Thematic review and illustrative videos of aggressive vertebral column hemangioma management: illustrative cases.

backgroundAggressive vertebral hemangiomas (AVHs) are benign vascular lesions that can exhibit locally invasive behavior. Because of their rarity, standardized treatment guidelines are lacking. We present 2 surgically managed cases, supplemented with intraoperative video, and conduct a thematic literature review evaluating treatment strategies. OBSERVATIONS: A 66-year-old female presented with low back pain radiating to the groin and gait instability. MRI demonstrated an L1 AVH. She underwent T12-L2 laminectomy, instrumented stabilization, and cement augmentation, followed by radiotherapy. Marked pain relief and functional improvement were reported. The second patient, a 14-year-old male, presented to his pediatrician with neck pain, hand weakness, and paresthesias. He sustained a fall at school and was brought to the emergency department with quadriparesis. Imaging revealed a C4-6 AVH with a C5 pathological fracture. Emergency C4-6 corpectomy, laminectomy, and posterior fixation were performed. Proximal upper extremity function partially recovered, but hand and lower extremity motor deficits persisted. A literature review demonstrated the importance of surgery and highlighted the roles of radiotherapy, cement augmentation, embolization, and alcohol-based injections in nonoperative and multimodal management. LESSONS: AVH management should be tailored based on location, extent of neural compression, and symptom severity. Surgical intervention remains central in cases with neurological compromise or instability. https://thejns.org/doi/10.3171/CASE25654.