Abstract

Background:Epidural venous plexus congestion at L5-S1 due to inferior vena cava (IVC) thrombosis led to an acute cauda equina syndrome (CES). Laminectomy to rule out an epidural abscess, allowing for resection of the dilated veins, led to immediate symptom resolution.

Case Description:A 47-year-old male presented with acute urinary retention and left greater than right lower extremity paresis of 2 weeks duration. Magnetic resonance imaging (MRI) revealed a contrast-enhancing space-occupying anterior epidural L5-S1 level lesion resulting in cauda equina compression. As the patient was septic, he underwent an emergency laminectomy for a presumed epidural abscess. Intraoperative findings, however, documented a markedly dilated epidural venous plexus secondary to a newly diagnosed IVC thrombus. One day postoperatively, the patient was symptom-free and neurologically intact.

Conclusions:Here we report a patient who uniquely presented with a CES characterized by acute paraparesis. This was attributed to a massively engorged anterior lumbar epidural venous plexus attributed to newly diagnosed IVC thrombus.

Keywords: Cauda equina syndrome, epidural venous plexus engorgement, inferior vena cava thrombosis

INTRODUCTION

Well-established causes of cauda equina syndrome (CES) include spinal tumors, infection/inflammation, critical stenosis, arteriovenous malformations, and hemorrhages.[ 11 ] Here, we describe a CES attributed to massive engorgement of the lumbar L5-S1 epidural venous plexus (EVPE) attributed to inferior vena cava (IVC) thrombosis. Following a decompressive laminectomy, the patients were asymptomatic and, again, neurologically intact.

CASE REPORT

A 47-year-old male presented with 2 weeks of a progressive left lower extremity paraparesis and 5 days of urinary dysfunction. On admission, he demonstrated a leukocytosis of 21.6 × 10³ cells/μL, along with Streptococcus viridans septicemia. Also noted was acute venous thrombosis extending from the left popliteal vein to the IVC (e.g., at the confluence of left and right common iliac vein) [ Figure 1 ]. He was immediately placed on both intravenous antibiotics and full-dose anticoagulation. When the lumbar magnetic resonance imaging (MRI) with and without contrast revealed a mass in the L5-S1 anterior epidural space, emergent decompressive laminectomy was performed to rule out an abscess/phlegmon [Figures 2 and 3 ]. However, ventral L5-S1 exploration revealed a significantly engorged EVPE compressing on the thecal sac without evidence of infection; the plexus was cauterized/coagulated and resected. The patient's symptoms/signs resolved within just one postoperative day, and he remained symptoms/sign free at 8 postoperative months.

Figure 1

A venacavagram performed during IVC filter placement demonstrating filling defect near the confluence of the common iliac veins (a) with delayed reconstitution of contrast flow into the right, but not left, common iliac vein (b). Findings are consistent with an occlusive thrombus in the left common iliac vein with extension into the proximal IVC which is near-occlusive in nature

Figure 2

(a) Sagittal T1-weighted MR sequence revealing a lesion in the L5-S1 anterior epidural space that is heterogeneously hypointense (arrow). (b) Sagittal T2-weighted MR sequence with anterior spinal epidural lesion that is mixed iso- and hyperintense centrally with a rim of hypointensity peripherally (arrows), most prominently seen at L4-S1 but also present at T12-L3 levels. There is evidence of mass effect with compression of the thecal sac

Figure 3

Sagittal (a) and axial (b) images of gadolinium-enhanced T1 MR sequence. Arrows depict heterogeneous contrast-enhancing lesions in the anterior epidural space that have serpiginous fill void centrally

DISCUSSION

EVPE engorgement causing low back pain, radiculopathy, and CES is rare, and the diagnosis is often missed. It was first described in the 1940s by Cohen[ 3 ] and Epstein[ 6 ] where epidural varices mimicked nucleus pulposis herniations/lumbar discs.

There are only 20 previously reported cases of myelopathy associated with EVPE secondary to IVC thrombosis, only five of which exhibited symptoms of CES [ Table 1 ].[ 1 2 4 5 7 8 9 10 12 13 ] Anticoagulation, pharmacomechanical thrombectomy, and IVC stenting were the treatment of choice in many of these cases. Here, following a decompressive laminectomy to rule out an epidural abscess and resect the anteriorly massive dilated L5-S1 venous plexus, the patient's symptoms resolved.

Table 1

Literature review of case reports of symptomatic epidural venous plexus engorgement secondary to IVC thrombosis

CONCLUSION

Symptomatic massive engorgement of the L5-S1 anterior EVPE resulted in a CES due to iliocaval thrombosis. Following a laminectomy to rule out an epidural abscess, coagulation/resection of the dilated venous plexus resulted in full symptom resolving.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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