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Vertebral hemangiomas are the most common benign vertebral neoplasms. That said, they are not true neoplasms but venous malformations. They are usually asymptomatic and incidentally detected due to their characteristic features on imaging for other reasons. Rarely, they can be locally aggressive (see: aggressive vertebral hemangioma).
Please refer to the article on primary intraosseous hemangioma for a general discussion in this entity.
The incidence of vertebral hemangiomas is about 10% at autopsy 1. The majority of hemangiomas are incidentally noted on routine radiographs of the spine. Often, small hemangiomas cannot be visualized on radiographs and are found with more advanced imaging such as CT or MRI, or upon gross dissection. The occurrence of vertebral hemangiomas is seen slightly more in females for unknown reasons and is more symptomatic in the 4th decade of life.
Most hemangiomas are asymptomatic. The collapse of the vertebral body or encroachment into the neural canal are some of the classic causes of pain. An increase in activity can cause the vertebral hemangioma to become painful, such as starting to exercise, housework and such. This is most likely due to axial loading through the body of the vertebra.
They are composed of vascular spaces which causes a displacement of the bone. It has two main histopathological types, cavernous (involves relatively large vessels) and capillary (involves small capillaries) angiomas 11. In some cases, specifically capillary types, lytic erosion into the epidural space can occur, however rare 2. They are slow-growing and most are not symptomatic.
The majority of all vertebral hemangiomas occur in the thoracic spine but can be found throughout the spine.
Axial CT will show a “polka-dotted” or "salt and pepper" appearance due to the thickened vertebral trabeculae 3-4. On sagittal CT, vertebral hemangiomas typically show the "corduroy" sign due to thicker or denser vertical trabeculae 14.
MRI shows extraosseous components better and depicts the hemangioma components as fat and water. Thickened trabeculae appear as low signal areas in both T1 and T2 images.
typical: lipid-rich will demonstrate high signal
atypical: lipid-poor will demonstrate low signal
T2: bright/high-intensity signal, usually greater than on T1, due to its high water content
STIR: variable signal intensity depending on the amount of fat in the lesion relative to the vascularity
T1 C+: significant enhancement is seen due to high vascularity
Treatment and prognosis
Treatment for most hemangiomas is not necessary. When neurological deficits or severe pain treatment is necessary. In symptomatic lesions, there are many options that must be weighed. Radiotherapy, balloon kyphoplasty or transarterial embolization with associated laminectomy are some of those options 5.
Serious bleeding can be a complication so care must be taken when undergoing open procedures.
metastases: usually have decreased signal intensity on T1 and increased signal intensity on T2
focal fatty marrow: will have decreased signal intensity on fat suppressed sequences
- 1. McAllister VL, Kendall BE, Bull JW. Symptomatic vertebral haemangiomas. Brain. 1975;98 (1): 71-80. Pubmed citation
- 2. Hillman J, Bynke O. Solitary extradural cavernous hemangiomas in the spinal canal. Report of five cases. Surg Neurol. 1991;36 (1): 19-24. Pubmed citation
- 3. Bremnes RM, Hauge HN, Sagsveen R. Radiotherapy in the treatment of symptomatic vertebral hemangiomas: technical case report. Neurosurgery. 1997;39 (5): 1054-8. Pubmed citation
- 4. Pastushyn AI, Slin'ko EI, Mirzoyeva GM. Vertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients. Surg Neurol. 1999;50 (6): 535-47. Pubmed citation
- 5. Fox MW, Onofrio BM. The natural history and management of symptomatic and asymptomatic vertebral hemangiomas. J. Neurosurg. 1993;78 (1): 36-45. doi:10.3171/jns.1993.78.1.0036 - Pubmed citation
- 6. Ross JS, Masaryk TJ, Modic MT et-al. Vertebral hemangiomas: MR imaging. Radiology. 1987;165 (1): 165-9. Pubmed citation
- 7. Laredo JD, Reizine D, Bard M et-al. Vertebral hemangiomas: radiologic evaluation. Radiology. 1986;161 (1): 183-9. Pubmed citation
- 8. Vinay S, Khan SK, Braybrooke JR. Lumbar vertebral haemangioma causing pathological fracture, epidural haemorrhage, and cord compression: a case report and review of literature. J Spinal Cord Med. 2011;34 (3): 335-9. doi:10.1179/2045772311Y.0000000004 - Free text at pubmed - Pubmed citation
- 9. Friedman DP. Symptomatic vertebral hemangiomas: MR findings. AJR Am J Roentgenol. 1996;167 (2): 359-64. doi:10.2214/ajr.167.2.8686604 - Pubmed citation
- 10. Laredo JD, Assouline E, Gelbert F et-al. Vertebral hemangiomas: fat content as a sign of aggressiveness. Radiology. 1990;177 (2): 467-72. Pubmed citation
- 11. Tafti D & Cecava N. Spinal Hemangioma. 2022. - Pubmed
- 12. Canbay S, Kayalar AE, Gel G, Sabuncuoğlu H. A novel surgical technique for aggressive vertebral hemangiomas. (2019) Neurocirugia (Asturias, Spain). 30 (5): 233-237. doi:10.1016/j.neucir.2018.08.003 - Pubmed
- 13. J.M. Hoyle, L.J. Layfield, J. Crim. The lipid-poor hemangioma: an investigation into the behavior of the “atypical” hemangioma. (2020) Skeletal Radiology. 49 (1): 93. doi:10.1007/s00256-019-03257-2
- 14. Liu SZ, Zhou X, Song A, Wang YP, Liu Y, The corduroy appearance and the polka dot sign, QJM: An International Journal of Medicine, Volume 113, Issue 3, March 2020, Pages 222–223, https://doi.org/10.1093/qjmed/hcz184