Pregnancy-related aggressive vertebral hemangioma presenting with radiculopathy: illustrative case

Abstract

BACKGROUND

Aggressive vertebral hemangiomas are uncommon vascular spinal lesions that may enlarge during pregnancy due to hormonal and hemodynamic changes. Elevated estrogen and progesterone levels, increased blood volume, and venous congestion can lead to rapid lesion expansion and epidural extension, causing neurological deficits. Although rare, these lesions should be considered in pregnant or postpartum women presenting with back or radicular pain.

OBSERVATIONS

A 30-year-old woman with epilepsy controlled by lamotrigine developed progressive low back and right leg pain during late pregnancy, worsening postpartum. MRI revealed an aggressive L4 vertebral hemangioma with epidural extension compressing the thecal sac and right L4 nerve root. The patient underwent L4 laminectomy, excision of the epidural component, and vertebroplasty. Persistent bleeding after initial posterior cement injection required a second injection through the left pedicle to fill the superior vertebral body, followed by fibrin glue application. She was mobilized on the 1st postoperative day, and her symptoms resolved completely.

LESSONS

Pregnancy-related aggressive vertebral hemangioma should be suspected in women with new-onset neurological symptoms during pregnancy or postpartum. Early diagnosis, multidisciplinary planning, and timely decompression with vertebroplasty yield excellent neurological recovery and functional outcomes.

https://thejns.org/doi/10.3171/CASE25860

Vertebral hemangiomas are benign vascular malformations of the spine that are incidentally found in up to 10%–12% of adults during routine imaging. Most remain asymptomatic throughout life; however, about 1% exhibit aggressive behavior characterized by cortical expansion, epidural or paravertebral extension, and, in some cases, neurological compromise.^1,2 These aggressive lesions may mimic metastatic or primary spinal tumors radiologically, making early recognition essential for appropriate management.³

Pregnancy is a well-recognized factor predisposing to symptomatic progression of previously silent vertebral hemangiomas. Physiological changes during gestation, including increased blood volume, hormonal surges of estrogen and progesterone, and elevated intra-abdominal and epidural venous pressure, can lead to vascular engorgement and rapid lesion expansion.^4,5 Consequently, a previously quiescent vertebral hemangioma may transform into an “aggressive” lesion during the third trimester or early postpartum period, presenting with back pain, radiculopathy, or even acute myelopathy.^6,7

Here, we present the case of a 30-year-old postpartum woman who developed right-sided radiculopathy secondary to an aggressive L4 vertebral hemangioma, successfully treated with decompressive laminectomy and vertebroplasty. We also provide a comprehensive review of the literature to highlight the clinical features, imaging findings, and management strategies of this rare but important condition.

Illustrative Case

Clinical History

A 30-year-old woman with a known history of epilepsy, well controlled by lamotrigine (100 mg/day), presented with progressive low back pain and right lower limb pain of 1 month’s duration. Her symptoms began during the last month of pregnancy and gradually intensified, radiating along the right anterior thigh and knee. She denied any preceding trauma, fever, or constitutional symptoms. There was no history of spinal procedures or malignancy. The patient had a normal vaginal delivery 3 weeks prior to presentation.

Neurological Examination

On admission, she was alert and hemodynamically stable. Neurological examination revealed right-sided L4 radicular pain and mild quadriceps weakness graded 4+/5 on the Medical Research Council scale. The right knee reflex was diminished, while ankle reflexes were preserved. Straight-leg raising on the right side produced pain at 45°, but there was no sensory level, sphincter disturbance, or gait abnormality. Cranial nerve and upper limb examinations were normal.

Radiological Findings

MRI of the lumbar spine revealed a well-defined hyperintense lesion occupying the L4 vertebral body on both T1- and T2-weighted images, with homogeneous postcontrast enhancement. The lesion extended into the epidural space, compressing the thecal sac and displacing the right L4 nerve root, consistent with an aggressive vertebral hemangioma (Fig. 1).

FIG. 1.

Preoperative MR images demonstrating the aggressive vertebral hemangioma. A:Sagittal T2-weighted image showing a hyperintense lesion involving the L4 vertebral body with posterior cortical breach and epidural extension. B: Sagittal T1-weighted image demonstrating a mildly hyperintense lesion replacing normal marrow signal within the L4 vertebral body. C:Axial T2-weighted image showing right-sided epidural extension compressing the thecal sac.

CT demonstrated coarse vertical trabeculae within the vertebral body, producing the characteristic “polka-dot” appearance on axial sections and “corduroy” pattern on sagittal reformats. Cortical thinning and posterior wall breach with epidural extension were evident (Fig. 2).

