Abstract

Background: A patient presented with lumbago/sciatica attributed to a magnetic resonance (MR)-documented hugely dilated, partially calcified, and extrinsically compressive epidural varicose vein (EVV).

Case Description: A 36-year-old male presented with 2 months of lumbago-sciatica; the only finding was a positive left-sided straight leg sign to 50°. The MR imaging demonstrated a hugely dilated, branching pattern flow void that caused marked displacement/compression of thecal sac and left S1 nerve root. The X-rays and computed tomography (CT) studies additionally showed a linear “string of beads” pattern of calcification at the L5/S1 level. Intraoperatively, an encapsulated, hugely dilated, compressive epidural vein was encountered; partial vein coagulation and gross total removal decompressed the neural elements. He recovered normal neurological function within 1 post-operative month.

Conclusion: A 36-year-old male presented with left-sided sciatica attributed to an MR and CT documented hugely dilated, partially calcified L5/S1 EVV. Once the EVV was coagulated and removed, the patient’s symptoms resolved.

Keywords: Disc herniation, Epidural varicose vein, Radiology

INTRODUCTION

Few studies document that an epidural varicose vein (EVV) can mimic a disc herniation, resulting in lumbar thecal sac and compression.[ 1 ] Here, a 36-year-old male presented with left-sided radiculopathy. When the magnetic resonance (MR) and computed tomography (CT) documented a hugely dilated, encapsulated EVV compressing the thecal sac and left S1 root. After undergoing coagulation and gross total EVV excision, he regained full neurological function and became asymptomatic.

CASE REPORT

A 36-year-old male presented with left lower extremity sciatica of 2 months’ duration. His only neurological finding was a left-sided positive straight leg raising sign to 50°. The MR imaging demonstrated a hugely dilated, branching pattern flow void that caused displacement of the thecal sac, and compression of the left S1 nerve root [ Figure 1 ]. X-rays and CT studies showed a “string of beads” pattern with calcification at the L5/S1 disc space [ Figures 2a - f ]. Intraoperatively, a well-encapsulated, hugely dilated EVV was identified; it was partially coagulated and then entirely removed [ Figures 3a and b ]. The decompression resulted in the patient’s complete neurological recovery within 1 postoperative month.

Figure 1:

Magnetic resonance imaging of L/S spine, (a) T1 weighted image (T1WI), (b) T1 weighted image (T2WI) sagittal and (c) coronal section demonstrated a well-defined linear, penetrating like flow void, indenting and compressing the thecal sac from left posterolateral aspect. This flow void was surrounded by hyperintense cleft in both sequences. Mild disc herniation at L4/L5 and L5/S1 was also evident. (d) T2WI and (e and f) T1WI, axial section demonstrated a hugely dilated malformation, displacing the thecal sac and compressing the left S1 traversing nerve root.

Figure 2:

X-ray, L/S spine, (a) anteroposterior and (b) oblique view demonstrated a “string of beads” pattern calcification at left L5/S1 level (marked by yellow arrowhead); (c) this calcified string seems to be adherent with inner aspect of L5 lamina (marked by yellow arrowhead); computed tomography scan of L/S spine, 3D reconstruction (d) right oblique, (e) posterior and (f) left oblique view demonstrated normal anatomical configuration of lumbosacral spine with no congenital or acquired bone abnormalities.

Figure 3:

(a) after retraction of the left S1 nerve root, status of the spinal canal and IVD was inspected; (b) after partial coagulation of venous malformation and removal of inflammatory pseudo capsule, left S1 nerve root became well decompressed (marked by white star). IVD: Intervertebral disc.

DISCUSSION

As the epidural venous plexus is valveless, disc herniations, spinal stenosis, tumors, abscesses, hematomas, conjoined nerve roots, and/or perineural cysts can all contribute to the development of EVVs.[ 1 , 2 ] These EVVs, however, only rarely become symptomatic in the lumbar spine due to thecal sac/nerve root compression. Ju et al. classified EVV into types B and C EVV; they could cause thecal sac/nerve root compression, and clinically as well as radiographically mimic lumbar disc herniations.[ 3 ] In this case, both the MR and CT findings were consistent with a left-sided L5/S1 EVV. Intraoperatively, a well-defined, hugely dilated, encapsulated, partially calcified, and compressive left-sided epidural mass was encountered at the L5S1 level. Although the lesion’s encapsulation and consistency were consistent with the diagnosis of an EVV, there was only mild accompanying calcification of the capsule, and no evidence of the typically encountered thrombosis. Notably, several other studies document EVVs comprised of abnormally dilated veins that not only become calcified, but additionally show evidence of repeated bleeding/multiple layers of thrombosis that contribute to further enlargement/progressive compression of neural elements.[ 4 ] In this case, the EVV was considered idiopathic and was coagulated and removed through a left L5/S1 fenestration procedure, following which the patient’s symptoms resolved.

CONCLUSION

A 36-year-old male presented with 2 months of increased left lower extremity radiculopathy. Both MR and CT studies documented a hugely dilated left-sided L5/S1 EVV that, once coagulated and successfully removed, was asymptomatic.

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. Jeong HJ, Sim WS, Park HJ, Lee SH, Oh MS, Cho MK. Severe lumbar radiculopathy with epidural venous plexus engorgement in a morbidly obese pediatric patient: A case report. Medicine (Baltimore). 2019. 98: e16842

3. Ju JH, Ha HG, Jung CK, Kim HW, Lee CY, Kim JH. Patterns of epidural venous varicosity in lumbar stenosis. Korean J Spine. 2012. 9: 244-9

4. Lee YS, Choi ES, Kim JO, Ji JH. A rare calcified thrombosis of the dilated epidural venous plexus presenting with lumbar radiculopathy: A case report. Spine J. 2011. 11: e28-31