International Journal of Surgery Case Reports 114 (2024) 109040

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Spinal epidural cavernous hemangiomas in the lumbar spine: A case report

Dingyan Zhao 1, Yukun Ma 1, Xing Yu *, Lianyong Bi, Xinliang Yue
Dongzhimen Hospital Afliated to Beijing University of Chinese Medicine, Beijing 100700, China

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Spinal epidural cavernous hemangiomas (SECHs) are relatively rare intradural epidural lesions of
Cavernous malformation the spinal canal, and those occurring in the lumbar spine are even rarer.
Spinal epidural cavernous hemangiomas Case presentation: A 60-year-old man presented for low back pain with right leg pain. His pee and feces were both
SECHs
normal but symptoms were very similar to a typical lumbar disc herniation. The MRI findings suggest an epidural
Case report
space of unknown nature in the spinal cord at the L2–3 level and a definite diagnosis of SECHs was made by
postoperative pathological examination.
Clinical discussion: Patients who are suspected of having SECHs should undergo initial classification and differ­
ential diagnosis based on MRI imaging features. It is crucial to identify the responsible segment in correlation
with the presenting symptoms. During surgery, the primary objective should be the complete removal of the
mass, while taking utmost care to protect the nerves. Dynamic stabilization systems, utilizing pedicle rods, can be
considered as one of the treatment options for such patients.
Conclusion: Patients presenting with low back pain and neurological symptoms should undergo MRI, and diag­
nosed with SECHs should undergo early surgical intervention. For patients with an intradural mass in the spinal
canal, complete resection should be performed while prioritizing nerve protection.

1. Introduction
Cavernous malformation (CM) is a type of intradural lesion charac­
terized by developmental deformities caused by vascular abnormalities
in the central nervous system. Among these lesions, spinal epidural
cavernous hemangiomas (SECHs) are relatively uncommon, accounting
for only 4 % of all epidural lesions [1]. SECHs can occur anywhere along
the spine, with a higher frequency observed in the dorsal thoracic region
and a lower incidence in the lumbar region [2]. We outline the treatment
provided to a patient admitted to our hospital with SECHs at the L2-L3
level of the lumbar spine.
The work has been reported in line with the SCARE 2020 criteria [3].
2. Presentation of a case
A 60-year-old man experiencing “low back pain with right leg pain
for 5 years, aggravated for 1 month” was taken to the hospital. He was
diagnosed with “lumbar disc herniation” and his pee and feces were both
normal. Examination: Lumbar spine activity was limited, muscle tension
on both sides of the L2-L4 spinous processes, tenderness and pain to
pressure and percussion (+). Muscle strength of each group of the lower
limbs was grade 4 bilaterally, muscle tone was normal. There were no
superficial and deep sensory abnormalities in the hip and pre-femoral
area of both lower limbs, the knee and the following areas. The right
leg raising and strengthening test was 60◦ (+) and the right femoral
nerve pull test was +. The preoperative Japanese Orthopedic Associa­
tion (JOA) lumbar score was 8, Oswestry Disability Index (ODI) score
was 27, and Visual Analogue Scale (VAS) scores were 6 and 7 for lumbar
and lower limb pain, Preoperative imaging results are shown in Fig. 1a-
h. The preoperative diagnosis was an intradural mass, SECHs?
The patient underwent lumbar posterior laminectomy, mass removal
and transpedicular internal fixation 3d after admission. Under general
anesthesia, a posterior median incision was performed to expose the
vertebral plate and the L2-L3 spinous processes. The surface of the mass
was smooth, fish-egg shaped, soft, with clear margins, rich in blood
supply and intact covering. After leaving the pathology for evaluation,
the tumor was complete and thorough removal (Fig. 1i). The patient's
vital signs were steady both throughout and following the procedure.
Postoperative pathology confirmed a cavernous hemangioma. The
tumor was mainly composed of a large number of thin-walled blood

* Corresponding author.
E-mail address: yuxingbucm@sina.com (X. Yu).
1
Dingyan Zhao and Yukun Ma are co first authors in this article.

