Abstract: We report a 69-year-old female with nearly 4 months of bilateral lower limb weakness and about 1 week of limited activity and pain. MRI of the thoracolumbar spine revealed that the lesion was mainly on the vertebral body and the corresponding intraspinal, epidural, and paravertebral soft tissues. In the Gd-enhanced images, the lesion was highly apparent and was diagnosed as a malignant tumor. However, the punctate bone density was increased upon PET/CT and ¹⁸F-FDG uptake was low. Furthermore, PET/CT imaging showed a cavernous hemangioma, and this was confirmed by histological examination of the tumor. The understanding of the cavernous hemangioma was deepened by literature review. A cavernous hemangioma can involve the vertebral body and vertebral appendages, and can even extend into the spinal canal and surrounding tissues. Cavernous hemangioma is a benign vascular malformation. The Gd-enhanced imaging is a valuable enhancement tool. Moreover, PET showed low ¹⁸F-FDG uptake. When the MRI lesions are widespread and obvious, malignancy should not be ruled out. Furthermore, PET/CT should be used for the differential diagnosis of benign lesions, such as cavernous hemangioma.