Professional Documents
Culture Documents
Spinal hemangiomas are the most common primary tumor of the spine. These lesions are of
vascular origin and usually involve a proliferation of normal capillary and venous structures.
These are usually an incidental finding found on radiological imaging of the body and spine. A
minority of these lesions can be associated with symptoms, primarily involving back pain and
neurologic complaints with some estimates of 0.9% to 1.2% becoming symptomatic. This
activity reviews the evaluation and management of spinal hemangiomas and explains the role of
the interprofessional team in managing patients affected by this condition.
Objectives:
Identify the etiology and histopathology of spinal hemangiomas.
Describe a complete evaluation and workup for patients presenting with suspected spinal
hemangioma.
Summarize the appropriate treatment options and case management for spinal
hemangioma.
Review the importance of coordination of the interprofessional team to provide optimal
care to patients with spinal hemangiomas and monitor for potential complications.
Introduction
Spinal hemangiomas are the most common primary tumor of the spine.[1] Usually benign, this
lesion is of vascular origin and like hemangiomas in other parts of the body usually involves a
proliferation of normal capillary and venous structures.[2] According to one study, they have
been identified in about 11% of patients at general autopsy.[3] These lesions are usually an
incidental finding often found on CT and MR imaging of the body and spine, and frequently in
radiographs of the thoracolumbar spine.[4] A minority of these lesions can be associated with
symptoms, primarily involving back pain and neurologic complaints with some estimates of
0.9% to 1.2% becoming symptomatic.[5] Symptoms can involve severe back pain worsened by
movement; however, mild to moderate pain can also be a presenting complaint.[6] In cases of
neurogenic pain, hemangiomas usually extend into the spinal canal or neural foramina.[7]
Etiology
Although the exact etiology and inciting factor of spinal hemangiomas genesis are not well
understood, a well-known characteristic of these benign lesions includes a vascular proliferation
of capillaries similar to hemangiomas in other parts of the body. Proliferation subsequently
causes a displacement of bone and in rarer cases erosion into the spinal canal. Unlike infantile
hemangiomas, hemangiomas of the spine do not spontaneously regress.
Epidemiology
The incidence of spinal hemangiomas has been reported as 11% in autopsy studies.[3] Most are
incidentally noted and can be characterized on radiographs of the spine as well as cross-sectional
imaging. Females are somewhat more affected than males.[8] Incidence has also been reported
on MRI studies as high as 27%.[8]
Histopathology
Grossly specimens can show periosteal elevation. Two histologic types of hemangiomas of the
vertebra can occur cavernous and capillary angiomas. Cavernous angiomas involve large blood
vessels not separated by normal bone. Capillary angiomas involve thin-walled capillary vessels
separated by normal bone. There is usually a capsule surrounding the lesion with adjacent bone
potentially exhibiting osteolysis.[9]
Evaluation
The role of imaging is critical in the evaluation of a hemangioma including lesion size, site, and
degree of lytic involvement of the spinal canal and neuroforamina. Radiograph usually shows a
prominent trabecular pattern with vertical striations. The density of the vertebral body is often
increased giving a sclerotic appearance. Vertebral body height and size should remain
unaffected. On CT imaging, hemangiomas have a classic corduroy(accordion) pattern from
coarsening of the trabeculae. Although rare, bone destruction and extension into the adjacent soft
tissues including the spinal canal can be evaluated on CT imaging. MR imaging can definitively
assess for soft-tissue extension.
Treatment / Management
Given that the vast majority of hemangiomas are asymptomatic and are a benign entity,
treatment and intervention are usually not employed in asymptomatic patients. In the setting of
symptomatic patients, different interventions have been used in their treatment. Endovascular
embolization has been used to treat painful vertebral hemangiomas and has been shown to
relieve spinal cord compression from epidural extension.[10] Percutaneous vertebroplasty has
also been shown to be effective in pain relief.[11] Transpedicular ethanol injection has
been employed in the treatment of spinal hemangiomas; however, complications have been
seen.[12] Radiation therapy has also been used to treat painful lesions considering spinal
hemangiomas are radiosensitive lesions.[13]
Differential Diagnosis
The differential diagnosis for sclerotic lesions of the spine is wide. Paget disease can be
considered in the setting of a vertebral body lesion mimicking a hemangioma; however, cortical
thickening is often present with a characteristic “picture frame sign.” Squaring of the vertebra
can also be appreciated. Sclerotic metastasis such as in the setting of prostate carcinoma,
osteosarcoma, and medullary thyroid carcinoma should also be considered in the differential.
Other differentials include lymphoma and multiple myeloma.
Complications
Complications, although rare, can infrequently occur. Pathologic burst fracture can be
problematic considering these highly vascular lesions can subsequently bleed causing a
hematoma and resultant cord compression.[14] Epidural extension, although also rare, can occur
leading to neurologic deficits in the setting of cord compression. Exiting nerve roots can also be
affected leading to neurologic symptoms. Spontaneous epidural hemorrhage can also occur,
although hemorrhage is usually an iatrogenic complication.
Consultations
Pain medicine
Orthopedics
Neurosurgery