Both fluoroscopic and computed tomography (CT) guidance can be used. After preparing an aseptic field, local anesthesia to the skin and the targeted vertebral arch is performed using a spinal needle. Three types of approach can be used to reach the vertebral body—the trans-pedicular, posterolateral oblique, and the costovertebral route at the thoracic level. To avoid risks, I recommend the transpedicular as the safest approach (Fig. 3). A 14-gauge bone-biopsy needle [Angiomed (Karlsruhe, Germany)] is inserted through the skin and pedicle into the vertebral body. In some cases, this needle is replaced by an 18-gauge needle, mainly in cases of VH with a soft-tissue involvement. In cases of hard bone, a hammer can be used, but use of a manual drill device is preferable.
FIGURE 1 Symptomatic noncomplicated hemangioma, without involvement of the neural arch. Typical jail bar picture.
A preliminary contrast media opacification test should be performed prior to ethanol injection to check for vascular safety. The procedure is safe when the contrast medium is retained by the VH, whereas the procedure should not be performed in case of fast washout. Therefore, 2 mL of contrast medium are manually injected into the VH and a fast angiographic sequence of radiographs or a short helical CT-scan acquisition is carried out to analyze the washout of the VH (Fig. 4). In safe cases, the injected contrast remains in the medullary area. The presence of thin epidural veins is not a contraindication to the ethanol injection. Contraindications are the presence of a significant venous reflux with early opacification of paravertebral veins or suspicion of leakage into the spinal canal. Then 5 mL of absolute ethanol is injected slowly. Ethanol may be mixed with iodine contrast to check the distribution of the alcohol (Figs. 5 and 6). The presence of an anesthesiologist is not required but optimal. An anesthesiologist was present in half of the procedures we have performed.
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