https://doi.org/10.1016/j.ijscr.2023.109040
Received 7 October 2023; Received in revised form 3 November 2023; Accepted 9 November 2023
Available online 22 November 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
D. Zhao et al. International Journal of Surgery Case Reports 114 (2024) 109040

vessels, with a single layer of endothelial cells and collagen fibres in the
tube wall, lacking the elastic and muscular layers, and the immunohis­
tochemical results were Vim (+), EMA (+), CD34 (vasculature +), CD31
(vasculature +), Ki-67 (individually +) and SMA (+). At 12 days post-
operatively, the patient was discharged from hospital with a lumbar
JOA score of 21, an ODI score of 39, and lumbar and lower extremity
VAS scores of 3 and 2. At the 4-month postoperative follow-up, the
lumbar JOA score of 19, an ODI score of 41, lumbar and lower extremity
VAS scores of 2 and 2. Postoperative imaging results are shown in Fig. 1j-
o. Patient was satisfied with the results of his treatment.
3. Discussion
Cavernous hemangiomas (CM), first characterized by Globus et al. in
1929, are uncommon yet insidiously developing, tumor-like vascular
malformations. Though they typically manifest in the supratentorial
region of the brain parenchyma, these formations can indeed occur
anywhere within the body [4]. Depending on their proximities to
structures such as the dura mater, these vascular malformations can be
catagorized into four types [5]: intramedullary, extramedullary intra­
dural, epidural, and vertebral. The instances of spinal epidural
cavernous hemangiomas (SECHs) are quite rare, constituting approxi­
mately just 4 % of epidural tumors [1]. Whether there exists a significant
gender disparity in the prevalence of SECHs remains contentious [1,2].
It is agreed that they are most often found in the thoracic vertebrae -
followed by lumbar, then cervical and sacral vertebrae - and most likely
to be located dorsal or dorsal-lateral to the spinal canal [2,6].
SECHs were considered as a vascular malformation initiated by
dysplasia [7]. Investigations of CM imply genetics [8], trauma [9],
hormonal expressions and haemodynamic factors [10] as potential in­
fluences on its formation. The clinical symptoms of SECHs depend on
their specific genesis site and how they interact with anatomical struc­
tures such as the spinal cord and nerve roots. Reviews suggest that up to
86 % of SECHs have been chiefly situated at the dorsal or dorsolateral
aspect of the spinal cord, with 9 % ventral and a mere 5 % occurring at
the intervertebral foramen [1]. Hence, most patients will still exhibit
signs of spinal cord and nerve root compression. SECHs usually follow a
course characterized by gradual onset. SECHs with sudden onset being a
rarity, potentially resulting from an increased pressure due to intra-
tumoral hemorrhage caused by trauma [4]. In this particular case, the
patient had a history of 5 years, with symptoms exacerbating gradually
and pain concentrated locally and extending to lower extremities – an
observation that aligns with previously documented cases.
At present, the clinical diagnoses for SECHs are reliant on MRI and
pathological examinations. MRI permits sagittal and coronal scanning,
thereby elucidating the location, size, and relationship of the lesion to
the surrounding tissues. SECHs typically exhibit an isosignal on T1-
weighted images and a slightly lower high signal than that of cerebro­
spinal fluid (CSF) on T2-weighted images [1,2,11]. When there's an
acute rupture and hemorrhage in SECHs due to trauma or various other
factors, both T1- and T2-weighted images display high signals on the
MRI [11]. Some patients may warrant an enhanced MRI to distinguish it
from other intraspinal masses, because SECHs may reflecting inhomo­
geneous enhancement. In our case, where the posterior aspect of the L2-
L3 spinal cord displayed a low signal on T1WI and a high signal on T2WI
during the preoperative MRI.
The conclusive diagnosis of spinal epidural cavernous hemangiomas
(SECHs) is reliant on pathological results. The initial differential

