In the course of clinical practice, spine specialists will inevitably encounter lesions that defy immediate classification. Missed or misinterpreted spinal lesions can lead to misdiagnosis of reversible conditions, prompt unnecessary biopsies or surgical interventions, and potentially produce dangerous delays in care. Recognizing critical imaging characteristics – and knowing when to pause, re-image, biopsy, or refer – can meaningfully alter spine patient outcomes in any clinical setting.

Presented by the NASS Section on Spine Oncology at NASS 2025 in Denver, faculty from neurosurgery, orthopedic surgery, neuroradiology, and interventional radiology collaborated to lead a case-based discussion on elusive spinal lesions across a spectrum of etiologies. Rather than simply reviewing the imaging characteristics of a few distinct pathologies, the session instead emphasized how structured, evidence-based decision-making frameworks—alongside a careful history and physical examination—can empower providers to navigate unexpected imaging findings with greater confidence.