I. Introduction Myth: Among all primary tumors of the spine, spinal hemangioma has been controversial. Most people think of tumors directly when they mention vascular “tumors”. In fact, hemangioma is not a true tumor, but a vascular malformation that is simply called a “tumor”. In fact, hemangiomas are generally tumors in the true sense of the word “tumor” when the word “tumor” is added, such as endothelioma, hemangioepithelioma, and hemangiosarcoma. Spinal hemangioma is a common lesion, accounting for about 2% to 3% of primary tumors of the spine. 10% to 11% of normal people have it, which means that about 100 to 200 million Chinese have spinal hemangioma in China, but most people do not have any symptoms and therefore are unaware of it. Most are found in the thoracic spine and 97% do not require treatment. Only about 3% of spinal hemangiomas require treatment. This group will slowly progress from asymptomatic to symptomatic and is called invasive spinal hemangioma. In general, this type of aggressive hemangioma also progresses slowly, with occasional sudden acceleration. It can occur at any age, most often after the age of 40. In general, even if it is an aggressive hemangioma, it is still essentially a vascular malformation, not a malignancy. Treatment of vascular malformations requires a visit to vascular surgery, while problems in the spine require a visit to orthopedics to decide whether to opt for surgery (including minimally invasive) or radiation therapy. The relevant departments work closely together at Beihang Hospital. If the orthopedic surgeon finds that the orthopedic problem is not serious, the patient will be referred to radiotherapy; while if the orthopedic aspect is very critical (high risk of fracture or paralysis), then the orthopedic aspect will be treated first, after which, depending on the condition, the patient may be referred to radiotherapy for follow-up treatment. According to clinical manifestations, spinal hemangiomas are classified into four types: asymptomatic without compression, with compression without symptoms, with painful symptoms, and with manifestations of nerve damage (special type: rapid progression during pregnancy). Combining imaging and clinical manifestations, hemangiomas with aggressive and invasive potential can be classified into four categories. Based on the site of the lesion, hemangiomas can also be classified into two types: confined within the vertebral bone (three types: located solely in the anterior or posterior column, and anterior + posterior column) and invasive into the soft tissue (paravertebral and/or intravertebral canal). The intradural invasion is further divided into two types: slight or severe compression of the spinal cord. Diagnosis 1. Diagnosis by imaging: In general, there is no new development in imaging compared with before. x-ray is the most basic examination method, but it can be shown only when the vertebral body is 30-50% destroyed. CT is the most effective way to evaluate the intraosseous lesions of hemangioma, because the trabeculae at the location of hemangioma thicken and form nodules, which show high-density “dot sign” or “honeycomb-like changes” in cross-section and “fenestrated” changes in sagittal plane. fenestrated” changes in the sagittal plane (Figure, see computerized version for better clarity). MRI can be used to evaluate the degree of soft tissue expansion, fat composition and spinal cord compression. 2.Tissue biopsy and pathological diagnosis Large block pathology can clarify the diagnosis of hemangioma, which often requires incisional biopsy or surgical excision to obtain. CT-guided puncture biopsy is also available, but there are risks of failed retrieval, excessive bleeding, and epidural hematoma. It is generally a relative contraindication to puncture biopsy. However, it is difficult to distinguish invasive hemangioma (vascular malformation) from hemangiosarcoma and hemangioendothelioma (malignant) by imaging alone. Treatment The prognosis of vascular lesions varies with their pathological types and clinical classifications, and a variety of treatment options are available. Asymptomatic spinal hemangiomas require only observation (asymptomatic, incidentally detected hemangiomas require only follow-up of symptoms and no review of imaging). Here we focus on the treatment of spinal invasive hemangiomas. Malignant tumors of vascular origin (hemangioendothelioma or hemangiosarcoma) are generally treated by radical surgery (Figure 4-5, Case 3) with preoperative adjuvant vascular embolization or radiotherapy, or postoperative adjuvant radiotherapy and/or chemotherapy if resection is incomplete. Principles of treatment for invasive hemangioma of the spine: radiotherapy: minimal nerve damage and slow progression. Vertebroplasty: simple pain and limited lesions. Surgery: severe nerve damage, unstable compression fracture of the spine, ineffective radiotherapy or unclear diagnosis. 1, radiation therapy (radiotherapy) – non-invasive treatment Radiotherapy is the treatment of choice, especially for patients over 60 years of age. The main indications are spinal hemangioma with pain or mild neurological symptoms, and the total recommended dose is generally 30-40 Gy. Complications of radiotherapy are: occasional malignancy. It is especially suitable for elderly and frail patients. Disadvantages: 1 in 10,000 malignant rate. After 3 months after radiotherapy, if the symptoms still exist, surgery can be performed. Because after radiotherapy, the bleeding is reduced and the safety of surgery is improved. 2.Minimally invasive treatment â‘´Vertebroplasty. At present, for cases with only pain and no nerve compression, it is commonly called “bone cement” (polymethylmethacrylate). (2) Anhydrous ethanol (alcohol) injection treatment. 5% alcohol injection is widely used in liver tumors and has achieved good results. Good results have also been obtained in spinal hemangioma. The risk is slightly higher, and it is used more often in the United States, but now the Ministry of Health in China restricts its use. （Surgery is preferred for spinal hemangiomas, especially for those with rapidly worsening nerve damage. 5% of patients may also require chemotherapy after surgery. Surgery is risky (bleeding, aggravation of nerve damage). Angiosarcoma should strive for complete excision of the entire mass. It is generally believed that hemangiosarcoma is a malformation, and even if it is clinically “invasive”, it is still a “benign lesion”, which can be completely removed (high trauma and high risk), or palliative surgery (release of nerve compression and prevention of fracture, low risk and low trauma). 4, combined treatment For patients with nerve damage, embolization + surgical decompression + radiotherapy is the conventional treatment in the past. Beihang Hospital once tried intraoperative injection of bone cement + stabilization + decompression in 20 cases with satisfactory results. It can significantly reduce bleeding.