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Engorgement of the cervical spinal epidural venous plexus simulating a spinal epidural mass.

A 63-yr-old white man with a known history of stage IV diffuse large B-cell lymphoma who was being treated with chemotherapy presented with complaints of intractable neck pain radiating to both shoulders. Valsalva maneuvers, such as coughing or nose blowing, increased the discomfort. The findings from a neuromusculoskeletal examination were essentially normal, except for limited cervical spinal mobility caused by pain. No evidence of myelopathy was noted on repetitive clinical examination. Decadron was initially prescribed, and a magnetic resonance imaging (MRI) with contrast of the cervical spine was obtained. The imaging study in a prone position demonstrated engorgement of the epidural venous plexus (EVP) from C1 to C5 (Figs. 1 and 2), which subsequently collapsed, disappearing in the upright position (Fig. 3). There was no evidence of a malignancyrelated enhancement of either the vertebrae or the spinal cord. The findings from an MRI of the brain were also normal. Cervical radicular pain in association with EVP is a relatively rare clinical phenomenon, as is the presence of accompanying myelopathic signs. The cervical spine EVP is a portion of a venous network of vessels forming a continuum from the pelvic plexus of veins caudally to the venous sagittal sinus of the cephalic brain. Valveless and at relatively low pressure, the EVP distends and collapses in response to changing pressures within the venous caval system with which it directly communicates at multiple levels. Its intersegmental pedicular branches within the rigid confines of the intervertebral spinal canals lie adjacent to the spinal roots. Volume distention in response to episodic pressure pulses emanating from the more proximal branches of the EVP can potentially compromise the adjoining spinal roots. In a similar scenario, low back and sciatic pain radiation in association with cardiopulmonary dysfunction and lumbar spinal stenosis have previously been attributed to cyclic distention of the lumbar EVP. Twentyfive percent of the EVP may be recognized by a nonenhanced MRI, with enhancement improving visualization by 85%. As demonstrated in this report, postural changes, that is,