Surgical treatment of lumbar epidural varices

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>An epidural varix of the lumbar spine is an acquired pathological entity that results from dilation of the internal vertebral venous plexus. The dilated veins in the epidural spaces or in the intervertebral foramen cause irritation or compression of the thecal sac and nerve roots, and this in turn causes lumbar radiculopathy. The lesions develop as an independent process or are accompanied by degenerative changes of the lumbar spine. Resection of varicose veins can be complicated when significant venous bleeding occurs. The purpose of the present study was to develop diagnostic criteria for lumbar epidural varices and methods of surgical treatment and to analyze the results of treatment.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>There were 43 surgically treated patients in whom lumbar radiculopathy was caused by epidural varices. The mean duration of symptoms was 11 months (range 5–49 months) and the mean age of the patients was 41 years (range 26–68 years). Segmentary varices were found in 14 patients, local varices in 21, and extensive varices in eight. Patients underwent preoperative magnetic resonance imaging and vertebral venography.</jats:p> <jats:p>Of 43 cases, the varicose veins were completely occluded in all 14 patients with segmentary varices of the segmentary-type lesion. Of 21 patients with local varices, total occlusion was obtained in 17 patients and partial occlusion in four. In the patients with extensive varices, total occlusion was not performed; instead, partial occlusion was undertaken.</jats:p> <jats:p>Resolution of lumbar radicular syndromes was observed, to some extent, in all patients. Radicular pain regressed in 12 of 14 patients with segmentary varices, in 18 of 19 patients with local varices, and in three of four patients with extensive varices. Nerve root–related sensory disturbances regressed in six of 10 patients with segmentary varices, in 11 of 15 patients with local varices, and in one patient with extensive varices. Motor deficits regressed in three of eight patients with segmentary varices, in three of six patients with local varices, and in none among those with extensive varices.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Epidural varicosity is a specific form of spinal disease. Its diagnostic clarification and surgical treatment are difficult and have only recently been developed. Precise diagnosis and a well-planned surgery allow for a positive outcome.</jats:p></jats:sec>

Epidural varicosis as a possible cause of radicular pain: a case report

“…With respect to the nature of the surgery, different approaches exist. Reports on surgical thermocoagulation of the venous plexus [2,9-12], interventional techniques [13] or surgical compression of the venous plexus with a resorbable gelatin sponge [14] have been reported. In most cases, this leads to a good surgical result with significant reduction of the symptoms [9].…”

Radiculopathy Caused by Lumbar Epidural Venous Varix -Case Report-

“…11) Venography after injection of contrast medium into the spinal process was used to diagnose epidural varices in patients with radiculopathy if MR imaging failed to disclose lumbar disk herniation or lumbar canal stenosis. 17) In our patient, MR imaging showed that the intervertebral disk had not degenerated and that the lesion was not continuous with the intervertebral disk. The lesion appeared as hyperintense on T 2 -weighted imaging with rim enhancement by Gd-DTPA.…”

“…Otherwise, 3 types have been proposed: type 1, segmentary varices caused by dilation of the intervertebral veins generally resulting in irritation of the nerve roots that pass through the intervertebral foramina together with these veins; type 2, local varices caused by limited dilation of the anterior and, less often, posterior longitudinal veins, or the intervertebral veins at one or two levels, resulting in irritation or compression of the thecal sac at the site of the origin of nerve root sleeve or nerve roots; and type 3, extensive varices associated with widespread epidural venous enlargement of the anterior, and less often, posterior longitudinal veins (Slin'ko et al 17) ). Our case corresponded most closely to the type 1 proposed by Zimmerman et al 19) and the type 2 of Slin'ko et al 17) Using the classification proposed by Hanley et al, 11) the hyperintense appearance suggested that the varix in our case was type 2, whereas the Gd-DTPA-enhanced rim suggested type 1 or 3. Intraoperatively we found no trace of hematoma or intravariceal thrombus, indicating a type 2 varix.…”

“…17) Based on MR imaging findings, epidural varices can be divided into type 1, thrombosed dilated epidural vein; type 2, epidural vein dilation due to activity; and type 3, submembranous, epidurallycontained hematoma (Hanley et al 11) ); or type 1 consisting of a single dilated varix, and type 2 of a localized collection of varices with multiple distended venous channels resulting in nerve root compression (Zimmerman et al 19) ). Otherwise, 3 types have been proposed: type 1, segmentary varices caused by dilation of the intervertebral veins generally resulting in irritation of the nerve roots that pass through the intervertebral foramina together with these veins; type 2, local varices caused by limited dilation of the anterior and, less often, posterior longitudinal veins, or the intervertebral veins at one or two levels, resulting in irritation or compression of the thecal sac at the site of the origin of nerve root sleeve or nerve roots; and type 3, extensive varices associated with widespread epidural venous enlargement of the anterior, and less often, posterior longitudinal veins (Slin'ko et al 17) ). Our case corresponded most closely to the type 1 proposed by Zimmerman et al 19) and the type 2 of Slin'ko et al 17) Using the classification proposed by Hanley et al, 11) the hyperintense appearance suggested that the varix in our case was type 2, whereas the Gd-DTPA-enhanced rim suggested type 1 or 3.…”

“…In the 1960s, 4.4% of lesions preoperatively diagnosed as lumbar disk hernia were believed to be vascular abnormalities. 9) However, computed tomography (CT) and magnetic resonance (MR) imaging have reduced the incidence of confirmed epidural varices to 0.067-1.2%, 15,17,19) although a rate of approximately 5% has been reported. 10) Only 1 of 823 patients (0.12%) subjected to lumbar surgery at our institute between 1994 and 2006 was confirmed to have lumbar epidural varix.…”