Case Report

A mobile hemangioblastoma of the cauda

equina: Case report and review of the literature
Haitao Luo, Juexian Xiao, Shigang Lv, Xingen Zhu, Zujue Cheng
Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, People’s
Republic of China

Context: Cases of migratory spinal tumors have been reported since 1963. Most involve spinal schwannomas,
which are benign tumors of the lining of nerve cells. We report a rare case of a mobile spinal hemangioblastoma,
which is a type of benign vascular tumor.
Findings: A 50-year-old man visited the hospital for painful swelling in his lower back. An MRI scan indicated that
a lesion was at the L5 vertebral level. Two weeks later, however, an enhanced MRI showed that the lesion had
migrated to the L4 vertebral level. During surgery, the location of the lesion remained consistent with the
enhanced MRI reviewed. The histopathological diagnosis was hemangioblastoma.
Conclusion: This is the first known report of a mobile spinal hemangioblastoma. Mobile spinal
hemangioblastoma requires careful preoperative and intraoperative evaluation of its real-time location to
avoid performing surgery at the wrong vertebral level.
Keywords: Hemangioblastoma, Mobility, Spine, Surgery

Introduction Case report

The phenomenon of migratory intradural extramedul-
lary tumors has been reported in many countries since
1963.1 The most common migratory intradural extrame-
dullary tumors of the spine are schwannomas, with
some reported cases of neurenteric cysts2 and ependy-
momas.3-4 Hemangioblastoma is a highly vascularized
benign tumor of the central nervous system, commonly
found in the spinal cord, cerebellum, and brainstem.5
Spinal hemangioblastoma accounts for nearly 13–26%
of all hemangioblastomas.6 Patients with spinal heman-
gioblastoma usually experience pain and exhibit signs of
segmental and long-tract dysfunction, which are caused
by syringomyelia associated with a mass effect due to
increasing tumor size.7 About 30% of hemangioblasto-
mas occur as a characteristic component of von
Hippel Lindau syndrome (VHL), while about 70%
occurs as sporadic lesion.8-10
In this paper, we describe a rare case of a migratory
lumbar hemangioblastoma that caused painful swelling
in the patient’s lower back.
Correspondence to: Zujue Cheng, Department of Neurosurgery, the Second
Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang,
330006, Jiangxi, People’s Republic of China. Email: juejue@126.com
Color versions of one or more of the figures in the article can be found online
at www.tandfonline.com/yscm.
A 50-year-old man presented to the outpatient clinic of
neurosurgery with painful swelling in his lower back. He
had experienced the pain for five months and it had wor-
sened in the last seven days. The pain was gradual onset,
constant in duration, and characterized as tingling and
numbness. There were no aggravating or relieving
factors. The patient reported no weakness, sensory
changes, or bladder or bowel symptoms. The patient had
a 10-year history of hypertension that was treated with
amlodipine and nifedipine. Physical examination revealed
a well-developed male with normal vital signs. A bilateral
straight leg raise test was weakly positive and a tendon
reflex test revealed slight hyperreflexia. Neurological exam-
inations were otherwise normal without focal findings.
An MRI of the lumbar spine revealed an intradural
extramedullary lesion located in the L5 region. The
upper bound of the lesion was parallel with the L5 ver-
tebral margin (Figure 1). Two weeks later, however, an
enhanced MRI indicated that the lesion had moved to
the L4 level. The upper bound of the lesion was parallel
with the L4 vertebral body (Figure 2). The patient was
in the same exam position for both MRIs. The lesion
had migrated one full bony vertebral segment. The
patient was scheduled for surgery with the presumptive
diagnosis of a migratory spinal tumor.

