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 on 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 are seen slightly more in females for unknown reasons and are more symptomatic in the 4th decade of life.
Most hemangiomas are asymptomatic. 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 bone. 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” appearance is strongly associated with vertebral hemangiomas.
Axial CT will show a “polka dotted” 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: high intensity signal due to its fat component
- T2: bright/high intensity signal, usually greater than on T1, due to its high water content
- T1 C+: significant enhancement 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 which 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.
- usually have decreased signal intensity on T1 and increased signal intensity on T2
- 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