FIG. 2.

Preoperative CT images demonstrating the vertebral lesion. A: Sagittal CT scan showing an expansile, lytic lesion involving the L4 vertebral body with cortical thinning and posterior wall involvement. B: Axial CT scan demonstrating the characteristic polka-dot trabecular appearance within the L4 vertebral body, consistent with an aggressive vertebral hemangioma.

Surgical Management

Given the patient’s progressive radiculopathy and MRI evidence of epidural compression, surgical intervention was indicated. Under general anesthesia, a posterior L4 laminectomy was performed. On exposure, a reddish, highly vascular epidural mass was identified compressing the dural sac and right L4 nerve root.

Initially, vertebroplasty was attempted directly through the posterior wall of the L4 vertebral body, and approximately 9 mL of high-viscosity cement (polymethylmethacrylate [PMMA]) was injected from the posterior edge of the corpus under fluoroscopic guidance. Standard measures to minimize cement leakage were used, including slow incremental injection, waiting for the cement to reach a doughy phase, and halting injection immediately if any posterior or foraminal extravasation was suspected. This provided partial filling of the vertebral body; however, persistent venous bleeding from the superior part of the body was observed.

Intraoperative fluoroscopy demonstrated incomplete cement distribution in the superior portion of the vertebral body. Because of the vertical trabecular pattern of the lesion and superior cortical thinning, uniform cement filling could not be achieved from a single entry point. To achieve complete filling and hemostasis, a second entry was made through the left pedicle, allowing controlled cement injection into the remaining superior portion of the vertebral body. Once homogeneous filling was confirmed, fibrin glue was applied to the residual epidural space to secure hemostasis and obliterate any potential venous channels.

Instrumented fixation was not performed, as the posterior elements were structurally intact, dynamic imaging demonstrated no mechanical instability, and complete PMMA augmentation restored vertebral body integrity. Avoiding instrumentation in this young patient also preserved motion segments and reduced surgical morbidity.

The bilateral L4 and L5 nerve roots were visualized, and adequate decompression of the thecal sac and both exiting roots was confirmed before closure. Meticulous hemostasis was achieved, and the wound was closed in anatomical layers over a subfascial drain.

Pathological Findings

Pathological examination of the excised epidural tissue demonstrated thin-walled, dilated vascular channels lined by a single layer of endothelial cells and separated by trabeculae of bone. No atypia, necrosis, or malignant features were identified. The lesion was consistent with a benign capillary-cavernous vertebral hemangioma, confirming the intraoperative impression of an aggressive vertebral hemangioma.

Postoperative Course

The patient was mobilized on the 1st postoperative day and reported complete resolution of right-sided radicular pain within 24 hours. Muscle strength returned to normal, and knee reflexes were symmetric. An early postoperative CT scan confirmed homogeneous cement filling of the L4 vertebral body achieved through the posterior and left pedicular injections, with no evidence of cement leakage or canal compromise (Fig. 3). Postoperative MRI obtained 2 weeks later demonstrated adequate decompression of the thecal sac, complete filling of the vertebral body, and absence of residual epidural component (Fig. 4). At 6 months of follow-up, the patient remained pain free and neurologically intact, with stable postoperative imaging findings.

FIG. 3.

Postoperative CT images demonstrating vertebroplasty and decompression. A:Sagittal CT image showing homogeneous cement filling within the L4 vertebral body following posterior and left pedicular injection. B:Coronal CT image confirming complete cement distribution and restoration of vertebral body integrity. C:Axial CT image illustrating uniform cement filling with adequate decompression of the spinal canal and no residual epidural component.

FIG. 4.

Postoperative MR images demonstrating adequate decompression and resolution of the epidural component. A: Sagittal T2-weighted image showing complete decompression of the thecal sac and stable cement filling of the L4 vertebral body. B: Sagittal T1-weighted image illustrating postoperative signal change and absence of residual enhancing lesion. C: Sagittal postcontrast T1-weighted image confirming no residual epidural component or enhancement. D:Axial T2-weighted image showing resolution of the right-sided thecal sac compression. E: Axial postcontrast T1-weighted image demonstrating intact dural contour without evidence of recurrence.

Informed Consent

The necessary informed consent was obtained in this study.

Discussion

Aggressive vertebral hemangiomas are uncommon vascular lesions that may become symptomatic when epidural or paravertebral extension compresses neural structures. Although most vertebral hemangiomas remain asymptomatic, pregnancy can induce profound biological changes that accelerate their growth. Elevated levels of estrogen and progesterone promote vascular proliferation, while increased intravascular volume and mechanical venous congestion from uterine compression enhance epidural venous pressure. These hemodynamic and hormonal effects collectively enlarge preexisting vertebral vascular channels, potentially transforming a quiescent lesion into an aggressive hemangioma capable of producing acute neurological compromise. The risk peaks during the third trimester and early postpartum period, when venous pressure and hormonal influence are greatest.

