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Vellara JF, Palliyil NS, Kp S, Satheesh A. Lumbar Spinal Epidural Varices Causing Acute Bilateral Lower Limb Radiculopathy: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00073. [PMID: 37651578 DOI: 10.2106/jbjs.cc.23.00148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
CASE A 61-year-old male patient presented with back pain and bilateral lower limb radicular pain. A Magnetic Resonance Imaging (MRI) scan of the lumbar spine was suggestive of engorged epidural veins behind the L5 vertebral body causing severe cauda equina compression. A venous Doppler scan demonstrated thrombosis of the inferior vena cava, which was identified as the primary pathology. He was started on anticoagulation, after which his radicular symptoms improved significantly. The patient was asymptomatic at the time of final follow-up at 1 year. CONCLUSION Epidural varices can rarely present with lumbar radiculopathy mimicking an acute disk prolapse clinically and radiologically. Careful interpretation of the MRI scan will ensure proper diagnosis and avoid unnecessary surgery.
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Campione A, Agresta G, Locatelli D, Pozzi F. Cauda equina syndrome secondary to portal vein thrombosis: case report of favorable outcome with conservative treatment. J Neurosurg Spine 2021. [DOI: 10.3171/2020.7.spine20625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Epidural varicosis is a rare though well-known cause of cauda equina syndrome (CES). Although inferior vena cava (IVC) obstruction is the most common finding in such cases, portal vein hypertension can lead to epidural venous plexus engorgement by means of lumbar portocaval shunt activation.
A 40-year-old woman presented with right-sided sciatica, which progressed to right foot drop and a 3-day history of vesical tenesmus and fecal retention. She was initially diagnosed with L4–5 lumbar disc protrusion. However, contrast-enhanced lumbar MRI scan showed the presence of epidural varices in the L3–S1 tract. Given the absence of vascular anomalies amenable to resection, etiological conservative treatment was addressed. Therefore, a complete diagnostic workup was performed and revealed deep vein thrombosis (DVT), pulmonary embolism, and portal vein thrombosis. Oral anticoagulant therapy was initiated and prompt resolution of CES was observed. To the authors’ knowledge, this is the first report of CES secondary to epidural varicosis in the setting of acute portal vein thrombosis and extrahepatic portal vein obstruction (EHPVO). In cases of epidural varicosis, conservative etiological treatment is the most appropriate choice as CES may be the epiphenomenon of underlying systemic pathophysiological processes.
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Affiliation(s)
- Alberto Campione
- Department of Neurosurgery, Ospedale di Circolo Fondazione Macchi—ASST Settelaghi; and
- Department of Neurosurgery, Università degli Studi dell’Insubria, and
| | - Gianluca Agresta
- Department of Neurosurgery, Ospedale di Circolo Fondazione Macchi—ASST Settelaghi; and
| | - Davide Locatelli
- Department of Neurosurgery, Ospedale di Circolo Fondazione Macchi—ASST Settelaghi; and
- Department of Neurosurgery, Università degli Studi dell’Insubria, and
- Head and Neck Surgery & Forensic Dissection Research Center, Department of Biotechnology and Life Sciences, Università degli Studi dell’Insubria, Varese, Italy
| | - Fabio Pozzi
- Department of Neurosurgery, Ospedale di Circolo Fondazione Macchi—ASST Settelaghi; and
- Department of Neurosurgery, Università degli Studi dell’Insubria, and
- Head and Neck Surgery & Forensic Dissection Research Center, Department of Biotechnology and Life Sciences, Università degli Studi dell’Insubria, Varese, Italy
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3
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Campione A, Agresta G, Locatelli D, Pozzi F. Cauda equina syndrome secondary to portal vein thrombosis: case report of favorable outcome with conservative treatment. J Neurosurg Spine 2021:1-6. [PMID: 33386000 DOI: 10.3171/2020.6.spine20625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/31/2020] [Indexed: 11/06/2022]
Abstract
Epidural varicosis is a rare though well-known cause of cauda equina syndrome (CES). Although inferior vena cava (IVC) obstruction is the most common finding in such cases, portal vein hypertension can lead to epidural venous plexus engorgement by means of lumbar portocaval shunt activation.A 40-year-old woman presented with right-sided sciatica, which progressed to right foot drop and a 3-day history of vesical tenesmus and fecal retention. She was initially diagnosed with L4-5 lumbar disc protrusion. However, contrast-enhanced lumbar MRI scan showed the presence of epidural varices in the L3-S1 tract. Given the absence of vascular anomalies amenable to resection, etiological conservative treatment was addressed. Therefore, a complete diagnostic workup was performed and revealed deep vein thrombosis (DVT), pulmonary embolism, and portal vein thrombosis. Oral anticoagulant therapy was initiated and prompt resolution of CES was observed. To the authors' knowledge, this is the first report of CES secondary to epidural varicosis in the setting of acute portal vein thrombosis and extrahepatic portal vein obstruction (EHPVO). In cases of epidural varicosis, conservative etiological treatment is the most appropriate choice as CES may be the epiphenomenon of underlying systemic pathophysiological processes.
