596 - Symptomatic Vertebral Hemangioma Without Cord Compression: A Case Report

Case Diagnosis: Vertebral hemangioma


Case Description: A 53-year old male with past medical history of facet syndrome status post radiofrequency ablation, type 2 diabetes mellitus, obesity, gastroesophageal reflux and tobacco use presented to clinic for low back pain following a fall 3 years prior. Pain was rated 7/10 with radiation into bilateral buttocks with intermittent numbness into bilateral toes, exacerbated by movement in all planes. He reported 75% improvement following interventional procedures before returning to pre-procedure baseline. Lumbar MRI from 2 years prior revealed facet hypertrophy and L3-L4 disc bulging.

Physical exam revealed flattened lumbar lordosis, lumbar para-spinal atrophy, negative straight leg, weakness with extension and tenderness with flexion of lumbar spine. X-rays of lumbar spine revealed moderate osteoarthritis.

Patient returned 2 months later without improvement. Repeat MRI of lumbar spine revealed hemangioma of L4 vertebral body occupying two-thirds of the cortex without cord encroachment. There was appreciable extension towards the anterior border of vertebral periosteum.


Discussions: Vertebral hemangiomas are benign, primary tumors of the spine often found incidentally on CT or MRI with a trabecular appearance, typically at the thoracic level. They are typically asymptomatic, with data purporting that roughly 0.9% to 1.2% are symptomatic.

Patients may present with back pain exacerbated by movement and neurologic deficits if there is cord involvement. With all other diagnoses excluded, hemangiomas may be the cause of back pain if they expand to the periosteum, or if they occupy the majority of the vertebral body.

Rarely, hemangiomas extend into the epidural space causing cord compression. Rarer still, hemangiomas may result in pathologic burst fractures given enough involvement of the vertebral body, warranting surgical intervention.


Conclusions: While thorough history taking and physical examination can elucidate sources of back pain and rule out red flag symptoms, it is imperative to broaden the differential diagnoses should patient return with persistent back pain.