Fig. 1. Imaging data of the case

a,b: The lumbar spine was seen to be degenerated, with the presence of overall physiological curvature and rostral osteophyte formation at the anterior margin of the
L1–2 vertebral body c,d:Anterior flexion and posterior extension demonstrate fair mobility of the L2–3 segments. e,f,g: MRI showed obvious compression of the spinal
cord at the level of L2–3, and an oval-shaped mass was seen in the dorsal aspect of the spinal canal with clear borders, smooth edges and intact periosteum. The mass
showed isointense signal on T1WI and high signal on T2WI and compression fat images. h:MRI showed that 75 % of the spinal canal was encroached, and the tumor
was on the right side. i: The tumor was removed intact. j,k:The nail rod system was in good position. l,m,n:MRI showed that the spinal cord space at L2–3 was
significantly enlarged. o:The L2–3 level showed that the morphology of the cauda equina in the spinal cord was restored and dispersed, surrounded by cerebrospinal
fluid, and the intervertebral foraminal space was good bilaterally.

2
D. Zhao et al.
diagnosis can also be made preoperatively on the basis of MRI. It is
crucial to differentiate SECHs from other types of epidural lesions, such
as metastatic tumors, lymphomas, abscesses, among others [12]. Met­
astatic tumors usually manifest as sizable soft tissue masses, commonly
accompanied by significant vertebral and accessory bone destruction
and a history of the principal tumor, and exhibit slightly higher signals
on T2-weighted images in MRI scans. Differentiating lymphoma from
the epidural type of SECHs can be challenging, especially when they
occur as a mass in the epidural space, indicated by a moderate signal on
both T1WI and T2WI. Epidural abscesses may display a moderate signal
on T1WI and a high signal on T2WI; these patients typically have a
history of trauma, surgery, or other infections. SECHs also need to be
distinguished from other vascular-rich tumors like spinal tumors, as
their signal and enhancement patterns are very similar. It's noteworthy
to identify the differences in morphology and growth patterns between
these two types of SECHs. Variance in the location is also distinctive of
the different types of SECHs. Epidural SECHs, positioned in the epidural
space, tend to exhibit a creeping growth pattern, resembling a staggered
or elongated oval shape. Conversely, a chordoma is mostly broad-based,
slow-growing mass adhering to the dura mater and is primarily situated
in the extramedullary subdural space.
The cornerstone of treatment for SECHs is surgical resection. Early
diagnosis and timely surgical intervention are imperative. For most
SECHs, complete resection is a possibility, particularly for the epidural
type. Protective measures for the spinal cord and nerve roots are indis­
pensable during surgery, especially for intramedullary and extra-
medullary intradural CM. Additionally, selecting the right fixation
method must take into account the lesion's location and the involved
segments. In this case, the preoperative X-rays showed minor activity in
the L2–3 segment without notable instability. Therefore, we applied the
Isobar system to preserve some of the patient's operational segment
mobility. The shock-absorbing ring at the center of the Isobar rods offers
unique cushioning properties, reducing stress on the rods. The pre-
curvature before implantation complements the physiological anterior
convexity of the segments, which diminishes stress concentration to
some extent. The range of motion (ROM) attached to the rods theoret­
ically maintains segmental activity while reducing the compensatory
ROM of neighboring segments [13]. During surgery, the L2–3 vertebral
plate was exposed, revealing the tumor along the right side of the dura
mater. This location consistent with the symptomatic manifestation. The
patient showed a satisfactory functional recovery and no sign of symp­
tom deterioration during the follow-up period.
4. Conclusion
In this study, we discuss a case of spinal epidural cavernous hem­
angiomas (SECHs) in the lumbar region. The patient's symptoms paral­