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Affiliation(s)
- Alberto Campione
- 1Department of Neurosurgery, Ospedale di Circolo Fondazione Macchi-ASST Settelaghi; and
- 2Department of Neurosurgery, Università degli Studi dell'Insubria, and
| | - Gianluca Agresta
- 1Department of Neurosurgery, Ospedale di Circolo Fondazione Macchi-ASST Settelaghi; and
| | - Davide Locatelli
- 1Department of Neurosurgery, Ospedale di Circolo Fondazione Macchi-ASST Settelaghi; and
- 2Department of Neurosurgery, Università degli Studi dell'Insubria, and
- 3Head and Neck Surgery & Forensic Dissection Research Center, Department of Biotechnology and Life Sciences, Università degli Studi dell'Insubria, Varese, Italy
| | - Fabio Pozzi
- 1Department of Neurosurgery, Ospedale di Circolo Fondazione Macchi-ASST Settelaghi; and
- 2Department of Neurosurgery, Università degli Studi dell'Insubria, and
- 3Head and Neck Surgery & Forensic Dissection Research Center, Department of Biotechnology and Life Sciences, Università degli Studi dell'Insubria, Varese, Italy
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Carpenter K, Decater T, Iwanaga J, Maulucci CM, Bui CJ, Dumont AS, Tubbs RS. Revisiting the Vertebral Venous Plexus-A Comprehensive Review of the Literature. World Neurosurg 2020; 145:381-395. [PMID: 33049379 DOI: 10.1016/j.wneu.2020.10.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 12/23/2022]
Abstract
The venous drainage of the vertebral and paravertebral regions is important for a better understanding of hematogenous disease spread. Moreover, the spine surgeon must be well acquainted with this anatomy to minimize intraoperative and postoperative complications. A comprehensive review of the vertebral venous plexus (Batson plexus) was performed with a concentration on the clinical and surgical correlations of this venous network.
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Affiliation(s)
- Kennedy Carpenter
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA
| | - Tess Decater
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Fukuoka, Japan.
| | - Christopher M Maulucci
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - C J Bui
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA; Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
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Extraspinal Vascular Malformation with Retrograde Drainage through a Radicular Vein: Treatment with Percutaneous Transgluteal Embolization. World Neurosurg 2020; 143:423-427. [PMID: 32777407 DOI: 10.1016/j.wneu.2020.07.224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/30/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Spinal arteriovenous fistulas have abnormal connections between spinal arteries and veins. Early diagnosis and management are essential for preventing permanent neurologic deficits. Although symptoms of myelopathy are commonly related to established types of spinal arteriovenous fistulas within the spine, extraspinal arteriovenous anomalies may also result in similar pathology and pose challenges to conventional endovascular treatment. CASE DESCRIPTION A 61-year-old man presented with progressive weakness and decreasing sensation in the lower extremities. He had a remote history of craniopharyngioma surgery and deep venous thrombosis. Examination showed decreased strength and reflexes in the lower extremities. Magnetic resonance imaging demonstrated T2 cord signal changes and flow voids within the spinal canal. Angiogram showed bilateral internal iliac artery arteriovenous malformations with retrograde flow into a radicular vein and venous congestion of the medullary veins. Percutaneous transgluteal puncture of the superior gluteal vein was performed, and the abnormal inflow to the radicular vein was obliterated with coiling and Onyx embolization. The patient had significant clinical improvement, and follow-up imaging demonstrated resolution of T2 cord signal changes and flow voids. CONCLUSIONS Extraspinal vascular malformations with vascular myelopathy are extremely rare. They include a broad spectrum of complex vascular disorders and often require alternate endovascular approaches.
