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Case 27

Vertebral haemangioma

Low back pain

Li Foong Foo

This 44 year old patient complained of low back pain. Plain films were obtained, followed by MRI.

Findings

There is exaggeration of the vertebral trabecula of the L2 vertebral body. The T1 weighted MRI (image C) shows a mottled pattern with increased signal in the affected vertebral body. There is relatively little change on the T2 weighted image.

Note also on the T2 weighted images the loss of water signal and disc bulging at L3/4 and L4/5, which was thought to be the source of the symptoms in this patient. No major disc prolapse was demonstrated however.

Diagnosis

Vertebral haemangioma

Discussion

Haemangioma of the vertebra is a benign, slow growing tumour of the blood vessels. It makes up 30% of all haemangiomas of bone and is found in approximately 10% of autopsies. It is commonly seen in women over 40 and has a predilection for the lower thoracic or upper lumbar spine.

Most vertebral haemangiomas are asymptomatic and are of no clinical significance. However vertebral collapse or extension into the spinal canal may result in pain, spinal cord compression and/or paraplegia.

Histologically, many abnormal vascular channels of varying calibre are seen interspersed within a fatty matrix. The haemangioma is usually of the cavernous type. There is also resorption of bone, with replacement by sinusoids, and thickening of remaining trabeculae.

On plain radiographs and CT, there is exaggeration of the vertebral trabeculae of the vertebral body (also called "accordion" or "honeycomb" vertebrae). This appearance may still be preserved after vertebral collapse. The cortical margin is intact in most cases and may bulge at the posterior aspect. The vertebral haemangioma may have extraosseous extension and surround the cord several levels above the bone lesion. Cord compression usually occurs in middle aged adults, sparing children and the older age group. paravertebral soft tissue extensions are occasionally seen.

A characteristic appearance is usually seen on MRI. A mottled pattern with increased signal intensity is seen on T1 weighted images due to fatty tissue interspersed with the thickened trabeculae. Extraosseous tumour, if present, is better evaluated with MRI than with any other imaging modality.

Note: Appearance of exaggerated vertical trabeculae as described above may also be seen in secondary osteoporosis, multiple myeloma, lymphoma, metastases, Paget's disease or blood dyscrasia. Hence, any symptomatic lesion of the vertebrae with features of a haemangioma must be carefully evaluated.

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