OBJECTIVE: To present a case of symptomatic, expansile L1 vertebral hemangioma. CLINICAL FEATURES: A 46-year-old man presented with progressive neurologic changes and insidious onset of low back pain. INTERVENTION AND OUTCOME: After a trial of 3 visits of conservative chiropractic care, no improvement was noted. Magnetic resonance imaging was obtained, revealing an expansile hemangioma with extra-osseous component compromising the conus medullaris at the level of the L1 lumbar vertebra. Neurosurgical intervention resulted in clinical improvement. CONCLUSION: Primary care physicians treating patients with low back pain should be aware of neurologic red flags requiring prompt attention. Magnetic resonance imaging is the imaging modality of choice when evaluating a neurologic abnormality presumably related to a space-occupying lesion. Although a disk herniation is the most common cause of these symptoms, clues in the history and examination must prompt physicians to expand their differential diagnosis to include a variety of other extradural masses.