelopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (76.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypical imaging features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative embolization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stays (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery duration (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168.2\u0026thinsp;\u0026plusmn;\u0026thinsp;83.3 (90\u0026ndash;500)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e670.1\u0026thinsp;\u0026plusmn;\u0026thinsp;674.8 (50-2500)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up duration (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.1\u0026thinsp;\u0026plusmn;\u0026thinsp;55.1 (12\u0026ndash;182)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAggressive VHs involved the cervical spine in 1 case, the thoracic spine in 67 cases, and the lumbar spine in 17 cases. Thirteen patients had multiple vertebral lesions with only one vertebra in each patient exhibiting symptomatic Enneking stage 3 (S3) lesions. Among these patients, 4 had hemangiomatous lesions confined to the vertebral bodies, while the remaining patients demonstrated extension into the posterior arch. In all cases, the hemangiomas extended outward from the vertebral body into the spinal canal and/or paravertebral soft tissue.\u003c/p\u003e \u003cp\u003eA unilateral pedicle was involved in 17 cases, while bilateral pedicles were affected in the remaining 65 cases. Nerve compression was attributed to soft tumor masses in 57 cases and to a combination of bony compression and soft tumor masses in 28 cases. CT and/or MRI findings of 47 patients were consistent with the typical imaging features of VHs. Among the 38 patients with atypical imaging findings, CT-guided biopsy was performed, with 28 cases (73.7%) confirmed pathologically. The pathological results for the remaining 10 patients were inconclusive with only blood tissues.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDecompression surgery with intraoperative vertebroplasty\u003c/h2\u003e \u003cp\u003eAll patients underwent decompression surgery with intraoperative vertebroplasty. The average surgery duration was 168.2\u0026thinsp;\u0026plusmn;\u0026thinsp;83.3 (90\u0026ndash;500) minutes, and the average blood loss was 670.1\u0026thinsp;\u0026plusmn;\u0026thinsp;674.8 (50\u0026ndash;2500) ml. Intraoperative blood transfusion was performed in 29 patients, with an average transfusion volume of 789\u0026thinsp;\u0026plusmn;\u0026thinsp;669 ml. A total of 14 patients underwent preoperative embolization, and the volume of intraoperative blood loss was 473.3\u0026thinsp;\u0026plusmn;\u0026thinsp;304.1 ml. In contrast, patients who did not undergo embolization had an average intraoperative blood loss of 721.9\u0026thinsp;\u0026plusmn;\u0026thinsp;735.7 ml. The difference between the two groups was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), demonstrating that preoperative embolization effectively reduces intraoperative blood loss. This finding was consistent with the report by Cotten et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSymptom relief\u003c/h2\u003e \u003cp\u003eOn admission, 33 patients (38.8%) reported mild pain (VAS 1\u0026ndash;4), 25 patients (29.4%) experienced moderate pain (VAS 5\u0026ndash;6), and 11 patients (12.9%) suffered from severe pain (VAS 7\u0026ndash;10). At the three-month postoperative follow-up, complete pain relief was achieved in 13 patients, 55 patients experienced mild pain, and 1 patient reported moderate pain. The average preoperative and postoperative VAS scores were 3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 and 1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1, respectively, indicating a statistically significant improvement in pain levels (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). At the final follow-up, 45 patients with preoperative neurological deficits had fully recovered to normal neurological function (Frankel E). The remaining patients demonstrated either improvement or stabilization of their neurological status, with no further deterioration observed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative complications\u003c/h2\u003e \u003cp\u003eA total of 19 perioperative complications were documented. Intraoperative complications included three cases of dural tears (3.5%), all of which were successfully repaired. After surgery, eight patients (9.4%) developed unexplained fever, and one patient (1.2%) experienced urinary system infection; these symptoms resolved with intravenous empiric antibiotic therapy. Cerebrospinal fluid (CSF) leakage occurred in three patients (4.5%) and was managed with flat bed rest combined with hypertonic saline infusion. Additionally, four patients (4.8%) experienced electrolyte disturbances that resolved with appropriate symptomatic treatment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up and recurrence\u003c/h2\u003e \u003cp\u003eNo patients were lost to follow-up, and all remained alive at the final follow-up. One patient reported mild localized numbness and pain at the