Spinal Hemangioma: Symptoms, Types, Causes and Treatment

Spinal hemangiomas are among the most common benign tumors found in the spine, yet their clinical significance and management can be confusing for patients and even healthcare professionals. While most cases are discovered incidentally and never cause symptoms, some can lead to pain, neurological issues, or even severe spinal cord compression. This article breaks down the symptoms, types, causes, and treatment options for spinal hemangioma, using up-to-date research findings to guide you through this complex yet important topic.

Symptoms of Spinal Hemangioma

Spinal hemangiomas are often silent, discovered by chance during imaging for unrelated issues. However, when they do cause symptoms, they can range from mild back pain to significant neurological deficits. Understanding the signs is crucial for timely diagnosis and management.

Symptom	Severity	Commonality	Source
Back pain	Mild–Severe	Common	1 8 11
Weakness	Moderate	Occasional	1 4 10
Radiculopathy	Moderate	Less Frequent	1 8 14
Myelopathy	Severe	Rare, Progressive	1 3 8
Paralysis	Severe	Very Rare	1
Paresthesias	Mild–Moderate	Occasional	10
Sphincter Issues	Severe	Rare	10

Table 1: Key Symptoms

Common Clinical Presentations

• Asymptomatic Cases:
  Most spinal hemangiomas are found incidentally and never cause symptoms during a person’s lifetime 8 11.
• Pain:
  When symptoms occur, back pain is the most common, often localized to the affected vertebral region 1 8 11. Pain can be persistent and sometimes severe.
• Neurological Deficits:
  In rare cases, these tumors can compress the spinal cord or nerve roots, leading to:
  • Weakness, especially in the legs
  • Numbness or paresthesias (tingling sensations)
  • Radiating pain following nerve pathways (radiculopathy)
  • Sphincter dysfunction—urinary or fecal incontinence—if the compression is severe 1 4 10.
• Acute Neurological Worsening:
  Although uncommon, some hemangiomas can cause rapid-onset neurological symptoms, including paralysis, due to sudden bleeding or expansion 1 3.

Patterns and Progression

The pattern of symptoms often depends on tumor location and type:

• Thoracic Spine Dominance:
  Most symptomatic cases occur in the thoracic spine, leading to symptoms like difficulty walking, gait instability, or sensory changes below the lesion 3 8 9.
• Slow vs. Rapid Progression:
  Symptoms generally develop slowly, but sudden deterioration can occur if there is acute hemorrhage into the tumor or surrounding tissue 1 3.

When to Seek Medical Attention

If you experience new, unexplained back pain, weakness, numbness, or changes in bladder or bowel function, especially if these symptoms are worsening, it is essential to seek medical evaluation. Early diagnosis can mean better outcomes if intervention is needed 1 8 14.

Types of Spinal Hemangioma

Spinal hemangiomas are not all the same. Their behavior, imaging characteristics, and treatment implications differ based on their type and location. Understanding these distinctions helps guide both diagnosis and management.

Type	Location	Defining Features	Source
Vertebral	Vertebral body	Corduroy/polka-dot sign, bone remodeling	5 8 12
Cavernous	Epidural/intradural	Hypervascular, can hemorrhage	2 3 10
Capillary	Epidural/intradural	Capillary channels, rare	4 9 10
Venous	Epidural	Cyst-like, variable imaging	2
Arteriovenous	Epidural	Fast-flow, rare, can bleed	2 10

Table 2: Major Types of Spinal Hemangioma

Vertebral (Intraosseous) Hemangioma

• Most Common Type:
  These arise within the vertebral body (the bone itself) and often show characteristic imaging features, such as the “corduroy sign” on sagittal MRI/CT and the “polka-dot sign” on axial imaging 5 8.
• Symptoms:
  Usually asymptomatic. When aggressive, they may expand, erode bone, and compress the spinal cord or nerves 8 12.