leled that of a traditional lumbar disc herniation, underlining the
necessity for a thorough MRI examination when presented with patients
showing similar symptomatology. The preliminary differential diagnosis
should be rooted in a detailed interpretation of the imaging findings. On
ascertaining the accountable segment, surgical intervention should be
expedited in a prudent and judicious manner, prioritizing the safe­
guarding of nerves during the procedure.
Consent
Written informed consent was obtained from the patient for publi-
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
Sources of funding
No funding was obtained for this study.
International Journal of Surgery Case Reports 114 (2024) 109040
Ethical approval
This study was approved by the Medical Ethics Committee of
Dongzhimen Hospital, Beijing University of Traditional Chinese Medi­
cine (approval number: 2022DZMEC-085-05).
Research registration
None.
Guarantor
Dingyan Zhao.
Provenance and peer review
Not commissioned, externally peer-reviewed.
CRediT authorship contribution statement
Dingyan Zhao: Writing- Original draft preparation and Methodology;
Yukun Ma: Writing- Reviewing and Editing; Xing Yu: Conceptualization,
Supervision; Xinliang Yue, Lianyong Bi: Data curation.
Declaration of competing interest
The authors report no conflict of interest.
References
[1] R. Manoharan, J. Parkinson, Pure epidural spinal cavernous haemangioma, Surg.
Neurol. Int. 19 (12) (2021) 523, https://doi.org/10.25259/SNI_805_2021.
[2] Esene IN, Ashour AM, Marvin E, et al. Pure spinal epidural cavernous hemangioma:
a case series of seven cases. J Craniovertebr Junction Spine. 2016;7(3):176-83. doi:
10.4103/0974-8237.188419.
[3] R.A. Agha, M.R. Borrelli, R. Farwana, K. Koshy, A. Fowler, D.P. Orgill, For the
SCARE Group, The SCARE 2018 Statement: updating consensus surgical CAse
REport (SCARE) guidelines, Int. J. Surg. (60) (2018) 132–136.
[4] T. Kuytu, T. Aydın, K. Türeyen, Spinal epidural cavernous hemangioma: case
report, Br. J. Neurosurg. 32 (5) (2018) 577–578, doi: 10.1080/
02688697.2017.1297365.
[5] Y. Shan, F. Ling, M. Li, et al., Diagnosis and treatment of spinal cord cavernous
angioma. Zhonghua Wai Ke Za Zhi 40 (4) (2002) 287–289. Chinese. pmid.
12133362.
[6] L. Zhang, G. Qiao, A. Shang, et al., Clinical features and long-term surgical
outcomes of pure spinal epidural cavernous hemangioma-report of 23 cases, Acta
Neurochir. 162 (11) (2020) 2915–2921, https://doi.org/10.1007/s00701-020-
04358-x.
[7] Y. Bayri, M.Ş. Ekşi, D. Yalçınkaya Koç, et al., Spinal epidural cavernous angioma:
two case reports and review of the literature, Acta Orthop Traumatol Turc. 49 (4)
(2015) 459–464, https://doi.org/10.3944/AOTT.2015.13.0090.
[8] P. Labauge, Familial forms of central nervous system cavernomas: from recognition
to gene therapy, Neurochirurgie 53 (2–3 Pt 2) (2007) 152–155. French, https
://doi.org/10.1016/j.neuchi.2007.02.007.
[9] W. Zhong, S. Huang, H. Chen, et al., Pure spinal epidural cavernous hemangioma,
Acta Neurochir. 154 (4) (2012) 739–745, https://doi.org/10.1007/s00701-012-
1295-3.
[10] J.H. Chi, G.T. Manley, D. Chou, Pregnancy-related vertebral hemangioma. Case
report, review of the literature, and management algorithm, Neurosurg. Focus 19
(3) (2005), https://doi.org/10.3171/foc.2005.19.3.8. E7.
[11] C. Cossandi, A. Fanti, A. Gerosa, et al., Rare case of dumbbell-shaped spinal
cavernous hemangioma and literature review, World Neurosurg. 120 (2018)
181–184, https://doi.org/10.1016/j.wneu.2018.09.003.
[12] A. Saracen, Z. Kotwica, Thoracic spinal epidural cavernous haemangioma with an
acute onset: case report and the review of the literature, Clin. Neurol. Neurosurg.
115 (6) (2013) 799–801, https://doi.org/10.1016/j.clineuro.2012.07.015.
[13] J. Guan, T. Liu, W. Li, et al., Effects of posterior lumbar nonfusion surgery with
isobar devices versus posterior lumbar interbody fusion surgery on clinical and
radiological features in patients with lumbar degenerative diseases: a meta-
analysis, J. Orthop. Surg. Res. 17 (1) (2022) 116, https://doi.org/10.1186/s13018-
022-03015-6.