To clarify our review methodology, a structured literature search was conducted in PubMed using the keywords “vertebral hemangioma,” “aggressive hemangioma,” “pregnancy,” “postpartum,” and “vertebroplasty.” Only English-language articles providing clinical details and imaging-supported diagnoses were included. Although pregnancy-associated vertebral hemangiomas have been described since the early 20th century, we selected a cutoff of 2000 to ensure consistency in diagnostic accuracy and treatment relevance, as earlier reports predated widespread MRI use and often relied on outdated management strategies such as primary radiotherapy or laminectomy alone.

Since 2000, 18 cases of pregnancy-related aggressive vertebral hemangioma have been reported in the PubMed-indexed English-language literature (Table 1). The mean maternal age among these cases is approximately 30 years, with most patients otherwise healthy and without previous spinal pathology. The thoracic spine has been the most common site of involvement, accounting for nearly 70% of cases, followed by the lumbar region, which accounts for roughly one-quarter. Only 1 case involved the cervical spine. The principal manifestations were paraparesis or paraplegia in thoracic lesions and radiculopathy or cauda equina syndrome in lumbar involvement. The earliest report of this modern era, by Schwartz et al., described paraplegia during the third trimester treated with corpectomy and fusion.⁸ Chi et al. subsequently presented a second trimester case and proposed a structured management algorithm.³ The sequence of later cases, including those by Inamasu et al., Vijay et al., Blecher et al., and Wang et al., collectively demonstrates that deterioration can occur at any gestational stage or soon after delivery, reaffirming the need for vigilance in pregnant patients with atypical or severe back pain.^{5,910, 13} It should be emphasized that these percentages reflect patterns observed in a small and heterogeneous collection of case reports rather than population-based data. As such, the apparent predominance of thoracic involvement, the mean maternal age, and the frequency of neurological presentations should be interpreted cautiously and viewed as descriptive trends rather than definitive epidemiological conclusions.

TABLE 1.

Published cases of pregnancy-related aggressive vertebral hemangiomas from 2000 to the present

Authors & Year	No. of Patients	Age (yrs)	Spinal Levels	Gestational Timing	Presentation	Treatment	Outcome
Schwartz et al., 20008	1	30	T11	3rd trimester	Paraplegia	Corpectomy + fusion w/ or w/o RT	Full recovery
Chi et al., 20053	1	26	C7	24th wk (2nd trimester)	Progressive spastic paraparesis	Decompression during pregnancy	Good maternal & fetal outcomes
Inamasu et al., 200610	1	32	L2	Early postpartum	Cauda equina syndrome	Laminectomy + vertebroplasty + fusion	Full recovery
Yuksel et al., 200723	1	31	T9	Postpartum	Paraparesis	Laminectomy	Full recovery
Vijay et al., 20089	1	26	T11	3rd trimester	Paraplegia	Embolization + corpectomy + fusion	Full recovery
Kiroglu et al., 200914	1	22	T4	36th wk (3rd trimester)	Progressive paraplegia	Emergency caesarean section, endovascular embolization; 2 yrs later, vertebroplasty & segmental fixation	Neurological improvement
Shinozaki et al., 201016	1	35	T2	Postpartum	Paraplegia	Laminectomy w/ or w/o embolization + fusion	Partial improvement
Blecher et al., 201013	1	30	L4	3rd trimester	Radiculopathy & weakness	Embolization + laminectomy + vertebroplasty	Full recovery
Jankowski et al., 201224	1	29	T6	Postpartum	Paraparesis	Corpectomy + fusion	Partial recovery
Moles et al., 20144	2	28, 35	T3, T7	35 & 36 wks of gestation (3rd trimester)	Rapid paraparesis	Decompression; vertebroplasty/RT	Both improved (mild deficit in one)
Slimani et al., 20146	1	19	L1	3rd trimester	Severe back pain → paraparesis	Cesarean → decompression; corpectomy w/ fusion postpartum	Excellent recovery
Jain et al., 201419	1	26	T11	Postpartum	Back pain → progressive spastic paraparesis	Conservative	Lost to follow-up
Fereydonyan et al., 20177	1	28	T5	Late pregnancy in 2 consecutive gestations	Recurrent paraparesis	Corpectomy w/ fusion, recurrence laminectomy, & hemangioma resection	Mild residual lower limb spasticity
Mohanty et al., 201818	1	29	T2	Early postpartum	Paraparesis w/ or w/o urinary difficulty	Laminectomy + vertebroplasty	Full recovery
Wang et al., 20185	3	27, 29, 35	T4–5, L1, L2	13, 28, & 41 wks of gestation	2 myelopathies, 1 radiculopathy	2 decompression + vertebroplasty; 1 vertebroplasty alone	All recovered completely
Prabhu & Rathod, 202111	1	19	T4	Late 2nd pregnancy; recurrence in 2nd gestation	Recurrent paraparesis	Repeat decompression + vertebroplasty; postpartum RT	Partial improvement
Raj et al., 202222	1	30	T12	31 wks (3rd trimester)	Cauda equina syndrome (urinary retention & limb weakness)	Caesarean section → embolization + transpedicular excision + instrumentation	Full recovery
Ridzoňová et al., 202221	1	26	T7	23 wks	Progressive paraparesis	Decompression during pregnancy	Partial improvement