Cavernous Hemangioma

• Locations:
  Typically found in the epidural space (outside the dura mater) or intradural/extramedullary (within the dura but outside the spinal cord) 2 3 10.
• Histology:
  Composed of large, dilated vascular channels.
• Clinical Course:
  Can cause neurological symptoms due to mass effect or bleeding. Epidural cavernous hemangiomas are notorious for causing spinal cord compression 3 10.

Capillary Hemangioma

• Rarity:
  Far less common than the cavernous subtype 4 9 10.
• Features:
  Composed of small capillary vessels, often with a solid pattern.
• Locations:
  Can arise from the spinal nerve root, epidural, or intradural spaces 4 9.
• Symptoms:
  Typically present with localized pain, weakness, and sometimes sphincter disturbances 4 10.

Venous and Arteriovenous Hemangiomas

• Venous:
  Present as cyst-like masses, often with variable MRI characteristics 2.
• Arteriovenous:
  Characterized by fast blood flow, these are rare and can bleed, leading to acute neurological symptoms 2 10.

Imaging and Diagnosis

• MRI is the gold standard:
  Different types show varying patterns of intensity and enhancement on MRI, which helps in distinguishing them from other spinal tumors 2 3 9 10.
• Differential Diagnosis:
  Includes metastases, meningiomas, schwannomas, and other tumors, making careful evaluation crucial 3 10.

Causes of Spinal Hemangioma

Though the exact cause of spinal hemangiomas remains somewhat mysterious, research points to both genetic and developmental factors. They are benign vascular malformations, but why and how they form is a subject of ongoing investigation.

Cause Type	Mechanism/Role	Evidence/Notes	Source
Genetic	Somatic mutations (GNAQ, GNA14, GJA4)	Drives abnormal vessel growth	7
Congenital	Developmental malformation	Vascular error during embryogenesis	8 9
Acquired/Growth	Hormonal or mechanical triggers	May stimulate expansion in adults	5 8 12
Unknown	Idiopathic	Many cases lack clear mechanism	8 10

Table 3: Causes and Risk Factors

Genetic Factors

• Somatic Mutations:
  Recent genetic studies have identified mutations in genes such as GNAQ, GNA14, and GJA4 in a high percentage of spinal and intracranial cavernous hemangiomas 7.
  • These mutations lead to upregulation of pathways controlling angiogenesis (formation of blood vessels), such as the PI3K-AKT-mTOR and MAPK pathways 7.
  • Notably, targeted medical treatments like rapamycin (mTOR inhibitor) have shown promise in select cases with these mutations 7.

Congenital and Developmental Origins

• Vascular Malformation:
  Spinal hemangiomas are believed to arise from errors in the development of blood vessels during embryogenesis. They are not true tumors but rather hamartomas (benign overgrowths of normal tissue elements) 8 9.
• Prevalence:
  They are detected in up to 10% of the population, suggesting a congenital predisposition 10.

Growth and Acquired Factors

• Hormonal Influence:
  Growth or symptom onset can occur during adulthood, possibly triggered by hormonal changes (such as pregnancy) or increased intra-abdominal pressure 5 8 12.
• Expansion and Aggression:
  Most hemangiomas remain stable, but some may expand, erode bone, or bleed, leading to symptoms 5 8.

Other Contributing Factors

• Mechanical Stress:
  Spinal trauma or increased mechanical load may contribute to lesion growth or symptom development in some cases 8 12.
• Idiopathic:
  In many patients, no clear cause or trigger is found 8 10.

Treatment of Spinal Hemangioma

Treatment of spinal hemangioma depends on the type, location, symptoms, and degree of neural compression. While most require no intervention, symptomatic or aggressive cases demand a tailored, multidisciplinary approach.

