- Department of Basic Sciences, School of Osteopathic Medicine, Touro University Nevada, Henderson, Nevada, United States.
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California, United States.
Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California, United States.
DOI:10.25259/SNI_166_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Omron Hassan, Courtney S. Lewis, Likitha Aradhyula, Brian R. Hirshman, Martin H. Pham. Engorged venous plexus mimicking adjacent segment disease: Case report and review of the literature. 09-May-2020;11:104
How to cite this URL: Omron Hassan, Courtney S. Lewis, Likitha Aradhyula, Brian R. Hirshman, Martin H. Pham. Engorged venous plexus mimicking adjacent segment disease: Case report and review of the literature. 09-May-2020;11:104. Available from: https://surgicalneurologyint.com/surgicalint-articles/10007/
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.
Keywords: Adjacent segment disease, Epidural venous plexus, Lumbar radiculopathy
Patients, who previously had spinal fusions, may develop recurrent lumbar radiculopathy due to adjacent-level disk herniations. However, new adjacent level disease may occasionally be attributed to engorged venous plexuses (EVP) rather than new disk herniations.[
Here, we present a 58-year-old female patient who had previously undergone an anterior lumbar interbody fusion (ALIF) but later returned with lumbar radiculopathy. Although adjacent segment disease from a new spinal disk herniation was suspected, particularly based on relatively routine MRI findings, an EVP was discovered intraoperatively and was appropriately excised.
A 58-year-old female presented with the left lower radiculopathy. Seven years ago, she had a prior L5-S1 ALIF. On examination she had decreased the left lower-extremity 1/5 motor function in the tibialis anterior and extensor hallucis longus distributions, plus a 3/5 in the gastrocnemius. The MRI showed what appeared to be an L4-L5 left-sided disk herniation above the level of her prior fusion (i.e., adjacent L4-L5 segment disk disease) [
She subsequently underwent an L4-L5 left-sided minimally invasive microdiscectomy. After the laminotomy was completed and nerve root identified, there was a large venous plexus in the nerve root axilla extending ventrally and laterally. This was successfully coagulated with bipolar cautery. Due to the fragility of the plexus and recurrent venous bleeding, multiple hemostatic agents were repeatedly employed to control the bleeding [
Intraoperative view down the minimally invasive tubular retractor showing (a) the lateral edge of the dural and nerve root with cottonoids and Surgicel® hemostatic material at both the nerve root shoulder and axilla after encountering copious venous bleeding. (b) View of the nerve root after exploration which demonstrated no herniated disk bulge or fragment.
Outcome and follow-up
Postoperatively, she reported immediate improvement of her foot strength and resolution of her left lower extremity and buttock pain. She was discharged on postoperative day 1 after a follow-up MRI confirmed an EVP as the ultimate etiology of her radiculopathy [
A review of the English-language literature demonstrated 25 reports ranging in publication year between 1916 and 2019 that described patients with EVPs who presented similarly to those with lumbar disk herniations [
Location and pathology of EVPs
EVPs are variously attributed to IVC thrombosis/hypoplasia and iliac vein stenosis. EVPs in the lumbar region represent dilations of the vertebral venous plexus system resulting from either increased blood flow or disrupted venous drainage. Notably, EVP at the cervical and thoracic levels have different regional etiologies.[
Encountering unanticipated EVPs during lumbar surgery
Although rare, clinicians should consider EVPs in their differential diagnosis when encountering patients with radiculopathy who also have a history of obesity, vascular conditions, current pregnancy, or are taking oral contraceptives.[
Differentiating between EVP and disk on MRI
Differentiating between EVPs and herniated disks can be difficult, as both have similar MRI appearances. However, lumbar disk herniations typically appear hypo/hyperintense on MRI reflecting their water content.[
We report a 58-year-old female with a lumbar EVP above the level of a prior L5-S1 ALIF. Although rare, EVP should be anticipated if additional EVP-related MRI findings are present.
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