|Year : 2021 | Volume
| Issue : 1 | Page : 3-6
Prevalence, location along the spine and demographic distribution of vertebral hemangiomas in southern India: An magnetic resonance imaging-based cross-sectional study of 624 subjects
Suresh S Pillai, M Harisankar
BMH Spine Centre, Baby Memorial Hospital, Kozhikode, Kerala, India
|Date of Submission||18-Jun-2021|
|Date of Acceptance||19-Jun-2021|
|Date of Web Publication||25-Jul-2021|
Suresh S Pillai
SR. Consultant Spine Surgeon, Baby Memorial Hospital, Calicut, Kerala
Source of Support: None, Conflict of Interest: None
Purpose: Vertebral hemangiomas (VHs) are the most common benign tumors of the spine. The aim of this study is to find the prevalence of VHs in the general population and its distribution along the vertebral column. Materials and Methods: The presence of VHs was assessed in the full spine magnetic resonance imaging of 624 participants. Demographic data were obtained from the patient's medical records. Results: VHs were present in 14.4% of the total study population. Multiple VHs were present in 2.2% of the study group and 15.5% of the participantswith VHs. The prevalence of VHs was sex independent with similar occurrence among males and females. The prevalence was age dependent with maximum appearing in the 40–59 age cohort. Lumbar vertebrae were found to be the most prone vertebrae for the occurrence of VHs. Conclusions: The prevalence of VHs is age dependent and sex independent. The lumbar region is the most common site of occurrence of VHs. The overall incidence of VHs is much higher than previously reported, probably due to the newer advancements in imaging techniques.
Keywords: Location, prevalence, South India, vertebral hemangioma
|How to cite this article:|
Pillai SS, Harisankar M. Prevalence, location along the spine and demographic distribution of vertebral hemangiomas in southern India: An magnetic resonance imaging-based cross-sectional study of 624 subjects. J Orthop Assoc South Indian States 2021;18:3-6
|How to cite this URL:|
Pillai SS, Harisankar M. Prevalence, location along the spine and demographic distribution of vertebral hemangiomas in southern India: An magnetic resonance imaging-based cross-sectional study of 624 subjects. J Orthop Assoc South Indian States [serial online] 2021 [cited 2022 Oct 3];18:3-6. Available from: https://www.joasis.org/text.asp?2021/18/1/3/322302
| Introduction|| |
Hemangiomas are benign tumors of newly formed blood vessels which replace the bone marrow at their site of proliferation. They are the most common benign lesions of the spine with a reported incidence of 10%–12% in the adult population., They are usually attributed to the dysembryogenic disturbances affecting the proper differentiation of blood vessels., Many authors describe hemangiomas not as tumors, but as hamartomas, i.e. tissue growing at a normal rate, but in a disorganized manner. As per a large-scale cadaver study, the prevalence of hemangiomas was reported to be 10.7% of the total adult population. However with the advent of newer imaging modalities, the reassessment of these figures becomes relevant and also feasible. Here, we present a study of 624 magnetic resonance imaging (MRI) scans done at our institute to look for any overt hemangiomas to determine the prevalence of hemangiomas in the population of southern India.
| Materials and Methods|| |
This retrospective cross-sectional study included patients from the southern part of India who have undergone MRI scans before this study. The scans were analyzed by a radiologist and an orthopedic spine surgeon to reduce the observer bias and to reduce intraobserver variability. Demographical data were then gathered from the individuals' medical records. This study was authorized by the ethical committee of our institute. As this study required neither intervention on the individuals included in the study nor any contact with them, the ethical committee granted a waiver from obtaining the individuals' informed consent.
Demographical parameters of the studied sample
The study included the analysis of 624 MRI scans of the entire vertebral column. The study population included 322 females and 302 males, with a mean age of 45.9 ± 15.1 (minimum age 7, maximum age 86).
The population was divided into four age cohorts (<18, 18–39, 40–59, and over 60 years of age).
Identification of vertebral hemangiomas
Vertebral hemangiomas (VHs) were detected in the MRI scans based on the following typical radiographic appearances.
- T1: high-intensity signal due to its fat component
- T2: bright/high-intensity signal, usually greater than on T1, due to its high water content.