surgical site, while two patients experienced slight numbness in their lower extremities. The remaining patients were symptom-free. The average follow-up duration was 76.1\u0026thinsp;\u0026plusmn;\u0026thinsp;55.1 (12\u0026ndash;182) months. Recurrence was observed in seven patients (8.2%), with an average recurrence time of 68 (12\u0026ndash;108) months postoperatively. One patient underwent a combination of surgery and radiotherapy, while the others were treated with radiotherapy alone. At the last follow-up, all patients had recovered with no neurological symptoms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBone cement filling effects\u003c/h2\u003e \u003cp\u003eThe average bone cement filling rate of all patients was 87.1% \u0026plusmn; 5.1%. We proposed that when the filling rate of bone cement was \u0026ge;\u0026thinsp;80%, the filling effect was satisfactory. In the recurrence group, the average filling rate was 77.8% \u0026plusmn; 5.2%, with 4 patients (33.3%) failing to achieve satisfactory filling, while in patients without recurrence, an average filling rate of 88.0% \u0026plusmn; 4.2% was achieved, with unsatisfactory filling observed in 8 patients (10.3%). The recurrence rate was 33.3% (4/12) in patients with unsatisfactory filling, while only 3 cases (4.1%) of recurrence were observed among those with satisfactory filling. The results revealed that satisfactory intraoperative filling could reduce the risk of recurrence (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eVHs were first described in 1867, with the initial radiologic characterization reported in 1926. VHs are a type of benign vascular malformation composed of vascular spaces lined by endothelial cells. The vast majority of VHs are asymptomatic and do not require specific interventions. However, aggressive VHs can cause vertebral body destruction and spinal cord compression, leading to pathologic fractures and neurological deficits, necessitating clinical management [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Due to its low incidence, there is currently no consensus on the optimal treatment strategy for aggressive VHs. Decompressive laminectomy, while technically straightforward, is often insufficient for complete tumor removal and is associated with a high risk of recurrence. In Pastushyn et al.\u0026rsquo;s study [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], 18.6% of patients who underwent laminectomy for VHs experienced recurrence.\u003c/p\u003e \u003cp\u003eComplete tumor resection, whether performed intralesional or extralesional, is associated with a lower recurrence rate. In Goldstein et al.\u0026rsquo;s study [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], no tumor recurrence was observed in patients with aggressive VHs who underwent en bloc resection. Among the 37 patients who underwent intralesional vertebrectomy, only two experienced recurrence, with a recurrence rate of 5.4%. However, these procedures were characterized by prolonged surgery duration, significant blood loss, and technical complexity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In the case of total en bloc spondylectomy reported by Inoue et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], the surgical duration extended to 565 minutes, with blood loss reaching 4000 ml despite preoperative embolization. Similarly, the average blood loss during intralesional vertebrectomy combined with preoperative embolization was 2100 (800\u0026ndash;5000) ml [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Chandra et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and Singh et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] reported that absolute alcohol embolization combined with decompression surgery allowed for relatively low blood loss. However, although this procedure was less technically demanding, it carried a greater risk of complications, such as infection, vertebral collapse and Brown-S\u0026eacute;quard syndrome [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe first introduced the use of decompression surgery with intraoperative vertebroplasty for the treatment of VHs in 2013. This approach achieved vascular shrinkage and obliteration through the sealing effect of bone cement. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In 2018, we conducted a comparative study between this technique and decompression surgery alone [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and our results demonstrated that this technique was a safe, effective and technically undemanding method for reducing blood loss and minimizing postoperative recurrence. Cotten et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] also highlighted that preoperative embolization combined with vertebroplasty further minimized intraoperative blood loss. Since our team publicized this technique, it has gained widespread recognition and adoption, with several similar and modified approaches subsequently reported in the literature [\u003cspan additionalcitationids=\"CR25 CR26 CR27 CR28\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. To the best of our knowledge, the sample size of this study represents the largest among the available studies on VHs treatment to date. During the follow-up period, recurrence was observed in seven patients, with a recurrence rate of 8.2%, which is higher than that of complete tumor resection but lower than that of laminectomy alone [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Compared with complete tumor resection, although this surgical approach had a higher recurrence rate, it offered distinct advantages, including simpler operation, greater safety, shorter surgery duration, and reduced intraoperative blood loss. Furthermore, when combined with postoperative radiotherapy, it could effectively reduce the risk of recurrence.