Intradural lumbar varix resembling a tumor: Case report of a magnetic resonance imaging-based diagnosis

Study Design.: Review the presentation and diagnosis of a lumbar intradural varix. Objective.: To report an innovative magnetic resonance imaging (MRI) technique that enabled radiographic diagnosis in a rare case of symptomatic lumbar intradural varix. Sumary of Background Data.: Lumbar variceal veins rarely occur intradurally, and may radiographically mimic nerve-sheath tumors. These lesions are typically diagnosed at surgery performed due to suspicion of tumor. METHODS.: A 55-year-old man presented with radicular lower back pain and normal neurologic examination. MRI revealed an ellipsoid intradural enhancing mass at the L2 level. The patient refused to undergo the surgical procedure that was recommended. Over 2-year follow-up, symptoms resolved together with weight reduction. Repeat MRI revealed an unchanged lumbar lesion in addition to engorged epidural and intradural veins, thought to be related to outflow obstruction secondary to past right nephrectomy and obliterated inferior vena cava. Breath-holding and Valsalva maneuvers during MRI caused a change in the shape of the intradural lesion. RESULTS.: The patient's refusal to undergo surgery led to noninvasive assessment of his lumbar spinal pathology. Diagnosis of nonthrombosed intradural varix was established on MRI-based detection of a change in the shape of the lesion following breath-hold and Valsalva maneuvers. Conclusion.: We diagnosed a nonthrombosed intradural varix by demonstrating a change in the lesions shape on MRI, following breath-hold and Valsalva maneuvers. This is the first report of nonpathologic, purely radiologic diagnosis of such a lesion. This is a relatively simple, noninvasive method of evaluating these patients.