Rare case of a radiographically occult sacral lesion detected on MRI presenting with intractable back pain

We report the imaging findings and histopathology of a rare case of sacral hibernoma in a female presenting with right buttock pain while sitting. The lesion was occult on radiographs and CT scan. A small, rounded right S2 lesion was hypointense on T ₁ weighted images and hyperintense on short tau inversion-recovery images. It demonstrated homogeneous contrast enhancement. The lesion was biopsied, and histopathology revealed an intraosseous hibernoma composed of brown fat cells. Intraosseous hibernomas are rare and demonstrate non-specific imaging findings requiring biopsy for diagnosis, although most hibernomas are incidental and asymptomatic. Initial treatment with microwave ablation and cementoplasty improved the patient's symptoms temporarily but cementoplasty caused radicular symptoms, and eventually, cement removal, bone curettage, grafting and sacral nerve root decompression were required for symptom remission.