\u003c/p\u003e \u003cp\u003eWe propose that inadequate filling of VH lesions during surgery is a primary contributing factor to recurrence. If the cement fails to seal all lesion areas, the residual lesions may continue to grow, and the blood supply may be reestablished. The complex morphology of hemangiomas (e.g., multilocularity, irregular borders) may further complicate complete filling. Additionally, the viscosity and setting time of the cement, the assessment of the lesion extent, the injection pressure, and the accuracy of the injection location all influence the filling outcomes. To minimize the risk of recurrence, we recommend that the filling rate should not be less than 80%. In our study, the average bone cement filling rate was 87.1% \u0026plusmn; 5.1%. Unsatisfactory cement filling was observed in 12 patients, among whom 4 patients experienced postoperative recurrence, with a recurrence rate of 33.3%. However, among the 73 patients with a fill rate of \u0026ge;\u0026thinsp;80%, only 3 cases of recurrence were observed (4.1%). The results demonstrated that unsatisfactory bone cement filling was significantly positively correlated with the risk of recurrence, and adequate filling significantly reduced recurrence (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eFor aggressive VHs with slowly or mildly progressive neurological deficits (muscle strength grade\u0026thinsp;\u0026gt;\u0026thinsp;3/5), radiotherapy at a dose of 40\u0026ndash;50 Gy, which can alleviate pain and eliminate hemangiomas through vascular necrosis and/or anti-inflammatory effects, is the preferred treatment [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Consequently, radiotherapy is also a viable option for managing some cases of recurrence. In our study, all six patients who experienced recurrence and underwent radiotherapy recovered well and were symptom-free at the final follow-up. Furthermore, adjuvant radiotherapy can be considered when postoperative imaging reveals suboptimal cement filling to reduce the risk of recurrence. Although radiotherapy is associated with potential complications, including radiation necrosis, radiation myelitis, and secondary malignancies, none of these complications were observed in our study. Heyd et al. noted that the risk of radiotherapy-induced secondary malignancies was overemphasized [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003e The primary limitations of this study include its retrospective design and the relatively limited sample size from a single center. The nonrandomized nature of the study introduces unavoidable bias and reduces the level of evidence. In the future, multicenter, large-scale, controlled clinical studies are necessary to establish robust management guidelines for patients with VHs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, our findings demonstrate that decompression surgery with intraoperative vertebroplasty is a safe and effective approach for treating aggressive VHs, significantly reducing intraoperative blood loss and alleviating neurological symptoms. Adequate intraoperative cement filling effectively reduces the risk of recurrence and postoperative radiotherapy is conducive to preventing and treating recurrence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBen Wang designed this study. Jiasheng Chen and Ben Wang collected data and follow-up related information, prepared figures and tables, and wrote the main manuscript text. Ruomu Qu and Xiang Li assisted with data collection and manuscript writing. Yanchao Tang, Panpan Hu, Zihe Li, Yan Li, and Hua Zhou assisted with data analysis and figures making. Xiaoguang Liu, Zhongjun Liu and Feng Wei revised the manuscript. All authors contributed to the article and approved the final submitted manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKato, K., et al., Vertebral hemangiomas: a review on diagnosis and management. J Orthop Surg Res, 2024. 19(1): p. 310. https://doi.org/10.1186/s13018-024-04799-5\u003c/li\u003e\n\u003cli\u003eBaudrez, V., C. Galant, and B.C. Vande Berg, Benign vertebral hemangioma: MR-histological correlation. Skeletal Radiol, 2001. 30(8): p. 442-6. https://doi.org/10.1007/s002560100390\u003c/li\u003e\n\u003cli\u003eHuvos AG. Hemangioma, lymphangioma, angiomatosis/lymphangiomatosis, glomus tumor. Bone tumors: diagnosis, treatment, and prognosis. 2nd ed. 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Spine (Phila Pa 1976), 2015. 