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Hassan O, Lewis CS, Aradhyula L, Hirshman BR, Pham MH. Engorged venous plexus mimicking adjacent segment disease: Case report and review of the literature. Surg Neurol Int 2020; 11:104. [PMID: 32494381 PMCID: PMC7265352 DOI: 10.25259/sni_166_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/16/2020] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Omron Hassan
- Department of Basic Sciences, School of Osteopathic Medicine, Touro University Nevada, Henderson, Nevada, United States
| | - Courtney S Lewis
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California, United States
| | - Likitha Aradhyula
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California, United States
| | - Brian R Hirshman
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California, United States
| | - Martin H Pham
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California, United States
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Freeman CW, Lazor JW, Loevner LA, Nabavizadeh SA. Variations of the CNS Venous System Mimicking Pathology: Spectrum of Imaging Findings. J Neuroimaging 2019; 29:673-688. [DOI: 10.1111/jon.12664] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 12/18/2022] Open
Affiliation(s)
- Colbey W. Freeman
- Department of RadiologyHospital of the University of Pennsylvania Philadelphia PA
| | - Jillian W. Lazor
- Division of Neuroradiology, Department of RadiologyHospital of the University of Pennsylvania Philadelphia PA
| | - Laurie A. Loevner
- Division of Neuroradiology, Department of RadiologyHospital of the University of Pennsylvania Philadelphia PA
| | - Seyed Ali Nabavizadeh
- Division of Neuroradiology, Department of RadiologyHospital of the University of Pennsylvania Philadelphia PA
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Tuan AS, Nabavizadeh SA, Pukenas B, Mohan S, Learned KO. Reversible dilatation of lumbar epidural venous plexus secondary to pelvic venous compression: mimicker of pathology. BJR Case Rep 2016; 3:20150287. [PMID: 30363285 PMCID: PMC6159269 DOI: 10.1259/bjrcr.20150287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 08/01/2016] [Accepted: 08/10/2016] [Indexed: 11/24/2022] Open
Abstract
Radiculopathy from dilated epidural varices is a rarely recognized phenomenon, and engorged varices may mimic a disc herniation, fistula or mass. We report a case of a distended bladder causing reversible pelvic venous congestion and resultant epidural venous plexus engorgement. We show marked engorgement of the epidural venous plexus and crowding of the cauda equina from a markedly distended bladder with resolution of these findings following bladder decompression. Familiarity with this clinical entity is crucial to avoid misdiagnosis and to prevent potential unnecessary surgical intervention.
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Affiliation(s)
- August S Tuan
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - S Ali Nabavizadeh
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Bryan Pukenas
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Suyash Mohan
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kim O Learned
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Lumbar epidural varices can also present with radiculopathy similar to acute intervertebral disc prolapse (IVDP). However as the magnetic resonance imaging (MRI) in these patients are usually normal without significant compressive lesions of the nerve roots, the diagnosis is commonly missed or delayed leading to persistent symptoms. We present a rare case of acute severe unilateral claudication with a normal MRI unresponsive to conservative management who was treated surgically. The nerve root on the symptomatic side was found to be compressed by large anterior epidural varices secondary to an abnormal cranial attachment of ligamentum flavum. Decompression of the root and coagulation of the varices resulted in complete pain relief. To conclude, lumbar epidural varices should be considered in the differential diagnosis of acute onset radiculopathy and claudication in the absence of significant MRI findings.
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Affiliation(s)
- Meenakshisundaram Subbiah
- Department of Spine Surgery, Sethu Sarada Hospital, Madurai, Tamil Nadu, India,Address for correspondence: Dr. Meenakshisundaram Subbiah, Sethu Sarada Hospital, No. 409, Church Road, Anna Nagar, Madurai - 625 020, Tamil Nadu, India. E-mail:
| | - Krishnan Yegumuthu
- Department of Spine Surgery, Sethu Sarada Hospital, Madurai, Tamil Nadu, India
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Lee JH, Song WJ, Kang KC. Myelopathy-mimicking symptoms of epidural venous engorgement and syringomyelia due to inferior vena cava stenosis at the thoracolumbar junction in a patient with Budd-Chiari syndrome. J Neurosurg Spine 2015; 23:467-70. [DOI: 10.3171/2015.1.spine14515] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Epidural venous engorgement can result from various lesions, such as arteriovenous malformation, thrombosis or occlusion of the inferior vena cava (IVC), or an abdominal masslike lesion. Most patients with these problems complain of low-back pain, radicular pain, or neurogenic claudication, which are symptoms suggestive of disc herniation or spinal stenosis. However, these patients rarely exhibit neurological deficits or cauda equina syndrome. The authors encountered a case of a 60-year-old man presenting with lower-extremity weakness and voiding difficulty for a period of 1 year. To investigate the patient’s myelopathy-mimicking symptoms, a lumbar spine MRI scan was performed. The MR images exhibited tortuous and dilated spinal vessels compressing the spinal cord and thecal sac at the T11-L3 level, which were concurrent with syringomyelia evidenced by a 22 × 2.5-mm cyst at the T11–12 level. 3D CT scanning of the whole aorta revealed total occlusion and regression of the IVC in the intrahepatic region 3 cm inferior to the right atrium and dilation of multiple collateral veins. The patient was diagnosed with chronic Budd-Chiari syndrome Type I. The authors performed venography, followed by intrahepatic IVC recanalization via stent placement under fluoroscopic and ultra sonographic guidance and without surgical exploration. After this treatment, there was a marked decrease in epidural venous engorgement and the patient’s symptoms resolved almost completely. This case indicates that epidural venous engorgement at thoracolumbar levels may cause symptoms suggestive of myelopathy and can be successfully treated by minimally invasive procedures to eliminate the underlying causes.
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