Statistical analysis was conducted using SPSS v 20.0 (IBM SPSS statistics (2017) 25.0). The prevalence of VH in the general population and subgroups were depicted using descriptive statistics. Chi-square test was done to find the association between qualitative variables and P < 0.05 was considered statistically significant.
| Results|| |
Prevalence of vertebral hemangiomas
The total number of subjects was 624. Out of these 90 persons were found to have VHs (14.4%). Fourteen patients had VHs at multiple levels making the total hemangiomas noted in this study to be 106.
Prevalence of multiple vertebral hemangiomas
Of the 90 individuals having VHs, 76 (84.4%) had only one vertebra affected. 13 (14.4%) had involvement of two vertebrae and 1 person (1.1%) had involvement of 3 vertebrae.
Multiple hemangiomas appeared in 2.2% of the total population and 14.4% of the affected individuals.
Out of the patients with multiple hemangiomas (n = 14), 4 were males (28.6%) and 10 were females (71.4%). Only one patient below the age of 40 years was noted to have multiple VHs. In the 40–59 age group, 7 (2.5%) had multiple VHs and in the age above 60 groups, 6 (4.7%) had multiple VHs.
Out of the 106 hemangiomas noted, 67 (63.2%) were in females and 39 (36.8%) were in males [Chart 1].
Among 322 females, 54 (16.8%) had evidence of VHs. Moreover, among 302 males in the study, 36 (11.9%) had hemangiomas in the MRI evaluation [Table 1]. The Chi-square test done showed a P = 0.053 rendering the difference statistically nonsignificant.
|Table 1: Gender distribution of patients with hemangiomas in the study group|
Click here to view
The mean age of individuals affected by vertebral hemangioma was 41 and those not affected by VH was 49.
While considering age cohorts, among the 106 VHs reported, 52 (49.1%) were in the 40–59 age group. 36 (34%) were in the above 60 age group and the rest 18 (17%) were in the 18–39 age group. No hemangioma was seen in the below 18 age group [Chart 2].
Chi-square test revealed a P < 0.05 thus establishing a statistical significance of age cohort of 40–59 having higher incidence of VHs.
Distribution of vertebral hemangioma in the spinal cord
In the present study, 60 VH (56.6%) were seen in the lumbar area, followed by the thoracic area with 41 (38.7%). Cervical hemangiomas constituted 3 (2.8%) and sacral constituted 2 (1.9%) of the total VH noted [Chart 3].
In females, 53.7% of the VHs were noted in the lumbar region and in males, 61.5% was noted in the lumbar region, thus making the lumbar region the most common site of VHs in this study. There were no significant differences in the distribution of hemangiomas along the vertebral column among the two genders [Chart 4].
The most commonly affected vertebrae were L1, L2, and L3 (15%, 14%, and 13%, respectively) followed by D12 and L4 (10% and 9%, respectively). No hemangioma was noted in the first six cervical vertebrae and D6 [Chart 5].
| Discussion|| |
The prevalence of VHs in this study was 14.4% among the total study population. In a large-scale cadaver study by Schmorl, the incidence was reported to be 10.7%. Another computed tomography (CT)-based study by Slon et al. showed the prevalence to be 26.0% in the total population. However, in their study, the incidence of large VH was just 9.7%, a value much closer to that published earlier. A recent review based on MRI by Barzin and Maleki shows a much higher incidence (26.9%) than what was found in our study.
Male:female ratio of incidence of VH in our study was 1:1.5. Though statistical evaluation showed no statistically significant association between gender and incidence of VH, other studies also show a female-biased occurrence rate of VHs (ranging from 1:1.2 to 1:2.25.).,,,, However, none of the studies could establish a statistically significant correlation between gender and incidence of hemangiomas in the vertebral column. This lack of correlation between gender and the incidence of hemangioma supports the general idea that sex hormones play no role in the development of VHs.
The age cohort with the maximum incidence of hemangiomas was between 40 and 59 years of age. This is in accordance with previous studies by Slon et al. and Barzin and Maleki, who also observed a rise in the incidence in patients above the age of 50. There is no significant difference between the peak age group between the two genders. This lack of prevalence peak in the fertile years of a female further strengthens the hypothesis that sex hormones play no significant role in the development of hemangiomas.