40(9): p. 656-64. https://doi.org/10.1097/BRS.0000000000000840\u003c/li\u003e\n\u003cli\u003eAcosta, F.L., Jr., et al., Treatment of Enneking stage 3 aggressive vertebral hemangiomas with intralesional spondylectomy: report of 10 cases and review of the literature. J Spinal Disord Tech, 2011. 24(4): p. 268-75. https://doi.org/10.1097/BSD.0b013e3181efe0a4\u003c/li\u003e\n\u003cli\u003eKato, S., et al., Surgical management of aggressive vertebral hemangiomas causing spinal cord compression: long-term clinical follow-up of five cases. J Orthop Sci, 2010. 15(3): p. 350-6. https://doi.org/10.1007/s00776-010-1483-z\u003c/li\u003e\n\u003cli\u003eSong, R.X., et al., [One-stage total en bloc spondylectomy and reconstruction via a single posterior approach for thoracic vertebral symptomatic hemangioma associated with spinal cord dysfunction]. Zhonghua Wai Ke Za Zhi, 2012. 50(4): p. 342-5.\u003c/li\u003e\n\u003cli\u003eWang, B., et al., Intraoperative vertebroplasty during surgical decompression and instrumentation for aggressive vertebral hemangiomas: a retrospective study of 39 patients and review of the literature. Spine J, 2018. 18(7): p. 1128-1135. https://doi.org/10.1016/j.spinee.2017.11.003\u003c/li\u003e\n\u003cli\u003eWang, B., et al., Atypical Radiographic Features of Aggressive Vertebral Hemangiomas. J Bone Joint Surg Am, 2019. 101(11): p. 979-986. https://doi.org/10.2106/JBJS.18.00746\u003c/li\u003e\n\u003cli\u003eCotten, A., et al., Preoperative percutaneous injection of methyl methacrylate and N-butyl cyanoacrylate in vertebral hemangiomas. AJNR Am J Neuroradiol, 1996. 17(1): p. 137-42.\u003c/li\u003e\n\u003cli\u003eSerlin, R.C., et al., When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain, 1995. 61(2): p. 277-284. https://doi.org/10.1016/0304-3959(94)00178-H\u003c/li\u003e\n\u003cli\u003eDoppman, J.L., E.H. Oldfield, and J.D. Heiss, Symptomatic vertebral hemangiomas: treatment by means of direct intralesional injection of ethanol. Radiology, 2000. 214(2): p. 341-8. https://doi.org/10.1148/radiology.214.2.r00fe46341\u003c/li\u003e\n\u003cli\u003ePastushyn, A.I., E.I. Slin\u0026apos;ko, and G.M. Mirzoyeva, Vertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients. Surg Neurol, 1998. 50(6): p. 535-47. https://doi.org/10.1016/s0090-3019(98)00007-x\u003c/li\u003e\n\u003cli\u003eOgawa, R., et al., Total en bloc spondylectomy for locally aggressive vertebral hemangioma causing neurological deficits. Case Rep Orthop, 2015. 2015: p. 724364. https://doi.org/10.1155/2015/724364\u003c/li\u003e\n\u003cli\u003eInoue, T., et al., Total spondylectomy of a symptomatic hemangioma of the lumbar spine. J Clin Neurosci, 2007. 14(8): p. 806-9. https://doi.org/10.1016/j.jocn.2006.06.004\u003c/li\u003e\n\u003cli\u003eFox, M.W. and B.M. Onofrio, The natural history and management of symptomatic and asymptomatic vertebral hemangiomas. J Neurosurg, 1993. 78(1): p. 36-45. https://doi.org/10.3171/jns.1993.78.1.0036\u003c/li\u003e\n\u003cli\u003eChandra, S.P., et al., Long-term outcome of treatment of vertebral body hemangiomas with direct ethanol injection and short-segment stabilization. Spine J, 2019. 19(1): p. 131-143. https://doi.org/10.1016/j.spinee.2018.05.015\u003c/li\u003e\n\u003cli\u003eSingh, P., et al., Treatment of vertebral hemangiomas with absolute alcohol (ethanol) embolization, cord decompression, and single level instrumentation: a pilot study. Neurosurgery, 2011. 68(1): p. 78-84; discussion 84. https://doi.org/10.1227/NEU.0b013e3181fc60e9\u003c/li\u003e\n\u003cli\u003eGoyal, M., et al., Alcohol ablation of symptomatic vertebral hemangiomas. AJNR Am J Neuroradiol, 1999. 20(6): p. 1091-6.\u003c/li\u003e\n\u003cli\u003eNiemeyer, T., et al., Brown-Sequard syndrome after management of vertebral hemangioma with intralesional alcohol. A case report. Spine (Phila Pa 1976), 1999. 24(17): p. 1845-7. https://doi.org/10.1097/00007632-199909010-00015\u003c/li\u003e\n\u003cli\u003eVasudeva, V.S., J.H. Chi, and M.W. Groff, Surgical treatment of aggressive vertebral hemangiomas. Neurosurg Focus, 2016. 41(2): p. E7. https://doi.org/10.3171/2016.5.FOCUS16169\u003c/li\u003e\n\u003cli\u003eZhang, H.L., et al., Thoracic Vertebral Hemangioma with Spinal Cord Compression: Multidisciplinary Surgical Treatment and Follow-up of Six Patients. Orthop Surg, 2016. 8(4): p. 462-467. https://doi.org/10.1111/os.12293\u003c/li\u003e\n\u003cli\u003eWang, G.X., et al., Compressive myelopathy and compression fracture of aggressive vertebral hemangioma after parturition: A case report and review of literature. Medicine (Baltimore), 2019. 98(50): p. e18285. https://doi.org/10.1097/MD.0000000000018285\u003c/li\u003e\n\u003cli\u003eChen, Y.L., et al., Surgical treatment of compressive spinal hemangioma : A case series of three patients and literature review. Orthopade, 2018. 47(3): p. 221-227. https://doi.org/10.1007/s00132-017-3503-6\u003c/li\u003e\n\u003cli\u003eHuang, Y., et al., Treatment of Typical Enneking Stage 3 Thoracic Aggressive Vertebral Hemangiomas with Pain and Neurologic Deficits: Results After at Least 36 Months of Follow-Up. World Neurosurg, 2020. 