Abstract

Background: A patient presented with sciatica attributed to a conjoined lumbosacral nerve root, an extruded disc herniation, and epidural varicose veins.

Case Description: A 60-year-old male presented with 5 months of sciatica (4/5 motor deficit). The lumbosacral magnetic resonance showed a right paracentral disc herniation causing thecal sac/L5-S1 nerve root compression. Intraoperatively, the patient had an L5-S1 conjoined nerve root, an extruded disc herniation, and type C epidural varicose veins. A wide fenestration and foraminotomy were performed to facilitate the removal of the extruded disc and partial coagulation of the epidural varicose veins. Surgery resulted in complete symptom resolution within the 1^st postoperative month.

Conclusion: A patient with intractable right-sided sciatic was found at surgery to have an L5-S1 conjoined nerve root, a herniated disc, and marked epidural varicosities. Following a wide fenestration/foraminal decompression, the patient’s symptoms fully resolved within the 1^st postoperative month.

Keywords: Conjoined nerve root, Epidural varicose vein, Extruded disc

INTRODUCTION

Conjoined nerve root and epidural varicose vein can mimic disc herniation both clinically and radiologically which possesses a diagnostic and management challenge to a Spine surgeon. Therefore, a detail neurological examination and correlation with neuroimaging feature plays a pivotal role to choose appropriate management strategy. Herein, this is the world’s first reported case of it’s kind with presence of Conjoined lumbosacral nerve root anomalies, accompanied by extruded disc herniation and epidural varicose vein, resulting in refractory lumbago-sciatica. We have highlighted the misleading imaging features and management challenges of this rare entity and briefly reviewed the pertinent literature.

IMAGE REPORT

A 60-year-old male presented with 5 months of sciatica that had exacerbated over the past 2 weeks. On examination, straight leg raising was positive on the right at 40°, and he had 4/5 motor strength in the L5/S1 distributions. The lumbosacral magnetic resonance imaging (MRI) showed a right L5/S1 paracentral disc herniation causing thecal sac/nerve root compression and marked varicosities (i.e. prominent flow voids) [ Figures 1a - d ]. Intraoperatively, a wide fenestration and right-sided foraminotomy were performed. We discovered a conjoined right L5-S1 nerve root along with an extruded disc herniation and type C epidural varicose veins [ Figures 2a - c ]. The disc was removed, and the varicose veins were partially coagulated [ Figure 2d ]. The patient had an uneventful postoperative recovery and was asymptomatic within the 1^st postoperative month.

Figure 1:

MRI of L/S spine, (a) T1WI sagittal and (b) T2WI sagittal section demonstrated LDH at L5/S1 level, causing thecal sac indentation and compression of the nerve roots. (c) T1WI axial section showed right paracentral LDH (marked by red arrowhead) with obliteration of lateral recess on both sides. (d) There was the presence of a flow void, capping the herniated disc material (marked by a yellow arrow) with significant displacement of the right exiting nerve root. Here, MRI: Magnetic resonance imaging, T1WI: T1-weighted image, T2WI: T2-weighted image, LDH: Lumbar disc herniation.

Figure 2:

Intraoperative photograph demonstrated. (a) Type C varicose vein, densely adhered and encircled the exiting nerve root (marked by blue arrowhead). (b) Wide fenestration and cranial mobilization of supraspinous and interspinous ligaments were done to facilitate HD removal. (c) An exceptionally large extruded disc with a downward migratory component removed in between the thecal sac and nerve root axilla. (d) Intraoperative microscopic appearance of the conjoined nerve root, densely adhered with type C varicose vein and thecal sac labeled. Here, HD: Herniated disc.

DISCUSSION

Conjoined nerve roots and epidural varicose veins can both clinically and radiographically mimic lumbar disc herniations.[ 1 , 2 ] Here, the typical magnetic resonance findings for conjoined nerve roots were not present; they typically include the sagittal shoulder sign, the fat crescent sign, and/or corner signs. Rather, here on the MRI, the patient had what appeared to be a typical focal L5/S1 herniated disc with added flow voids consistent with venous varicosities.[ 2 , 3 ] Adequate decompression of the conjoined nerve root allowed for the disc to be successfully removed and facilitated partial coagulation of the varicose veins that were additionally contributing to nerve root compression.

CONCLUSION

Meticulous clinico-radiological evaluation is mandatory to predict the radiological mimics of lumbar disc herniation. In the era of minimally invasive spine surgery, microscopic decompression of the neural elements is better to achieve a favourable neurological outcome.

Ethical approval:

Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

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2. Raut VK, Khan AH, Ahmad M, Barua S, Ahmed N, Khan SI. Spinal epidural varicosity resembling prolapsed intervertebral disc on MRI: A diagnostic dilemma for lumbar canal stenosis. J Neurol Stroke. 2021. 11: 23-5

3. Trakolis L, Petridis AK. Contralateral discectomy as a novel approach for disc herniation compressing a conjoined nerve root: Illustrative case. J Neurosurg Case Lessons. 2024. 8: CASE24301