OBJECTIVE: To discuss an unusual presentation of spina bifida occulta (SBO) mimicking an aggressive bone lesion. CLINICAL FEATURES: A 59-yr-old man suffered from intermittent neck pain. The plain film radiographs revealed rarefaction of the C6 spinous process that mimicked an aggressive bone lesion. Computed tomography and previous radiographs of the region confirmed an SBO defect of the C6 level. INTERVENTION AND OUTCOME: Supportive therapy was applied to the patient for his presenting neck complaint. Chiropractic manipulative treatment was not applied to the lower cervical spine until the possibility of an aggressive bone lesion was excluded. CONCLUSION: An unusual presentation of SBO was presented. This case demonstrated the usefulness of specialized imaging to further delineate questionable anatomical presentations, which at times mimic destructive bone lesions.