Several different conditions can create holes or hole-like areas in the spine, ranging from harmless age-related changes to serious diseases like cancer. The most common are disc herniations into the bone (called Schmorl’s nodes), fluid-filled cysts, benign vascular growths, and bone loss from osteoporosis. Less commonly, cancers like multiple myeloma can create “punched-out” holes in the vertebrae. What’s causing your specific finding depends on where the hole is, what it looks like on imaging, and whether you have symptoms.
Disc Material Pushing Into the Bone
One of the most common causes of a visible hole in a vertebra is a Schmorl’s node. This happens when the soft, gel-like center of a spinal disc pushes through the endplate (the hard cap on top or bottom of the vertebra) and herniates into the bone itself. On imaging, it looks like a small pit or divot in the vertebral body. A large study of over 4,100 people found Schmorl’s nodes in about 5% of men and 3% of women, though rates vary depending on the imaging method used.
Most Schmorl’s nodes cause no symptoms at all and are discovered by accident during an MRI or CT scan for something else. When they do cause pain, though, it can be severe. Symptomatic cases show inflammation and swelling in the bone marrow surrounding the node, which triggers pain receptors in that swollen tissue. People with multiple Schmorl’s nodes are more likely to have disc disease and chronic lower back pain.
Fluid-Filled Cysts in or Around the Spinal Cord
Cysts are another category of “holes” that can show up on spinal imaging. Two types are particularly notable: syringomyelia and Tarlov cysts.
Syringomyelia
Syringomyelia is a condition where a fluid-filled cavity (called a syrinx) develops inside the spinal cord itself. Many cases are linked to a Chiari malformation, where brain tissue extends down into the spinal canal and disrupts the normal flow of cerebrospinal fluid. Spinal cord injuries, tumors, and inflammation around the cord can also cause it. In trauma-related cases, the syrinx may not develop until months or even years after the original injury. Because the cyst sits within the spinal cord, it can press on nerve fibers and cause progressive weakness, numbness, or changes in sensation over time.
Tarlov Cysts
Tarlov cysts are fluid-filled sacs that form on the nerve roots near the base of the spine, most often around the sacrum. The second sacral nerve root is the most common location. Their exact cause is still debated, but one theory suggests that trauma causes small bleeds that block normal fluid drainage around the nerve, leading to cyst formation. Another theory points to genetic factors that promote abnormal tissue growth along the nerve roots. People with connective tissue disorders like Marfan syndrome or Ehlers-Danlos syndrome appear to be at higher risk.
Once formed, Tarlov cysts tend to persist because cerebrospinal fluid flows into them through a one-way valve created by scarring around the cyst opening. Physical trauma or heavy exertion can cause fluid to build up further. Many Tarlov cysts are small and painless, but larger ones can compress nearby nerves and cause pain, numbness, or bladder and bowel issues.
Blood-Filled Bone Cysts
Aneurysmal bone cysts are benign, expanding lesions filled with blood-filled cavities separated by thin walls of tissue. They have a sponge-like appearance on imaging. These cysts primarily affect children and young adults, with 75% of cases occurring before age 20 and a slight predominance in females. They are rare in the spine but can be locally aggressive, expanding into surrounding bone and potentially compressing the spinal cord or nerves. Despite their dramatic appearance, they are not cancerous.
Benign Vascular Growths
Vertebral hemangiomas are the most common benign tumor of the spinal column. They’re clusters of abnormal blood vessels within the vertebral bone, and autopsy studies have found them in roughly 11% of adults. On CT scans, they create a distinctive honeycomb pattern of small holes within the vertebra, caused by a mix of blood-filled spaces and fatty tissue woven between reorganized bone. The vast majority are completely harmless and found incidentally. Only a small fraction grow large enough to cause symptoms by expanding into the spinal canal.
Bone Loss From Osteoporosis
Osteoporosis doesn’t create a single visible “hole,” but it does make the inner structure of vertebrae increasingly porous and hollow-looking. Healthy bone has a dense network of tiny struts called trabeculae that give it strength. In osteoporosis, the cells that break down bone outpace the cells that rebuild it. This imbalance causes the struts to thin, and once they get thin enough, something irreversible happens: the stress concentrated at the base of a tiny resorption pit causes microscopic damage that triggers even more bone removal, until the strut snaps entirely. Research has shown that in a strut about 90 micrometers wide, a resorption pit deeper than about 32 micrometers will cascade into a full perforation rather than healing.
This is why osteoporotic bone loss accelerates over time. Once a strut is perforated and gone, it cannot regrow. The vertebra becomes weaker with each lost connection, eventually making it vulnerable to compression fractures, sometimes from forces as minor as bending forward or coughing.
Cancer-Related Bone Destruction
The most concerning cause of holes in the spine is cancer. Multiple myeloma, a blood cancer involving plasma cells, is one of the classic culprits. It creates well-defined, punched-out holes (lytic lesions) in bone that are typically 5 millimeters or larger. Skeletal involvement occurs in 80 to 90% of myeloma patients, and the spine is one of the most commonly affected sites. Other cancers that frequently spread to the spine, including breast, lung, kidney, and prostate cancers, can also destroy vertebral bone and create visible holes on imaging.
What distinguishes cancerous lesions from benign ones is often their appearance and behavior. Myeloma lesions tend to be multiple, well-circumscribed, and scattered across several bones. They may be accompanied by unexplained weight loss, fatigue, or bone pain that worsens at night. A single lytic lesion in the spine, called a plasmacytoma, can also occur in isolation.
How These Are Found and Distinguished
CT scans are generally better for evaluating structural bone lesions like lytic holes, fractures, and erosions because they show bone architecture in fine detail. MRI is the preferred tool for soft tissue problems, including spinal cord cysts like syringomyelia and bone marrow changes like the inflammation surrounding a symptomatic Schmorl’s node. MRI can also reveal cysts and swelling that are completely invisible on CT. In many cases, both imaging types are used together to get the full picture.
The location and pattern of the holes matters enormously for diagnosis. A honeycomb pattern in a single vertebra suggests a hemangioma. A small divot at the top or bottom of a vertebral body is likely a Schmorl’s node. Multiple punched-out lesions across several vertebrae raise concern for myeloma. A fluid-filled cavity inside the spinal cord points to syringomyelia. Your radiologist and doctor use these patterns, along with your age, symptoms, and medical history, to determine what’s actually going on and whether treatment is needed.