Vertebral hemangioma

Last revised by Patrick O'Shea on 23 Sep 2022

Vertebral hemangiomas are the most common benign vertebral neoplasms. 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. 

Atypical hemangiomas have lower fat content, lipid-poor hemangiomas is a term preferred by some authors 13 as not confuse with aggressive vertebral hemangiomas.

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.

The classic “corduroy cloth” or "jail bar" appearance is strongly associated with vertebral hemangiomas. 

Axial CT will show a “polka-dotted”  or "salt and pepper" appearance due to the thickened vertebral trabeculae 3-4.

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. 

  • T1
    • ​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 
  • T1 C+: significant enhancement is seen due to high vascularity

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

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Cases and figures

  • Case 1
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  • Case 2
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  • Case 3: with polka dot sign
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  • Case 4: with polka dot sign
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  • Case 5
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  • Case 6
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  • Case 7
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  • Case 8: bone scan (Tc-99m RBC labeled SPECT/CT)
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  • Case 9
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  • Case 10: atypical vertebral hemangioma
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