Teaching Case

Male patient, 44 years of age, with no medical history of interest. Consultation for chronic lumbociatalgia associated with paresthesias of both lower limbs.

No significant findings are observed on the lateral radiograph of the lumbar spine. In the axial plane of the CT, the involvement of the entire vertebral soma of L5 is observed, with the presence of multiple punctate foci giving the impression of salt and pepper (Fig. 1). In the sagittal and coronal reconstructions, dense and lucid interspersed bands are observed, giving the impression of bars (Fig. 2a, b). In MRI, signal hyperintensity is observed in both the T1 and T2-weighted images, as well as in the fat-suppressed images (STIR), showing a lesion that occupies the entire vertebral body of L5, which breaks its posterior wall and invades the medullar canal by more than 50%, compressing the descending and emerging nerve roots at this level (Fig.3a-c).

Vertebral haemangiomas are frequent lesions, which are observed in about 10% of the autopsies performed. Usually they are incidental findings and do not produce symptoms. They do not constitute a neoplasm, but rather a congenital anomaly derived from the sequestration of mesodermal embryonic tissue in the vertebrae [1, 2].
In rare cases (1% of all vertebral haemangiomas) they can cause symptoms, which is termed invasive hemangioma. They are characterised by bone expansion, extraosseous extension, local blood flow alterations and can be the origin of pathological fractures, associated with a deficit/neurological symptoms [1, 2]. The most affected vertebrae are the thoracic vertebrae. In the imaging studies, typical images characterised by radio-lucidity of the affected vertebral body will be observed on plain radiography; on CT, in the axial plane there is a dotted appearance of salt and pepper, and in the sagittal planes of cell bars. In MRI the signal will be given by the presence of fat and vascular tissue arranged between the trabeculae of the bone, and the intensity of the signal will depend on the proportion of the content of these. Invasive haemangiomas usually contain less fat and a greater vascular stroma [1, 2, 3]. With the contrast medium they tend to enhance in an avid way, which is why they can be confused with metastasis [4], however, with the presence of the other image features previously mentioned, the diagnosis can be reached, preventing patient's anguish and moreover unnecessary treatment.
The treatment can be surgical, especially in large lesions; with radiotherapy use; or through techniques performed by interventional radiologists such as sclerosis or embolisations of the vessels, or percutaneous vertebroplasty with injection of cement semiliquid that undergoes a solid state polymerisation process, which gives a mechanical support to the vertebra, improving pain and decreasing the risk of fractures [2, 3]. In the case of our patient, this last technique was performed with satisfactory results (Fig. 4).