When should imaging be done for a newborn with a lumbar skin hemangioma?

Imaging for Newborn Lumbar Skin Hemangioma

All newborns with lumbar skin hemangiomas should undergo imaging evaluation due to the high risk of LUMBAR syndrome and associated spinal dysraphism, which can cause permanent neurologic damage if untreated. 1

Initial Imaging Approach

Start with spinal ultrasonography in infants under 6 months of corrected age as the initial screening modality. 1

• Ultrasonography avoids ionizing radiation and typically does not require sedation 1
• This modality is effective only before posterior spinal elements ossify (generally before 6 months) 2
• Doppler ultrasonography of the abdomen and pelvis should also be performed to screen for genitourinary and other anomalies associated with LUMBAR syndrome 1

When to Proceed Directly to MRI

MRI should be performed when concerned about associated structural abnormalities, which is the case with all lumbar hemangiomas. 1

The following scenarios mandate MRI evaluation:

• Any midline lumbosacral hemangioma regardless of size - the positive predictive value for spinal dysraphism is 51.2%, with a relative risk of 640 for spinal anomalies 3
• Associated cutaneous markers of dysraphism including sacral dimple, skin appendage, tuft of hair, lipoma, or dermal sinus tract 1
• Ulcerated hemangiomas - these carry higher risk for underlying spinal anomalies 3
• Normal ultrasonography but high clinical suspicion - ultrasound sensitivity for detecting spinal anomalies in this population is only 50% 3
• Infants older than 6 months - when ultrasonography is no longer technically feasible 2

Critical Timing Considerations

MRI screening should ideally be performed around 6 months of age when fat formation in the filum terminale is fully expanded, providing optimal diagnostic accuracy. 2

• Even isolated lumbosacral hemangiomas without additional cutaneous markers carry a 35% risk of spinal anomalies (relative risk 438) 3
• Early detection prevents complications including CNS infection, aseptic meningitis, spinal cord compression, and neurologic deterioration from cord tethering 4
• Young infants can often be fed and swaddled before MRI to sleep through the procedure without sedation 1

Common Pitfalls to Avoid

• Do not rely on hemangioma size alone - even small lesions can be associated with significant spinal dysraphism 2, 3
• Do not skip imaging based on normal neurologic examination - most infants are asymptomatic at presentation, but untreated lesions can cause progressive neurologic deterioration 5, 3
• Do not accept normal ultrasonography as definitive - proceed to MRI given the poor sensitivity of ultrasound in this high-risk population 3
• Do not delay imaging - 80% of hemangiomas reach final size by 3 months, and early identification of spinal anomalies allows for timely neurosurgical intervention 6

Consultation Recommendations

If uncertainty exists about imaging necessity, consult with a hemangioma specialist, pediatric neurologist, neurosurgeon, or radiologist to determine the appropriate imaging protocol. 1