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Lumbar Vertebral Hemangioma With Extradural Extension, Causing Neurogenic Claudication: A Case Report

  • October 2011
  • Acta medica Iranica 49(10):697-700
Authors:
Morteza Faghih Jouibari
Morteza Faghih Jouibari
Morteza Faghih Jouibari
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Alireza Khoshnevisan at Tehran University of Medical Sciences
Alireza Khoshnevisan
Seyed Mohammad Ghodsi at Tehran University of Medical Sciences
Seyed Mohammad Ghodsi
Farideh Nejat at Tehran University of Medical Sciences
Farideh Nejat
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Abstract

The authors present a rare case of lumbar vertebral hemangioma extending to the epidural space with a bisected appearance and impinging on thecal sac. This 52-year-old lady presented with one year history of low back pain and bilateral leg radiation. Plain radiography showed vertical linear streaks at L2 vertebral body and axial computed tomography (CT) scan revealed small "polka dot" appearance within the vertebral body. Magnetic resonance imaging (MRI) showed low signal intensity on T1-weighted images in L2 vertebral body which was not characteristic for hemangioma. The patient underwent an L2 laminectomy, spinal canal decompression and posterior spinal instrumentation. This study indicates that lumbar vertebral hemangioma can extend to the epidural space and cause neurologic symptoms. Magnetic resonance imaging may not show diagnostic features, especially in active lesions and plain radiography and CT scan may be helpful.
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CASE REPORT
Corresponding Author: Alireza Khoshnevisan
Department of Neurosurgery, Shariati Hospital. Tehran University of Medical Sciences, Tehran, Iran
Tel: +98 21 88602218, 912 1007205, Fax: +98 21 88602219, E-mail: akhoshnevisan@yahoo.com
Lumbar Vertebral Hemangioma with Extradural Extension, Causing
Neurogenic Claudication: A Case Report
Morteza Faghih Jouibari, Alireza Khoshnevisan, Seyed Mohammad Ghodsi,
Farideh Nejat, Soheil Naderi, and Sina Abdollahzadeh
Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
Received: 3 May 2011; Received in revised form: 1 Jun. 2011; Accepted: 22 Jun. 2011
Abstract-
The authors present a rare case of lumbar vertebral hemangioma extending to the epidural space
with a bisected appearance and impinging on thecal sac. This 52-year-old lady presented with one year
history of low back pain and bilateral leg radiation. Plain radiography showed vertical linear streaks at L2
vertebral body and axial computed tomography (CT) scan revealed small "polka dot" appearance within the
vertebral body. Magnetic resonance imaging (MRI) showed low signal intensity on T1-weighted images in
L2 vertebral body which was not characteristic for hemangioma. The patient underwent an L2 laminectomy,
spinal canal decompression and posterior spinal instrumentation. This study indicates that lumbar vertebral
hemangioma can extend to the epidural space and cause neurologic symptoms. Magnetic resonance imaging
may not show diagnostic features, especially in active lesions and plain radiography and CT scan may be
helpful.
© 2011 Tehran University of Medical Sciences. All rights reserved.
Acta Medica Iranica, 2011; 49(10): 697-700.
Keywords: Lumbar vertebral hemangioma; Extradural extension; Neurogenic claudication
Introduction
Hemangiomas are congenital vascular malformations
and pathologists frequently consider them as
hamartomatous malformations (1).
Only 0.9-1.2% of all
hemangiomas are symptomatic (2,3), most of them are
confined to the thoracic spine and extremely rare in the
lumbar area (4). Here we present a case of lumbar
vertebral hemangioma with extradural extension causing
low back pain and neurogenic claudication.
Case Report
A 52-year old female patient was admitted to
neurosurgery department of Shariati Hospital with low
back pain and radiation to both lower limbs. The onset
of symptoms dated back to one year ago and was
associated with stiffness and discomfort in both legs
which was precipitated by walking and prolonged
standing. She was unable to sleep well due to severe
paresthesia in her legs and feet. Neurological
examination revealed 4/5 motor function at both lower
limbs. Lasegue's sign was present at 45 degrees for both
legs. Laboratory investigations were performed which
ruled out inflammatory and infectious conditions. Plain
radiographs of lumbar spine showed vertical linear
streaks ("corduroy cloth" appearance) at L2 vertebral
body (Figure 1). Axial computed tomography (CT) scan
at the level of lesion showed small "polka dot"
appearance within the body (Figure 2).
Figure 1. Lumbar spine shows vertical linear streaks
("corduroy cloth" appearance) at L2 vertebral body.
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Lumbar vertebral hemangioma with extradural extension
698 Acta Medica Iranica, Vol. 49, No. 10 (2011) 
Figure 2. Axial CT scan shows small "polka-dot" appearance
in the body. Neural arch is intact.
Magnetic resonance imaging (MRI) revealed low
signal intensity with small scattered areas of increased
signal intensity on T1-weighted images and marked
increased signal on T2-weighted images in involved
vertebral body. The lesion contained signal void areas
on axial T2-weighted sequences (Figure 3A, 3B). After
intravenous administration of contrast, entire body
showed intense heterogeneous enhancement (Figure
3C). Also there was bisected expansion to extradural
space impinging on thecal sac which enhanced
homogenously (Figure 3D).

