A 74-year-old male patient with ongoing persistent lower lumbar spine pain, shortness of breath, and cough was initially treated symptomatically for his pain and for presumed pneumonia. Computed tomography (CT) demonstrated an 11 mm right middle lobe lesion and an indeterminate 13 mm right adrenal lesion, prompting further evaluation with positron emission tomography (PET)-CT. A PET-CT demonstrated a fluorodeoxyglucose (FDG)-avid left renal mass suggestive of malignancy with an associated L2 vertebral body and left humeral head destructive lesion. He underwent total spine magnetic resonance imaging (MRI) and lumbar spine CT imaging, revealing a large destructive L2 vertebral body lesion with a pathologic fracture and 4-mm soft tissue extension into the ventral spinal canal, resulting in moderate left-sided spinal canal narrowing (Fig. 1). Significant L2-L3 left subarticular zone, neural foraminal narrowing, and compression on the left traversing L3 and exiting L2 nerve roots were also identified. There was no cord compression or signal abnormality. The patient was referred for embolization prior to planned surgical resection.

The patient was placed under general anesthesia and standard access with a 5 French sheath in the common femoral artery was achieved. A 5 French Mickelson catheter (Cook Medical Inc., Bloomington, IN, USA) was employed to selectively catheterize the left L2 segmental artery and an angiographic run demonstrated an obvious pathologic blush in the region of the L2 vertebral body (Fig. 2A). Opacification of a spinal pial artery (artery of Adamkiewicz) was not seen. An Echelon microcatheter (eV3, Plymouth, MN, USA) was advanced through the Mickelson catheter (Cook Medical Inc., Bloomington, IN, USA) into the distal left L2 segmental artery and Onyx-18 (eV3, Plymouth, MN, USA) was injected, creating a cast within the segmental artery. The injected Onyx-18 was allowed to reflux into the vertebral body until the metastatic lesion was completely embolized (Fig. 2B-C). A total volume of 0.64 milliliters (mL) of Onyx was used. Subsequent selective injection of the right L2 segmental artery demonstrated minimal pathologic blush. The total fluoroscopy time for the procedure was 33 minutes, and the procedural duration was 2.5 hours. Post-procedure plain X-ray films confirmed Onyx distribution in the left half of the vertebral body, within the tumor (Fig. 3). The patient subsequently underwent an uneventful corpectomy and fusion with minimal blood loss (less than 100 cc) and recovered without complications.

A 52-year-old male patient presented with six months of progressive bilateral lower extremity weakness and worsening sensory function, leading to multiple falls. There were also spasms and spasticity of the lower extremities bilaterally, and several episodes of fecal and urinary incontinence. A CT and total spine MRI revealed multiple lesions with coarse trabeculae in the thoracic (T1, T3 and T11) and lumbar spine (L1), most severe within the T3 vertebral body. These lesions extended to the posterior elements and soft tissues in the surrounding paravertebral and epidural space, causing significant anterior cord compression (Fig. 4).

An open biopsy confirmed an intraosseous hemangioma, and the patient was referred for embolization prior to anticipated surgical resection. The patient was placed under general anesthesia and standard access with a 5 French sheath in the common femoral artery was achieved. The right T4 segmental artery was selectively catheterized with a Cobra catheter (Terumo, Somerset, NJ, USA). Angiography demonstrated a large pathologic blush in the region of the T3 vertebral body, corresponding to the known hemangioma (Fig. 5A). Opacification of a spinal pial artery was not seen. An Echelon microcatheter was advanced into the segmental artery and the vascular supply to the hemangioma was embolized with a total of 0.24 mL of Onyx-18 (Fig. 5B). The procedural total fluoroscopy time was 27 minutes, and procedural duration was 2.5 hours. Post-embolization angiography via the Cobra catheter confirmed no further pathologic blush (Fig. 5C, Fig. 6). The patient recovered uneventfully from the embolization and surgical resection, the latter with 300 cc of estimated blood loss.