A 68 year old with lower extremity numbness, vibratory sensation loss, coldness and burning of his feet, unsteady gait, frequent falls and a sensory level had an MRI demonstrating aT7 and T8 vertebral body/posterior element lesion with epidural extension, cord compression and foraminal extension (Figures 1-5). Decompressive laminectomy/resection confirmed vertebral hemangioma, a common benign neoplasm that typically remains asymptomatic, found incidentally in 10% of the population. Progressive vertebral body hemangiomas may cause cord or nerve root compression due to epidural tumor extension, expanded bone, hematoma or fracture. Radiographs demonstrate course vertical striations caused by thick trabeculae. CT in indolent lesions demonstrates fat density while compressive lesions demonstrate soft tissue density. Indolent lesions follow fat signal on MRI; symptomatic lesions are T1 isointense/T2 hyperintense. Work-up for aggressive hemangiomas includes angiography to determine vascularity, identify feeding/draining vessels and identify blood supply to the cord. Biopsy helps differentiate hemangioma, lymphoma, myeloma or metastasis. Management of symptomatic hemangiomas includes vertebroplasty for pain, radiation for pain, compression or pre-op and decompressive laminectomy for epidural disease. Embolization of feeding vessels may be performed pre-op or may be curative. Hemangioma causing cord compression and neurologic symptoms by extraosseous extension is much less common than benign hemangioma. Imaging features may suggest potential for progression.
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