A B

C D
Figure 3. Magnetic resonance images at T1-weighted sagittal view (A) demonstrate hypointensity in L2 vertebral body with small
areas of high signal intensity. There are small signal void areas in T2 weighted axial image (B). T1-weighted sagittal sequence with
contrast substances (C) shows heterogeneous contrast enhancement. Axial view demonstrates extradural expansion of lesion with
bisected appearance (D).
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M. Faghih Jouibari, et al.
Acta Medica Iranica, Vol. 49, No. 10 (2011) 699
Figure 4. Post operation radiography.
Imaging studies suggested a vascular lesion with
hemangioma being the most likely differential diagnosis.
Recommendation was made for angiography and
embolization to be performed. However, due to financial
issues it did not proceed. The patient underwent an L2
laminectomy. There was a gray-reddish, fleshy and
highly vascular mass in ventral side of thecal sac which
bled extensively during removal. The spinal canal was
decompressed and posterior spinal instrumentation with
bone fusion was implanted to stabilize this region of
spinal column (Figure 4).
Histopathologic examination of the tissue revealed
small capillary spaces lined by small cells without
mitotic figures consistent with the diagnosis of capillary
hemangioma (Figure 5). Postoperative course was
uneventful. Two months later she found total recovery
from all previous neurological deficits and returned back
to her daily work. She was followed regularly and now
she is symptom free after one year.
Figure 5. Photomicrograph showing a collection of small
capillaries, some ones containing red blood cells, without
mitotic figures or fat cells. H & E, original magnifications;
400X.
Discussion
Vertebral hemangioma is considered to be a benign
lesion of bone, usually of dysembryogenetic origin or a
hamartomatous lesion (4).
Vertebral hemangioma has an
estimated incidence of 11% in the population, based on
autopsy series and reviews of plain spine films (5,6).
Merely about one percent of lesions are symptomatic
(2,3), among them, 54% are characterized only by pain,
but 45% are associated with variable neurologic
symptoms (7).
Neurological symptoms due to cord
compression by thoracic vertebral hemangioma have
been reported in several cases, but it is extremely rare in
lumbar vertebral lesions (8,9). In our case, neurogenic
claudication and weakness of lower limbs were caused
by an extradural extension of lumbar vertebral
hemangioma compressing the thecal sac.
Plain film is a valuable simple method to suggest the
diagnosis of a vertebral hemangioma. It may show
vertically striated vertebral bodies producing "corduroy
cloth" appearance or a coarse "honeycomb" appearance
(4). Laredo et al. found that six features were seen
significantly more often in those compressing the cord:
location between T3 and T9, involvement of the entire
vertebral body, extension to the neural arch, an
expanded cortex with indistinct margins, an irregular
honeycomb pattern, and soft tissue mass (10). The
characteristic finding of CT scan is a "polka dot"
appearance within the vertebral body because the
vertical trabeculae are imaged in cross section (4).
Vertebral hemangiomas show increased signal on TI-
and T2-weighted magnetic resonance images. Chemical
shift images and histological studies demonstrate that
adipose tissue causes the increased signal on T1-
weighted images (11). Unlike most vertebral
hemangiomas which are hyperintense on T1 weighted
images, in our patient, the hemangioma had low signal
on T1-weighted images. Laredo et al. suggested that
fatty vertebral hemangiomas may represent inactive
forms of vertebral hemangioma, while soft-tissue
content at CT and low signal intensity at MRI may
indicate a more active vascular lesion with potential to
compress the spinal cord (12). Similarly the activity of
the lesion in this case was compatible with hypointensity
on T1-weighted images and low content of fat as found
in histopathologic examination.
In our patient, plain radiography and CT scan were
in favor of hemangioma but MRI didn't show the
characteristic feature of hemangioma (hyperintensity on
T1-weighted images) which this underscores the
importance of plain radiography and CT scan in the
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Lumbar vertebral hemangioma with extradural extension
700 Acta Medica Iranica, Vol. 49, No. 10 (2011) 
diagnosis of vertebral hemangioma. The bisected
appearance of the epidural component on axial images is
notable and caused by a low signal tissue on T1 and T2-
weighted images which may correspond to the posterior
longitudinal ligament.
This report indicates that lumbar vertebral
hemangioma is not always an innocent radiologic
finding; it can extend to the epidural space and cause
neurologic symptoms. Magnetic resonance imaging may
not show the characteristic features, especially in active
forms. Plain radiography and CT scan can be helpful in
this situation. Early diagnosis and adequate neural
decompression can cause remarkable improvement.
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... Third, most previous studies have only reported on hemangiomas and lipomas so little is known about sclerosis, aneurysmal bone cysts, osteoid osteoma or osteoblastoma. Fourth, studies on the association with back pain have been limited to case reports, [8][9][10][11][12][13][14][15][16][17][18][19] and some retrospective studies [20][21][22][23][24][25][26][27] which are hard to generalize meaningfully. ...
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