MRI remains the diagnostic modality of choice, revealing T1 and T2 hyperintense lesions with avid postcontrast enhancement. Aggressive variants may exhibit T1 hypointensity due to reduced fat content and increased vascularity. CT typically demonstrates thickened vertical trabeculae producing the characteristic polka-dot and corduroy patterns. These imaging features allow confident differentiation from metastatic or infectious lesions, which is crucial in pregnant patients who may otherwise undergo unnecessary oncological evaluation.^7,11–13

Management depends on neurological status and gestational age. While conservative measures may suffice in mild or stable cases, most patients develop rapid neurological decline requiring surgery. Posterior decompression through laminectomy remains the cornerstone of treatment, often complemented by vertebroplasty for mechanical stability and hemostasis. The polymerization of PMMA compresses residual vascular spaces, effectively controlling intraoperative bleeding. Several authors, including Vijay et al., Kiroglu et al., and Blecher et al., have emphasized this dual advantage.^9,13,14 The use of PMMA for vertebral hemangiomas has its origins in the pioneering work of Galibert and Deramond, who first reported percutaneous acrylic vertebroplasty for a cervical vertebral hemangioma in 1987.¹⁵ This landmark French contribution established vertebroplasty as a minimally invasive, effective technique for stabilizing hemangiomatous vertebrae and controlling vascularity through thermal polymerization. Their foundational work laid the basis for modern PMMA augmentation, which has now been used for nearly 3 decades and remains a cornerstone in the management of aggressive vertebral hemangiomas.¹⁵ Preoperative embolization can also significantly reduce intraoperative blood loss, but is generally reserved for postpartum patients due to fetal radiation exposure. Radiotherapy, once a mainstay, is now rarely used and is contraindicated during pregnancy.^16–20

The broader vertebroplasty literature also strongly supports the use of PMMA in aggressive vertebral hemangiomas. Beyond pregnancy-related cases, numerous reports and small series have demonstrated that PMMA provides immediate internal stabilization, reduces vascularity through thermal polymerization, and tamponades venous channels to control intraoperative bleeding. These effects contribute to rapid symptom relief and durable radiological stability. When performed with high-viscosity cement, slow incremental injection, and continuous fluoroscopic monitoring, PMMA vertebroplasty has a low complication rate and reliably minimizes cement leakage.^{4,5,10,11,13–15,18} Our experience is consistent with these findings, as complete axial filling of the vertebral body achieved both mechanical reinforcement and effective hemostasis, negating the need for instrumented fusion in this young patient.

Across these 18 cases, outcomes were highly favorable when decompression was performed promptly. Approximately 85%–90% of patients achieved full neurological recovery, while partial improvement occurred in a small minority. Recurrence is rare but has been documented, particularly during subsequent pregnancies, highlighting the importance of long-term imaging surveillance in women of childbearing potential.^4,7,11 The most recent cases by Raj et al. and Ridzoňová et al. reinforce the same principle: timely multidisciplinary coordination and early decompression lead to excellent maternal and fetal outcomes.^21–24

Despite the consistency of favorable results, some limitations should be acknowledged when interpreting the available literature. Nearly all reports are single-patient case studies or small series, subject to reporting bias and incomplete data on long-term follow-up. Maternal age, gestational week, and postoperative obstetric outcomes are inconsistently documented, limiting the pooling of statistical analyses. In addition, treatment strategies varied widely depending on institutional experience, available resources, and timing of presentation. Because no standardized guidelines exist, the current understanding of prognosis and recurrence risk is mainly based on anecdotal evidence. Future multicenter registries or systematic data collection could help clarify optimal timing, surgical approach, and perinatal management strategies for these rare but clinically significant lesions.

