General
- Benign tumours vary in size
- Are the most common primary spinal tumours
Definition
- Essential: Tightly packed capillary-sized and cavernous vessels lined by a single layer of benign endothelial cells, set in a mesenchymal stroma with fibroblasts, and an absence of foamy stromal cells.
WHO Grade
- Benign lesions
Classification
Enneking staging system:
- Benign:
- A grade 1—tumor limited to its origin and encapsulated;
- B grade 2—tumor limited to its origin, encapsulated and with adjacent tissue reaction,
- C grade 3—tumor encapsulated and extensive with adjacent tissue reaction.
- Malignant:
- D IA—tumor encapsulated, with adjacent tissue reaction and island of tumor within tissue reaction;
- E IB—tumor encapsulated, with extensive adjacent tissue reaction and island of tumor within tissue reaction;
- F IIA—tumor not encapsulated, with adjacent tissue reaction, island of tumor within tissue reaction, and skip metastasis;
- G IIB—tumor not encapsulated, with appreciable adjacent tissue reaction, island of tumor within tissue reaction, and skip metastasis.
Numbers
- Vertebral haemangiomas have a prevalence of 10-12 % in the general population.
Localisation
- Most are primary lesions of bone that impinge on the CNS
- Thoracic and Lumbar vertebrae
- Dural and parenchymal lesions are less common
- Less frequently in the skull.
Histopathology
Macrosopic
- Haemangiomas are soft, red, and lobular masses associated with small feeder and drainer vessels.
Microscopic
- Haemangiomas show a lobular pattern separated by fibrous septa;
- Vessels range from small, poorly canalized channels to blood-filled cavernous spaces.
Immunophenotype Features
- In haemangiomas, endothelial cells express ERG, CD31, and CD34, and the Ki-67 index is usually less than 10 percent.
Pathogenesis
- Haemangiomas may be part of a PIK3CA-related overgrowth syndrome, such as Klippel-Trenaunay syndrome.
Imaging
- Usually incidental lesions
- MRI
- General
- MRI shows extraosseous components better and depicts the haemangioma components as fat and water. Thickened trabeculae appear as low signal areas in both T1 and T2 images.
- T1
- Typical: lipid-rich will demonstrate high signal
- Atypical: lipid-poor will demonstrate low signal
- T2
- Bright/high-intensity signal, usually greater than on T1, due to its high water content
- T1 C+
- Significant enhancement is seen due to high vascularity
- CT
- Axial CT will show a “polka-dotted” or "salt and pepper" appearance due to the thickened vertebral trabeculae. On sagittal CT, vertebral haemangiomas typically show the "corduroy" sign due to thicker or denser vertical trabeculae.
- Larger lesions demonstrate the characteristic ‘honeycomb’ appearance or ‘corduroy sign’ on sagittal and coronal CT, which are prominent vertical striations of thickened trabecular bone.
Images
Clinical features
- Vertebral haemangiomas mainly asymptomatic
- Small proportion of these tumours may expand the bone and cause pathological fractures, or extend into the epidural space and compress neural structures.
- For aggressive haemangiomas (defined as expanding and eroding osseous confines" and are classified as Enneking stage 3)-1% of all haemangiomas (Teleale 2026)
- Back pain: 53.7%
- Radiculopathy: 16.8%
- Myelopathy: 60%
- Motor deficits: 60%
- Sensory deficits: 18.7%
Management
- Indicated for symptomatic lesions only
- Options
- If without cord compression and neurological deficits
- Kyphoplasty
- Vertebroplasty
- For persistent pain and locally advanced tumors.
- Radiotherapy
- For cord compression
- Surgical decompression
- Spinal canal decompression
- Corpectomy
- Supplementary treatment
- Endovascular embolisation
Prognosis
- Haemangiomas usually do not recur after complete resection.