What is a vertebral hemangioma, specifically its characteristics, symptoms, and treatment options in adults, particularly those with a history of cancer, osteoporosis, or those on anticoagulant therapy?

Vertebral Hemangioma: Definition and Clinical Overview

A vertebral hemangioma is a benign vascular malformation (not a true tumor) consisting of hamartomatous proliferation of endothelial tissue within the vertebral body, representing the most common benign spine lesion with an incidence of 1.9-27% in the general population. 1, 2, 3

Pathophysiology and Epidemiology

• Vertebral hemangiomas are vascular malformations rather than true neoplasms, characterized by hamartomatous proliferation of endothelial tissue within the vertebral body 3
• These lesions affect approximately 10% of the world population based on autopsy studies, though the vast majority remain asymptomatic throughout life 3
• The thoracic spine is most commonly affected (approximately 70% of cases), followed by lumbar (21%) and cervical regions (9%) 1, 4
• Symptomatic hemangiomas represent less than 1% of all vertebral hemangiomas, typically presenting during adult age with mean age at diagnosis around 44-48 years 1, 4, 5
• There is a slight female predominance in symptomatic cases 4

Clinical Presentation and Symptoms

Asymptomatic Lesions (>99% of cases)

• The overwhelming majority of vertebral hemangiomas are discovered incidentally on imaging performed for unrelated reasons and never cause symptoms 1, 3
• These incidental findings require no treatment and can be observed 1

Symptomatic Lesions (<1% of cases)

• Localized pain is the most common presenting symptom in symptomatic cases, typically resistant to conservative medical management 1, 4, 5
• Neurological deficits occur when there is epidural extension causing spinal cord or nerve root compression, including:
  • Myelopathy (most common neurological presentation, occurring in 62% of symptomatic cases) 4
  • Radiculopathy (34% of symptomatic cases) 4
  • Cauda equina syndrome (rare) 4
• Progressive walking difficulty and sensory disturbances in lower extremities indicate spinal cord compression 2
• Rapid progressive neurological deterioration indicates aggressive behavior requiring urgent intervention 4

Radiographic Characteristics

• Standard posteroanterior and lateral spine radiographs provide adequate visualization to detect vertebral hemangiomas as incidental findings during scoliosis evaluation 6
• Classic radiographic appearance shows vertical striations ("corduroy" or "jail-bar" pattern) on plain films due to thickened vertical trabeculae 1
• CT imaging demonstrates characteristic "polka-dot" appearance on axial views from thickened trabeculae 1, 4
• MRI characteristics typically show T1- and T2-weighted hyperintense lesions, though atypical aggressive variants may show different signal characteristics 2
• If radiographic appearance is equivocal or the lesion appears atypical, particularly with focal pain or neurological symptoms, advanced imaging with CT or MRI should be obtained 6

Aggressive/Atypical Variants

• Aggressive vertebral hemangiomas (also termed atypical) account for less than 1% of all vertebral hemangiomas and exhibit extraosseous expansion into the epidural space 2
• Epidural soft-tissue compression is the main mechanism of neurological deficit in aggressive cases, occurring in 62% of symptomatic patients 4
• Combined bony and soft tissue compression occurs in 38% of symptomatic cases 4
• Pathologic vertebral fracture can occur in aggressive variants, present in approximately 18% of symptomatic cases 4
• Trocar biopsy is indicated when imaging findings are atypical and malignancy cannot be excluded 4

Treatment Approach Based on Clinical Presentation

Asymptomatic Incidental Lesions

• Observation alone is appropriate for asymptomatic lesions discovered incidentally, as these do not require intervention 1
• No specific follow-up imaging is necessary unless symptoms develop 1

Symptomatic Lesions with Pain Only (No Neurological Deficit)

• Radiotherapy is the first-line treatment for symptomatic vertebral hemangiomas presenting with localized pain without neurological compromise 4, 3
• Conservative pain management with observation is reasonable for mild symptoms, though all symptomatic patients should be offered definitive treatment options 1
• Percutaneous vertebroplasty provides complete and enduring resolution of painful symptoms in 100% of cases when pain is the sole symptom, with mean follow-up of 5.8 years demonstrating sustained benefit 5
• Vertebroplasty is performed via unipedicular approach under fluoroscopic guidance with local anesthesia 5
• Extravertebral cement leakage occurs in approximately 12.5% of vertebroplasty cases but rarely causes clinical symptoms 5

Symptomatic Lesions with Neurological Deficit

Mild or Slowly Progressive Deficit

• Radiotherapy is the first-line treatment when neurological deficit is mild or develops slowly 4
• Radiotherapy alone achieves durable results without recurrence in cases without severe compression 4

Severe or Rapidly Progressive Deficit

• Surgical decompression is indicated when neurological deficit is severe, develops rapidly, or when radiotherapy fails 4
• Posterior decompression with maximal resection of the hemangioma is the standard surgical approach 1, 4
• Intraoperative vertebroplasty combined with decompression significantly reduces blood loss (average 1093 mL) compared to decompression alone (average 1900 mL) 4
• Preoperative arterial coil embolization should be performed when feasible to reduce intraoperative bleeding, particularly for aggressive variants 2
• Surgical decompression achieves neurological improvement in 70% of patients with myelopathy and complete pain resolution in those with pain alone 1
• Corpectomy is required for cervical lesions with significant vertebral body involvement 1

Adjuvant Radiotherapy After Surgery

• Postoperative radiotherapy is essential to prevent local recurrence, as surgical decompression alone without radiotherapy results in 50% recurrence rate 4
• Combined surgical decompression with adjuvant radiotherapy prevents recurrence in long-term follow-up 4

Special Considerations for High-Risk Populations

Patients with Cancer History

• Trocar biopsy is mandatory when imaging findings are atypical or when there is concern for metastatic disease versus hemangioma 4
• The preoperative diagnosis of vertebral hemangioma based on imaging alone is accurate in 91% of cases, but biopsy should be obtained when uncertainty exists 1

Patients on Anticoagulation

• The risk of vertebral canal hematoma after neuraxial procedures in anticoagulated patients is very small (1:118,000 in general practice) and likely even lower in older patients 7
• For vertebroplasty procedures, anticoagulation management should follow institutional protocols balancing thrombotic risk against bleeding risk 7
• Permanent neurological damage from vertebral canal hematoma can be reduced by prompt recognition of back pain with radicular distribution, motor/sensory impairment, or altered bowel/bladder function within 24 hours post-procedure 7

Patients with Osteoporosis

• Vertebroplasty is particularly effective in osteoporotic patients with painful vertebral hemangiomas, providing immediate pain relief and vertebral stabilization 5
• Pathologic fracture through hemangiomatous vertebrae occurs more commonly in osteoporotic patients and may be the presenting feature 4

Critical Pitfalls to Avoid

• Do not dismiss midline cutaneous hemangiomas overlying the spine in pediatric patients, as nearly 70% of children with spinal dysraphism display at least one high-risk cutaneous marker, and infantile hemangiomas overlying the lumbosacral spine raise suspicion for underlying dysraphic malformation 7
• Do not perform surgical decompression alone without adjuvant radiotherapy, as this results in 50% local recurrence rate compared to zero recurrence with combined treatment 4
• Do not delay surgical intervention in patients with rapidly progressive or severe myelopathy, as these cases require urgent decompression to prevent permanent neurological injury 4
• Do not assume all vertebral lesions with typical hemangioma appearance are benign in patients with cancer history; obtain biopsy when imaging findings are atypical or clinical presentation is inconsistent 4
• Do not confuse vertebral hemangiomas with cavernous malformations, which are distinct vascular lesions requiring different management approaches 7