Lumbar Epidural Varix Causing Radicular Pain: A Case Report and Differential Diagnosis of Lumbar Cystic Lesions

Vascular loops mimicking herniated lumbar discs: fair warning

The authors report their experience with twenty-one consecutive patients who presented with symptoms and imaging characteristics of a herniated lumbar disc; of whom, at the time of surgery had a vascular loop instead. The procedure was performed on 14 women and seven men with a mean age of 39 years. Clinical complaints included lumbar aching with one limb overt radiculopathy in all patients; with additional sphincter dysfunction in two cases. Symptoms had developed within a mean period of three months. In all patients, the disc was exposed through an L5-S1 (n = 10); L4-L5 (n = 5) and L3-L4 (n = 6) open minimal laminotomy. In 16 patients, rather than a herniated disc they had a lumbar epidural varix, while an arterio-venous fistula was found in the remaining five cases. In all cases, the vascular disorder was resected and its subjacent disc was left intact. One patient had a postoperative blood transfusion. While the radiculopathy dysfunction improved in all patients, four patients reported lasting lumbar pain following surgery. The postoperative imaging confirmed the resolution of the vascular anomaly and an intact disc. The mean length of the follow-up period was 47 months. Either epidural varix or arterio-venous fistula in the lumbar area may mimic a herniated disc on imaging studies. With the usual technique they can be operated safely. Resection of the anomaly can be sufficient for alleviating radiculopathy symptoms.

Extravertebral low back pain: a scoping review

BACKGROUND

Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.

METHODS

A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.

RESULTS

The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.

DISCUSSION

Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.

CONCLUSION

The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

Venous congestion as a central mechanism of radiculopathies

Compression of roots/nerves can disrupt some of their functions, but does not necessarily cause pain. This is illustrated by the frequency of nearly asymptomatic spinal stenosis or disc herniations. In fact, pain of radiculopathies (and nerve entrapments) may mostly be the consequence of intraneural oedema induced by microscopical venous stasis around roots/spinal ganglia (or nerves) not or poorly shown by imaging. This narrative review first lists arguments for a role of congestion of vasa-nervorum in the pathophysiology of radiculopathies, including those induced by disc herniation and spinal stenosis, but also other sources of overpressures in spinal venous plexuses (pregnancy, vena cava atresia and thrombosis, portal hypertension, epidural varices, arterio-venous fistula, vertebral hemangioma or hemangioblastoma). It also details sources of venous congestion around nerves outside the spine, from pelvis (May-Thurner syndrome, Nut-cracker syndrome) to buttocks (superior and inferior gluteal veins), and even thighs and legs. A better recognition of a preeminent role of venous congestion in radiculopathies, plexopathies, and nerve entrapments, should have major consequences: (i) discard the dogma that compression is mandatory to induce root/nerve suffering, since root/nerve adherences in two locations can impair blood flow in vasa-nervorum through root/nerve stretching; (ii) implementation of sensitive techniques to visualise impingement of blood flow around or within roots and nerves; (iii) better prevention of roots/nerves adherence, or arachnoiditis induced by extravascular fibrin deposition secondary to venous stasis.; (iv) optimizing treatments dampening clot formation and/or extravascular fibrin leakage in the intradural/peridural spaces, or around roots/nerves, like guided injection of tissue plasminogen activator.

Engorged venous plexus mimicking adjacent segment disease: Case report and review of the literature

Background

An engorged venous plexus may mimic nerve compression from a herniated disk on the magnetic resonance (MR) studies as they both have similar signal intensities. During a laminectomy, if an engorged venous plexus is encountered instead of a disk herniation, there may be marked unanticipated bleeding.

Case Description

A 58-year-old female who had a prior anterior lumbar interbody fusion later returned with recurrent radiculopathy. Adjacent segment disease from a spinal disk herniation was suspected based on the surgical history, physical examination, and imaging (MRI) findings. Rather than a disk, an engorged venous plexuses (EVP) was encountered intraoperatively.

Conclusion

Here, we discussed our findings regarding a lumbar EVP rather than a herniated disk and reviewed the current literature. Although rare, a higher index of suspicion for these vascular malformations based on combined historical information and MRI studies should allow one to better detect and/or anticipate an EVP rather than a routine disk.