Outcomes Following Different Treatment Modalities of Aggressive Vertebral Hemangiomas: A Systematic Review and Patient-Level Meta-Analysis.

Background and objectives: Vertebral hemangiomas are the most common primary spine tumors with an estimated prevalence of 10% to 12%. Approximately 1% are "aggressive", expanding and eroding osseous confines. Treatment aims at limiting their growth and symptomatology. This study evaluated the effectiveness of various treatment modalities for symptoms and recurrence control.

Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 compliant study. Medline and Scopus were searched in March 2024. Inclusion criteria were English language, published between 2000 and 2023, adults (older than 18 years), primary aggressive vertebral hemangioma (AVH) Enneking stage 3. Data included patient-level demographics, treatment, outcomes, and recurrence. Excluded were case reports, studies focusing on nonaggressive vertebral hemangioma, other primary or metastatic tumors, and studies on the treatment of recurrent AVHs. Results of descriptive studies, pooled proportions, correlation, and regression are presented in tables and forest plots.

Results: Sixteen studies with 150 AVHs in 149 patients. Mean age (SD) was 50.4 (16.8) years, and 55/149 (36.9%) were men. Mean follow-up (SD) was 49.8 (57) months. Weighted pooled proportions: gross total resection 18.2%, recurrence 7.9%, symptom resolution 43.4%, and Frankel score improvement 68.4%. Initial sensory deficit (OR: 29.1, P = .02) and performing corpectomy/spondylectomy (OR: 0.034, P < .01) were independent predictors for symptom resolution. Embolization (49.5%, P = .0151), open surgery (48.8%, P = .0019), and complete resection (82.1%, P < .0001) showed strong correlation with symptom improvement. Higher symptom resolution was observed with kyphoplasty/vertebroplasty (82.5%, P < .0001), no open surgery (78.9%, P = .0019), and no surgical tumor resection (72%, P < .0001). No independent predictors were found for recurrence.

Conclusion: Embolization, intralesional ablation, vertebroplasty, and kyphoplasty are options for AVH without cord compression and neurological deficits. For cord compression, open surgery with or without these interventions can be considered. Radiation is for persistent pain and locally advanced tumors. The extent of tumor progression is correlated with symptom control.