Treatment of Aggressive Vertebral Hemangiomas Through Superselective Percutaneous Ethanolization of Epidural Components: An Innovative Minimally Invasive Technique

Purpose: This retrospective study investigates a novel technique for treating aggressive vertebral hemangiomas, focusing on selective ethanol sclerotherapy of invasive epidural extensions.

Materials and Methods: All patients treated between 2012 and 2025 at two hospitals in Ghent (Belgium) were included. All procedures were performed by the same interventional radiology team. Eligible patients presented with progressive or impending neurological symptoms due to epidural extension of aggressive hemangiomas. Prior embolization or resection excluded patients, except in cases of urgent laminectomy.
Under general anesthesia, patients were positioned on the angiography table (Artis Q / Artis Icono biplane, Siemens, Munich, Germany – Azurion 7 biplane, Philips, Amsterdam, Netherlands). Cone-beam CT (CBCT) was fused with preprocedural MRI for planning. Needle guidance software (myNeedle Companion, Siemens, Munich, Germany – XperGuide, Philips, Amsterdam, Netherlands) assisted selective puncture of epidural components directly using a fine diagnostic needle or coaxially through a bone biopsy needle. After aspiration, 1–2 ml of contrast was injected under biplane fluoroscopy to confirm intralesional position and exclude leakage. A maximum of 3 ml of pure ethanol (96%) was then injected under subtraction fluoroscopy. CBCT confirmed diluted contrast stasis in the epidural extensions.

Results: Seven patients (mean age 48 years; 57% female) were included, with treated vertebral levels ranging from 3^rdthoracic to 2^nd sacral. Technical success was achieved in all procedures. One patient experienced transient postprocedural side effects. All patients with neurological deficits demonstrated initial symptomatic improvement. Recurrence occurred in two patients, requiring retreatment at 10 and 22 months, respectively. One patient exhibited vertebral body height loss on follow-up imaging, for which additional kyphoplasty was performed after a second treatment. Median observation after the last intervention was 21 months. Follow-up MRI demonstrated reduction of the targeted epidural components and restoration of cerebrospinal fluid space at the treated level.

Conclusion: This study supports the feasibility and clinical benefit of superselective percutaneous ethanol sclerotherapy of epidural extensions of aggressive vertebral hemangiomas, without treatment of the vertebral body. Despite the retrospective design with small sample size, the procedure offers an alternative for surgical vertebral body resection and even for vertebroplasty.