Treatment	Indication	Outcome/Consideration	Source
Observation	Asymptomatic, typical	Safe, no intervention	8 11
Surgery	Neurological symptoms, compression	High cure, low recurrence	1 8 11 12 14
Embolization	Pre-surgical, high vascularity	Reduces blood loss, risk of fracture	1 14
Vertebroplasty	Pain, instability	Relieves pain, stabilizes spine	8 12 14
Radiotherapy	Residual/recurrent tumor, inoperable	Reduces recurrence, minor side effects	1 12 13 14
Stereotactic Radiosurgery	Select cases, inoperable	Minimally invasive, promising results	13
Targeted Therapy	Select genetic cases	Under investigation	7

Table 4: Main Treatment Options

Observation and Conservative Management

• Most Cases:
  Asymptomatic hemangiomas do not require intervention or follow-up, unless there are changes in symptoms or imaging 8 11.
• Pain Alone:
  Stable, mild pain can be managed with conservative measures or minimally invasive therapies 8.

Surgical Intervention

• Indications:
  Surgery is the mainstay for patients with neurological deficits, spinal cord or nerve root compression, or rapid symptom progression 1 8 11 12 14.
• Procedures:
  • Decompressive laminectomy/corpectomy: Relieves pressure on the spinal cord.
  • Gross-total or subtotal resection: Complete or near-complete tumor removal.
  • En bloc spondylectomy: Rarely needed, associated with higher risk 12.
• Outcomes:
  Surgery provides remission of symptoms in most patients, with low recurrence rates 11 12 14.

Preoperative Embolization

• Purpose:
  Reduces blood flow to the tumor before surgery, decreasing intraoperative blood loss 1 14.
• Risks:
  Slightly increased risk of postoperative vertebral fracture 14.

Percutaneous Techniques

• Vertebroplasty and Kyphoplasty:
  Injection of cement to stabilize the vertebral body, reduce pain, and sometimes obliterate tumor 8 12 14.
• Sclerotherapy/Ethanol Injection:
  Less commonly used, typically for select cases 8.

Radiotherapy

• Role:
  Used as an adjunct after incomplete resection, for inoperable tumors, or recurrent disease 1 12 13 14.
• Benefits:
  Reduces recurrence rates, particularly in aggressive or residual cases 1 14.
• Side Effects:
  Usually minor and transient 14.

Stereotactic Radiosurgery

• Emerging Option:
  Minimally invasive, image-guided radiosurgery (SRS) can be effective for select epidural cavernous hemangiomas, leading to rapid symptom improvement and tumor shrinkage 13.

Targeted Medical Therapy

• Future Directions:
  In select cases with defined genetic mutations (e.g., GNAQ), targeted drugs like rapamycin have shown potential in reducing tumor size and symptoms 7.

Prognosis

• Recurrence and Survival:
  Overall prognosis is excellent, with rare recurrence and virtually no mortality from spinal hemangioma when appropriately managed 11 12 14.
• Complications:
  Most complications arise from surgery or aggressive intervention, underscoring the need for individualized treatment plans 12.

Conclusion

Spinal hemangiomas are common, usually benign vascular tumors of the spine. While most are silent, some can cause significant pain or neurological symptoms.

Key Takeaways:

• Most spinal hemangiomas are found incidentally and do not require treatment.
• Symptomatic lesions can cause back pain, neurological deficits, or even paralysis, especially if aggressive or hemorrhagic.
• There are several types of spinal hemangioma, with vertebral, cavernous, and capillary being the most clinically relevant.
• Causes include genetic mutations, congenital vascular malformations, and possible hormonal or mechanical triggers.
• Treatment is highly individualized—ranging from observation, surgery, embolization, vertebroplasty, to adjuvant radiotherapy and, in emerging cases, targeted therapy.
• Surgical removal offers high rates of cure for those with neurological compromise, and adjuvant therapies improve outcomes in select cases.

If you or someone you know is experiencing unexplained back pain or neurological symptoms, timely medical evaluation can make a significant difference in outcome. Understanding spinal hemangioma empowers patients and clinicians to make informed, effective decisions.