© The Academy of Spinal Cord Injury Professionals, Inc. 2018

DOI 10.1080/10790268.2018.1547855 The Journal of Spinal Cord Medicine 2020 VOL. 43 NO. 5 719
Luo et al. A mobile hemangioblastoma of the cauda equina
Figure 1 Initial preoperative MRI scan revealing a mass in the
L5 vertebral margin.
We used a standard midline approach with laminect-
omy and durotomy to expose the lamina and posterior
elements of the L3-L5 vertebrae. The lesion was found
in the L4 region, which was consistent with the second
MRI scan. The tumor was found to originate from a
redundant nerve root of the cauda equina. Complete
resection of the tumor was done without causing
damage to the cauda equina. After achieving sufficient
Figure 2 Immediate preoperative MRI scan obtained two
weeks after the initial scan, demonstrating the migration of the
mass up to the L4 vertebral body region.
720 The Journal of Spinal Cord Medicine 2020 VOL. 43 NO.
hemostasis, a layered closure of the surgical incision
was performed. Histopathological examination con-
firmed the diagnosis of a hemangioblastoma (Figure 3).
The patient’s symptoms improved significantly after
the procedure, with complete remission of his lower
back pain. A complete resection of the tumor was
shown in a post-operative lumbar MRI (Figure 4).
The patient did not have any clinical manifestation of
VHL. Moreover, he had a negative genetic test for
VHL and a normal retinal examination. No additional
central nervous system lesions were found on a brain
MRI. No tumor was visible on abdominal and pelvic
CT scans.
Although it has never been previously reported in the
literature, a diagnosis of migratory lumbar hemangio-
blastoma was made based on MRI and histopathologi-
cal findings.
Discussion
Spinal hemangioblastoma is the third most common
spinal tumor, accounting for (2–6%) of all spinal
tumors. Hemangioblastoma can be found at all levels
of the spinal cord, with most occurring in the cervical
(60%) and thoracic (40%) levels and very few originating
in the lumbar level.11,12 The average age of occurrence is
between 33 and 48 years old.7-10 Clinical manifestations
vary with tumor growth patterns and location, age of
the patient, and concomitant syringomyelia.
Spinal hemangioblastoma symptoms tend to follow
an indolent course; however, an intradural lesion could
lead to compression of the lumbar and sacral nerve
roots within the lower spinal canal, and thus cause
painful swelling in the lower back. The treatment is sur-
gical removal of the lesion to decompress the spinal
canal. In this paper, the tumor causing the patient’s
lower back pain was identified to be a mobile hemangio-
blastoma migrated from the L5 to the L4 vertebral level
of the spine over two weeks. Some theories have been
put forward to explain the migration of an intradural
extramedullary tumor. The tumor migration could
result from positional adjustments or procedures that
cause fluctuations in cerebrospinal fluid pressure,13-16
such as the usage of contrast medium,15,17 muscular relax-
ation induced by anesthesia and Valsalva maneuvers,14,18
and laminectomy procedures.13,15 Alternatively, the
tumor may obtain increased mobility in the lower
lumbar spinal canal because of the absence of cord
below L1 and the longer length of the lumbar nerve
roots.19 For the case reported in this paper, we speculated
that the tumor migration may have been because the
hemangioblastoma did not have close adhesion to the
lumbar and sacral nerve roots and the arachnoid, and
5

Figure 3 Histological images of the lumbar spine showing the lesion. H&E, original magnification 10 × 10(A). H&E, original
magnification 10 × 40(B). Pathology imaging photomicrographs of the surgical specimen showed many capillaries at different
stages of maturation and some scattered vacuolated cells, which is consistent with a spinal canal hemangioblastoma diagnosis.
loose connection with the cauda equina. Tumor migration
is a problem because multiple laminectomies may have to
be performed if the tumor keeps moving.
To avoid excessive and unnecessary laminectomies,
various methodologies have been recommended, includ-
ing preoperative MRI,18 intraoperative ultrasonogra-
phy,14 intraoperative myelography20 and advanced
intraoperative MRI.20 Unfortunately, intraoperative
ultrasonography and intraoperative MRI are not
readily available in most of the institutions in developing
countries. Intraoperative myelography is known to poss-
ibly cause tumor migration.20 Therefore, in developing
countries, repeated preoperative MRI becomes the
most feasible diagnostic test to check whether or not a
tumor has migrated.
Figure 4 A post-operative enhanced MRI demonstrating
complete resection of the tumor.
Luo et al. A mobile hemangioblastoma of the cauda equina
It is critical to avoid performing surgery at the wrong
vertebral level in the surgical management of a mobile
spinal hemangioblastoma because it may result in
failure to remove the tumor and additional sur-
geries.13,18 Khan et al. performed two negative surgical
explorations in a case due to tumor migration.20
According to a review of the literature, about 80% of
migration distances occur within one distance level,
however, up to five distance levels has been reported in
spinal tumors.13 In our case, the tumor migration was
for one level only.
We presented a very rare case of migrating tumor in
the lumbar spine, the pathology of which was a heman-
gioblastoma. We emphasize the importance of repeated
imaging and careful planning before surgical interven-
tion of intradural extramedullary tumors to avoid per-
forming surgery at the wrong vertebral, especially
when the tumor is in the lumbar spine.
Conclusions
In summary, this is the first report of mobile hemangio-
blastoma in the spine. Repeated imaging and intrao-
perative ultrasonography are recommended for
presurgical local examination of such tumors to avoid
potentially performing surgery on a mobile tumor at
the wrong vertebral level.
Disclaimer statements
Funding None.
Conflicts of interest There is no conflict of interest to
declare.
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