The most common location of hemangiomas in our study was the lumbar area closely followed by the lower thoracic area. This is in agreement with previous studies, with only meager differences in the percentage between different regions. In the present study, among the lumbar vertebrae, L5 has the lowest incidence of VH and this is in agreement with the study by Slon et al., who proposes that this may be due to the strategic position of L5 in the lumbar lordotic curve positioning it outside the line of the center of gravity. This causes less linear stress loading than the other lumbar vertebrae and this might contribute to the higher incidence of VH in the other lumbar vertebrae. However, the authors could not find any other references supporting the above hypothesis and it warrants further biomechanical studies to prove a significant correlation between loading and development of hemangioma in a vertebra.
There were 14 cases of multiple hemangiomas in our study, which contributes to around 15.6% of the subjects with hemangioma. There was no sexual predilection for the incidence of multiple hemangiomas in our study, and this is in accordance with the studies by Slon et al. and Barzin and Maleki.,
Limitations of the study
In this study, we used MRI scans to screen the subjects for VHs. A correlative CT scan would have been helpful in identifying smaller lesions in the vertebra and since it is having higher sensitivity than MRI in picking up hemangiomas. However, whole spine CT scans op patients are not routinely done and hence, we had to resort to MRIs instead.
Having said that, a CT-based study with a larger study group would help in studying the prevalence of this lesion with greater precision.
| Conclusions|| |
VHs are the most common benign lesions of the spine with an incidence of around 10%–20%. The most common location of VH is in the lumbar region and lower thoracic area. Among the lumbar vertebrae, L5 has the lowest incidence probably due to its position in the lumbar lordotic curve.
There are no significant differences in the distribution of VH between the two genders implying that the sex hormones play no major role in the development of these lesions.
The most common age group is the 40–59 group suggesting that elder people are more at risk compared to the younger population and that the lesion might be growing and evolving as the person ages.
The incidence of multiple hemangiomas is not uncommon and shows no gender predilection.
The incidence of VH is much higher than that was previously thought and with the advent of newer imaging modalities, the diagnosis of hemangiomas has become easier than before.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Slon V, Stein D, Cohen H, Sella-Tunis T, May H, Hershkovitz I. Vertebral hemangiomas: Their demographical characteristics, location along the spine and position within the vertebral body. Eur Spine J 2015;24:2189-95.
Rodallec MH, Feydy A, Larousserie F, Anract P, Campagna R, Babinet A, et al.
Diagnostic imaging of solitary tumors of the spine: What to do and say. Radiographics 2008;28:1019-41.
Huvos AG. Hemangioma, Lymphangioma, Angiomatosis/Lymphangiomatosis, Glomus Tumor. Bone Tumors: Diagnosis, Treatment, and Prognosis. 2nd
ed. Philadelphia: Saunders; 1991. p. 553-78.
Fox MW, Onofrio BM. The natural history and management of symptomatic and asymptomatic vertebral hemangiomas. J Neurosurg 1993;78:36-45.
Schmorl G. The Human Spine in Health and Disease. JAMA network 1972; 1971. p. 504.
Baudrez V, Galant C, Lecouvet FE, Malghem J, Maldague BE, Vande Berg BC. Vertebral hemangioma: MR-histological correlation in autopsy specimens. In: Radiology. 20th
and Northampton STS, Easton, PA 18042 USA: Radiological Society of North America; 1999. p. 245.
Barzin M, Maleki I. Incidence of vertebral hemangioma on spinal magnetic resonance imaging in Northern Iran. Pak J Biol Sci 2009;12:542-4.
Laredo JD, Assouline E, Gelbert F, Wybier M, Merland JJ, Tubiana JM. Vertebral hemangiomas: Fat content as a sign of aggressiveness. Radiology 1990;177:467-72.
Dahlin DC, Unni KK. Bone Tumors: General Aspects and Data on 8,547 Cases. 4th ED/INIS,Issue 10,vol 19,1986.
Roelvink NC, Kamphorst W, August H, van Alphen M, Rao BR. Literature statistics do not support a growth stimulating role for female sex steroid hormones in haemangiomas and meningiomas. J Neurooncol 1991;11:243-53.