• Raffaele De Marco, Gianluca Piatelli, Andrea Rossi, Luigi Aurelio Nasto, and Marco Pavanello.
• Department of Neurosurgery, IRCCS Istituto "G. Gaslini", via G. Gaslini 5, 16148, Genoa, Italy. r_dema@outlook.it.
• Eur Spine J. 2022 Dec 1; 31 (12): 374837583748-3758.

PurposeTo discuss a treatment algorithm for vertebral hemangioma in children.MethodsVertebral hemangioma (VH) is a rare cause of low back pain in children. In most cases, VHs present as incidental findings and do not require invasive diagnostic procedure. In case of symptomatic presentation, different approaches can be used. Over the years, we have developed a treatment algorithm for VH in children based on our clinical experience. In this manuscript, we propose a stepwise approach to treatment of VHs based on tumor extension and the degree of spinal cord/nerves compression with or without neurological deficit.ResultsAccording to the proposed protocol, we discuss two cases of aggressive VH treated at our institution by a multidisciplinary team. The first case is about a young girl treated with percutaneous one-level posterior instrumentation followed by medical adjuvant therapy for an L4 "Stage 3" VH. The second case is about an 8-year-old boy with rapidly progressive myelopathy due to T11 "Stage 4" VH treated with a combined anterior and posterior surgery (i.e., posterior decompression and fusion followed by vertebrectomy and expandable cage placement) after preoperative arterial embolization.ConclusionGiven the lack of international guidelines and consensus with regard to treatment of VHs in children, we believe our proposal for a stepwise approach combining clinical and radiological characteristics of the lesion may help guide treatment of this condition in children.© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

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