Vertebral haemangiomas 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 haemangioma).
Please refer to the article on primary intraosseous haemangioma for a general discussion on this entity.
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Terminology
Atypical haemangiomas have lower fat content, lipid-poor haemangiomas is a term preferred by some authors to avoid confusion with aggressive vertebral haemangiomas 13.
Epidemiology
The incidence of vertebral haemangiomas is about 10% at autopsy 1. The majority of haemangiomas are incidentally noted on routine radiographs of the spine. Often, small haemangiomas cannot be visualised on radiographs and are found with more advanced imaging such as CT or MRI, or upon gross dissection. The occurrence of vertebral haemangiomas is seen slightly more in females for unknown reasons and is more symptomatic in the 4th decade of life.
Clinical presentation
Most haemangiomas 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 haemangioma to become painful, such as starting to exercise, housework and such like. This is most likely due to axial loading through the body of the vertebra.
Pathology
They are composed of vascular spaces which causes a displacement of the bone. There are two main histopathological types 11:
cavernous (involves relatively large vessels)
capillary (involves small capillaries)
In some cases, specifically capillary types, lytic erosion into the epidural space can occur, however this is rare 2. They are slow-growing and most haemangiomas are asymptomatic.
Distribution
The majority of vertebral haemangiomas occur in the thoracic spine but they can be found throughout the spine.
Radiographic features
The classic “corduroy” or "jail bar" appearance is strongly associated with vertebral haemangiomas.
CT
Axial CT will show a “polka dot” or "salt and pepper" appearance due to the thickened vertebral trabeculae 3,4. On sagittal CT, vertebral haemangiomas typically show the "corduroy" sign due to thicker or denser vertical trabeculae 14.
MRI
MRI shows extraosseous components better and depicts the haemangioma components as fat and water. Thickened trabeculae appear as low signal areas in both T1 and T2 images.
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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
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 haemangiomas 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 embolisation with associated laminectomy are some of those options 5.
Serious bleeding can be a complication so care must be taken when undergoing open procedures.
Differential diagnosis
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
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