Epidural venous plexus enlargements presenting with radiculopathy and back pain in patients with inferior vena cava obstruction or occlusion

Abstract

Study design: In the last 2 years, we have examined 9640 patients experiencing back pain or sciatica, using MRI. There were 13 (0.13%) patients who had radicular symptoms that clinically mimicked lumbar disc herniation or spinal stenosis. All of these patients had inferior vena caval obstruction or occlusion that caused engorgement in the epidural and paravertebral venous system, causing nerve root compression.

Objective: To illustrate the imaging characteristics of 13 patients with epidural engorged veins due to inferior vena cava obstruction or occlusion causing sciatica and low back pain.

Summary of the background data: Abnormalities or pathological changes of epidural venous network may give rise to symptoms similar to or mimicking lumbar disc herniation or spinal stenosis. Multiple lumbar epidural varices can cause nerve root and thecal sac compression. Lumbar epidural varices have been infrequently described in the literature. To date, the cause of anterior epidural venous enlargement has been poorly understood, and both congenital and acquired causes have been proposed. This report describes enlarged epidural veins in patients with inferior vena caval thrombosis or obstruction presenting with radicular syndromes.

Methods: The authors have seen 13 patients with radicular symptoms. All of the patients had inferior vena caval obstruction or occlusion that caused engorgement in the epidural veins, causing nerve root compression. The ages of these patients ranged from 20 to 53 (mean, 30) years. All of the patients were examined with color Doppler ultrasonography and magnetic resonance scanner.

Results: Ten of 13 patients had inferior vena cava thrombosis located just under the renal vein orifices. In two patients, there was compression to inferior vena cava due to parity. In the remaining patient, a huge intra-abdominal mass was observed, and this mass was causing inferior vena cava obstruction and invasion. Enlargements of epidural venous plexus were demonstrated in all of these cases. All of the patients presented with the acute onset of low back pain followed shortly thereafter by acute radicular symptoms. The compression to inferior vena cava could not be treated in one patient because of intra-abdominal malignancy. The remaining 12 patients with inferior vena cava obstruction or occlusion experienced complete resolution of symptoms after treatment or delivery.

Conclusion: The authors believe that epidural venous engorgement should be considered when the symptoms of patients with deep venous and inferior vena cava thrombosis are accompanied by radicular and/or back pain, because pathologic processes compressing a nerve root can cause pain.