In summary, pregnancy-related aggressive vertebral hemangioma is a rare but potentially disabling entity that demands early recognition. Since 2000, 18 well-documented cases have illustrated a consistent pattern of third trimester or postpartum onset, thoracic predominance, and favorable recovery with decompression and vertebroplasty. Awareness of its clinical and radiological features, multidisciplinary planning, and timely surgical intervention remain the key determinants of maternal neurological outcome. In women with a known diagnosis of vertebral hemangioma before pregnancy, new-onset back pain accompanied by radiculopathy or neurological deficit should raise suspicion for hormonally influenced lesion progression. In such patients, pregnancy-related hormonal changes may trigger aggressive behavior, and this possibility must be considered in the differential diagnosis. Management should therefore be individualized, taking into account gestational age, symptom severity, radiological findings, and patient-specific factors through a multidisciplinary approach to ensure optimal maternal and fetal outcomes.

Although the patient presented in the early postpartum period, the pathophysiological forces driving lesion progression likely began during late pregnancy, when venous pressure, circulating blood volume, and hormonal activity peak. The immediate postpartum decline in intra-abdominal pressure may transiently alter spinal venous dynamics, occasionally unmasking symptoms that developed subclinically during gestation. Recognition of this mechanism is important, as postpartum neurological deficits may be mistakenly attributed to delivery-related musculoskeletal strain rather than to a vascular spinal lesion.^21–24

Peripartum management also includes counseling regarding future pregnancies. Recurrence or reactivation of aggressive vertebral hemangiomas during subsequent gestations has been documented, particularly in cases with residual lesion or incomplete vertebral stabilization. Patients should be informed that although the risk is low after complete decompression and vertebroplasty, pregnancy-associated hormonal surges may theoretically stimulate further vascular proliferation. Preconception spinal imaging may be considered to document stability, and patients should be advised to promptly report new or progressive back or radicular pain during future pregnancies. Close collaboration between neurosurgery, obstetrics, and maternal-fetal medicine is recommended for surveillance and individualized management planning.^21–24

Observations

This case demonstrates how vertebral hemangiomas, typically benign and asymptomatic, can transform into aggressive lesions during pregnancy or the postpartum period under hormonal and hemodynamic influences. In women with a known vertebral hemangioma prior to pregnancy, the development of new-onset back pain, radiculopathy, or neurological deficit should raise suspicion for hormonally induced lesion enlargement. Our patient presented in the early postpartum period with right-sided radiculopathy secondary to an aggressive L4 hemangioma. Dual-route vertebroplasty through a posterior and left pedicular approach, followed by fibrin glue application, achieved complete filling and durable hemostasis. Early mobilization on the 1st postoperative day and full neurological recovery highlight the efficacy of this individualized surgical strategy.

Lessons

Pregnancy-related aggressive vertebral hemangioma should be considered in the differential diagnosis of back pain accompanied by radiculopathy or neurological deficit during late pregnancy or the postpartum period. Hormonal influences, increased venous pressure, and mechanical factors may trigger rapid enlargement of an otherwise asymptomatic lesion, leading to epidural extension and neural compression.

Management should be individualized based on gestational age, symptom severity, and radiological findings, with decisions made through multidisciplinary collaboration among the neurosurgery, obstetrics, anesthesiology, and radiology departments. MRI remains the diagnostic modality of choice, and timely surgical decompression combined with vertebroplasty provides effective neural decompression, hemostasis, and durable spinal stability.

A review of the 18 published cases from 2000 to the present demonstrates a consistent pattern of onset in the third trimester or early postpartum period, a predominance of thoracic involvement, and favorable outcomes when prompt intervention is performed. Awareness of this entity, careful evaluation of new or progressive neurological symptoms in pregnant or postpartum patients, and early referral for specialist assessment remain essential to prevent permanent neurological deficits and optimize maternal outcomes.

Acknowledgments

We gratefully acknowledge the collaboration of the surgical and anesthesiology teams involved in the patient’s care and thank the radiology department for providing high-quality imaging essential for diagnosis and treatment planning.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Gulsever, Solmaz. Acquisition of data: Gulsever. Analysis and interpretation of data: Gulsever, Ozturk. Drafting the article: Gulsever, Solmaz. Critically revising the article: Gulsever. Reviewed submitted version of manuscript: Gulsever, Ozturk. Approved the final version of the manuscript on behalf of all authors: Gulsever. Administrative/technical/material support: Solmaz. Study supervision: all authors.

Correspondence

Cafer Ikbal Gulsever: Hakkari State Hospital, Hakkari, Turkey. cafer.gulsever@gmail.com.