Vertebral Haemangioma

A vertebral haemangioma is a benign, non-cancerous lesion made up of a tangle of small, thin-walled blood vessels and blood-filled spaces within the spongy bone of a vertebra, the building block of the spinal column. These vessels are interspersed among the bony struts, or trabeculae, of the vertebral body, set within a stroma that is typically rich in fat. It is widely regarded not as a true tumour in the ordinary sense but as a developmental or hamartomatous lesion, a localised overgrowth of normal tissue elements, and it is slow-growing or static in nature.

The lesions are most commonly found within the vertebral body, the rounded front portion of the vertebra. In a smaller proportion, perhaps ten to fifteen per cent, the lesion extends into the posterior elements, the bony arch behind the body, and it is uncommon for a haemangioma to arise there in the first place. Under the microscope they are usually classified as cavernous or capillary types, depending on the calibre of the vessels involved.

The crucial point is that these are vascular lesions of bone, not growths of the spinal cord or nerves, and not cancer. They neither spread to other parts of the body nor arise from the spread of cancer elsewhere. In the typical case, a vertebral haemangioma simply occupies a small portion of a single vertebra and does nothing more.

Vertebral haemangiomas are among the most common lesions encountered anywhere in the spine. Classic post-mortem studies found them in around eleven per cent of adult spines — roughly one person in nine or ten — and modern cross-sectional imaging detects them even more often, with studies based on CT and MRI reporting prevalences of the order of a quarter of those scanned. Estimates of ten to twenty per cent of adults are commonly quoted.

They can be found at any age but are seen most often in middle age, around the fourth and fifth decades of life. Some series describe a modest female predominance for symptomatic lesions. A proportion of people, perhaps a fifth to a third in some series, have more than one haemangioma, particularly in the thoracic region. The thoracic spine is the most frequent location, followed by the lumbar spine, then the cervical spine; involvement of the sacrum is uncommon.

The defining feature of vertebral haemangiomas, from a practical standpoint, is that the vast majority are silent. They are typically discovered by chance, when a scan of the spine is carried out to investigate something else entirely. The figures quoted in the literature are consistent: somewhere between eighty-nine and ninety-nine per cent of vertebral haemangiomas are asymptomatic.

Because they are so common and so frequently silent, a haemangioma seen on a scan in a person who has back pain is, more often than not, simply coincidental. The lesion and the symptom happen to coexist, but the haemangioma is not the source of the pain. Longitudinal studies that have followed haemangiomas over many years describe most of them as stable, with progression to any neurological consequence being a rare event observed in only a tiny fraction of cases.

As the lesion develops, the horizontal struts of bone within the vertebra are lost while the vertical struts thicken and become prominent. Viewed end-on, in cross-section, the thickened vertical struts appear as multiple small, round dots scattered through the vertebral body. This is the so-called polka-dot sign, sometimes likened to a salt-and-pepper appearance. Viewed lengthways, the same thickened vertical struts produce a striped or striated pattern, resembling corduroy cloth or jail bars.

On magnetic resonance imaging, the typical haemangioma is bright on T1-weighted images because of its fat content, and bright on T2-weighted images because of its water and vascular content. This combination, together with the coarse internal trabeculae, is highly characteristic. Computed tomography is regarded as the best means of demonstrating the bony architecture, and shows the polka-dot pattern with particular clarity. Because the diagnosis can usually be made confidently from imaging, biopsy is only rarely needed.

Typical haemangiomas are the everyday, fat-rich lesions that account for the large majority. They are bright on both T1- and T2-weighted MRI, show the classic polka-dot and corduroy patterns, are confined within the bone, and are essentially always incidental and harmless.

Atypical haemangiomas contain less fat and more vascular tissue. Because of the reduced fat, they lose some of the characteristic brightness on the T1-weighted images and may appear darker or intermediate in signal. This altered appearance can resemble more sinister lesions such as a metastatic deposit, so an atypical haemangioma is principally an imaging puzzle rather than a lesion that is behaving dangerously.

Aggressive haemangiomas are the genuinely rare entity at the far end of the spectrum, representing only about one per cent of all vertebral haemangiomas. The term aggressive here describes behaviour, not malignancy: these lesions remain benign and non-cancerous, but they have expanded beyond their usual confines, often filling the whole vertebral body and extending into the bony arch behind, sometimes with a soft-tissue component pushing into the space around the spinal cord. They show a marked predilection for the thoracic spine, classically between T3 and T9.

Although the overwhelming majority of vertebral haemangiomas are silent, a very small proportion — of the order of one in a hundred — become symptomatic, generally through local expansion narrowing the spinal canal, extension beyond the bone to press on the spinal cord or nerve roots, or fracture of a weakened vertebra. Less commonly, bleeding or interference with the cord's blood supply has been described. There is also a recognised, though uncommon, association with pregnancy: the hormonal and circulatory changes of pregnancy, particularly in the later stages, can cause a previously silent thoracic haemangioma to enlarge and, very occasionally, to compress the cord, with improvement frequently described after delivery.

The assessment rests principally on imaging. MRI demonstrates the characteristic signal pattern and is uniquely able to show any extension of the lesion beyond the bone and any effect upon the spinal cord or nerves. Where a lesion has an atypical appearance, additional sequences including fat-suppression techniques and contrast-enhanced imaging are used. CT is the best modality for displaying the bony architecture, showing the polka-dot pattern with clarity, and is frequently used to confirm an indeterminate MRI. Plain X-rays may show the corduroy appearance when a lesion is large. Biopsy is needed only rarely.

Decisions about vertebral haemangiomas are individualised and rest with the treating clinicians and, for the rare complex cases, with specialist multidisciplinary teams. Observation is the course described for the overwhelming majority of vertebral haemangiomas, which are typical, incidental and without symptoms; routine repeat scanning of such a lesion is generally regarded as unnecessary.

Onward referral and multidisciplinary assessment is the pathway described for the small minority that are atypical on imaging, that are causing symptoms, or that show aggressive features. The range of treatment options described for the rare symptomatic or aggressive haemangioma includes continued observation; vertebroplasty (injection of bone cement); embolisation of the blood supply; radiotherapy, including focused stereotactic techniques; and surgery, ranging from decompression to more extensive removal. Combinations are described for the most challenging cases.

For the overwhelming majority of people, the outlook is entirely reassuring. The typical lesion is benign, tends to remain stable over the years, causes no symptoms and needs no treatment. Concern attaches only to the very rare aggressive or atypical lesions, and even these are benign and well catered for by effective specialist treatments. Any individual outlook is a matter for the treating team.

This page is general medical education and is not a substitute for individual advice. New or worsening weakness, numbness, saddle numbness, or any disturbance of bladder or bowel control requires urgent assessment.

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• —Primary benign neoplasms of the spine (PMC10297602)

This information is for general patient education and is not a substitute for an individual consultation. Always seek personalised advice from a qualified spinal specialist.