A Rare Presentation of Concurrent Typical, Atypical, and Aggressive Thoracic Vertebral Hemangiomas: Insights into Histological Variability and Multidisciplinary Management

Background: Vertebral hemangiomas are typically benign and asymptomatic, but a small subset, known as aggressive vertebral hemangiomas, may present with neurological deficits due to extraosseous extension and spinal cord compression. These cases require timely diagnosis and a multidisciplinary management approach. Case Presentation: A 42-year-old man presented with acute-onset severe mid-back pain for 2 months. Neurological examination revealed exaggerated reflexes without motor or sensory deficits. Magnetic resonance imaging showed expansile lesions at T7, T9, and T10, with additional angiomatous lesions at T3 and T4. T7 and T10 lesions caused spinal cord compression. Preoperative embolization of T7 and T10 was performed using polidocanol. The patient subsequently underwent vertebroplasty at T7, T9, and T10 levels, pedicle screw fixation from T4 to T11, posterior decompression at T6 to T7 and T9 to T10. Intraoperative biopsies revealed a cavernous hemangioma at T7 and a capillary hemangioma at T9. No malignancy was found. Results: Postoperative recovery was uneventful, with early mobilization and significant functional improvement. At 2-year follow-up, the patient had no pain or neurological symptoms, and radiographs showed stable fixation with no recurrence. Conclusion: Aggressive vertebral hemangiomas, though rare, should be considered in patients with progressive neurological symptoms. Early diagnosis, embolization, surgical decompression, and stabilization can yield excellent outcomes.