134: p. e642-e648. https://doi.org/10.1016/j.wneu.2019.10.158\u003c/li\u003e\n\u003cli\u003eShamhoot, E.A., A.M. Balaha, and A.A. Ganna, Role of Combined Vertebroplasty and Spinal Decompression in the Management of Aggressive Vertebral Hemangiomas. Asian J Neurosurg, 2020. 15(4): p. 919-925. https://doi.org/10.4103/ajns.AJNS_291_20\u003c/li\u003e\n\u003cli\u003eWang, B., et al., The Role of Radiotherapy and Surgery in the Management of Aggressive Vertebral Hemangioma: A Retrospective Study of 20 Patients. Med Sci Monit, 2018. 24: p. 6840-6850. https://doi.org/10.12659/MSM.910439\u003c/li\u003e\n\u003cli\u003eHeyd, R., et al., Radiotherapy for symptomatic vertebral hemangiomas: results of a multicenter study and literature review. Int J Radiat Oncol Biol Phys, 2010. 77(1): p. 217-25. https://doi.org/10.1016/j.ijrobp.2009.04.055 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Aggressive vertebral hemangioma, Intraoperative vertebroplasty, Decompression surgery, Radiotherapy, Surgical strategy","lastPublishedDoi":"10.21203/rs.3.rs-6529168/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6529168/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eAggressive vertebral hemangiomas (VHs) are rare benign tumors but can cause neurological deficits. Currently, the optimal treatment strategy for aggressive VHs remains controversial. The purpose of study is to evaluate the safety and efficacy of decompression surgery with intraoperative vertebroplasty for the treatment of aggressive VHs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 85 aggressive VH patients with neurological deficits who underwent decompression surgery with intraoperative vertebroplasty between January 2010 and May 2024 were included in this study. Clinical data such as patient demographics, symptoms, neurological function, pain levels, radiologic features, surgical information, pathology, and perioperative complications, were recorded and analyzed. Enneking staging was determined based on radiological findings. Neurological function and pain levels were assessed using the Frankel grade and the Visual Analogue Scale (VAS), respectively. The minimum follow-up duration was 12 months.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe average age of 85 patients (49 male and 36 female) was 51.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3 (21\u0026ndash;77) years. Lesions were located in the cervical spine in 1 case, the thoracic spine in 67 cases, and the lumbar spine in 17 cases. All surgery procedures were completed successfully with an average surgery duration of 168.2\u0026thinsp;\u0026plusmn;\u0026thinsp;83.3 (90\u0026ndash;500) minutes and an average blood loss of 670.1\u0026thinsp;\u0026plusmn;\u0026thinsp;674.8 (50\u0026ndash;2500) ml. Preoperative embolization significantly reduced intraoperative blood loss (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Postoperatively, the pain levels of patients were significantly alleviated (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The average follow-up duration was 76.1\u0026thinsp;\u0026plusmn;\u0026thinsp;55.1 (12\u0026ndash;182) months and all patients remained alive at the final follow-up. Recurrence was observed in eight patients, one of whom underwent surgery combined with radiotherapy, while the remaining seven received radiotherapy alone, and at the last follow-up, these patients were symptom-free. Adequate and satisfactory intraoperative filling of bone cement could reduce the risk of recurrence (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDecompression surgery with intraoperative vertebroplasty can effectively reduce blood loss, alleviate neurological symptoms and reduce the risk of recurrence, and is a safe and effective approach in the management of aggressive VHs.\u003c/p\u003e","manuscriptTitle":"Decompression surgery with intraoperative vertebroplasty: A reduced invasiveness treatment strategy for aggressive vertebral hemangiomas","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-17 15:49:45","doi":"10.21203/rs.3.rs-6529168/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-16T10:22:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-14T20:00:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227296586420046364959253875146276691493","date":"2026-02-03T16:40:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-12T09:04:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319749084879714248857282632395798908989","date":"2025-06-12T07:42:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-11T22:11:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-05T04:50:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-05T04:46:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2025-04-25T12:58:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"68ef6f5f-df4f-421c-8b8b-7c5584926529","owner":[],"postedDate":"June 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T13:46:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-17 15:49:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6529168","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6529168","identity":"rs-6529168","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}