Gastric balloon: A rare cause of lumbar radiculopathy.

BACKGROUND: Factors that are known to cause lumbar epidural venous plexus (EVP) engorgement include inferior vena cava (IVC) obstruction, portal hypertension, vascular agenesis, morbid obesity, and/or hypercoagulable states. Here, we present a 32-year-old female admitted with the new onset of lumbar radiculopathy attributed to a gastric balloon causing compression of the IVC and engorgement of the EVP. CASE DESCRIPTION: A 32-year-old female was admitted with a left L5 radiculopathy. She had a history of morbid obesity and had undergone intragastric balloon insertion 4 months ago. The abdominal/pelvic CT documented an intragastric balloon producing a voluminous gastric mass with resultant compression of the IVC. The lumbar MRI showed the resultant marked multilevel engorgement of the lumbar EVP. Here, following balloon removal, the patient was immediately symptom free and remained asymptomatic over the next postoperative year.
CONCLUSION: An intragastric balloon can produce a voluminous gastric mass that can result in IVC occlusion and engorgement of the EVP, leading to lumbar radiculopathy. Removal of the balloon results in immediate and permanent resolution of the compressive symptoms. Copyright:

INTRODUCTION

There are multiple causes of engorgement of the lumbar epidural venous plexus (EVP); including inferior vena cava (IVC) obstruction; portal hypertension, vascular agenesis, morbid obesity, pregnancy, intra-abdominal mass, Budd-Chiari syndrome, or hypercoagulable states.[1,6]

Gastric balloons should now be added to the list, as they too can lead to marked gastric distention with resultant IVC compression and massive lumbar EVP engorgement resulting in radiculopathy.

CASE DESCRIPTION

A 32-year-old female with morbid obesity had undergone an intragastric balloon insertion 4 months ago. She is now presented with the left L5 distribution leg pain and dysesthesias/ paresthesias of 3 months’ duration, exacerbated in the supine position. On examination, she had 4/5 weakness involving the left L5/S1 distributions (i.e. extensor hallucis longus/dorsiflexors and plantar flexors).

Diagnostic study

The abdominal CT scan and lumbar MRI showed a voluminous gastric mass attributed to the gastric balloon that compressed the IVC [Figures 1-3]. This resulted in massive engorgement of the lumbar EVP (i.e. Batson’s plexus with intracanalicular/foraminal extension).

Figure 1:

Axial CT scan shows large intra-abdominal mass corresponding to a gastric balloon compressing the inferior vena cava.

Figure 3:

T2-weighted axial MRI (a-d) shows enlarged lumbar epidural plexus (white arrows) compressing the nerves roots through the foramina.

T2-weighted sagittal MRI (a and b) shows enlarged lumbar epidural plexus (white arrows).

Following urgent removal of the balloon, the patient was asymptomatic and remained symptoms free 1 year later.

DISCUSSION

Anatomy of Batson’s plexus

A gastric balloon resulting in marked gastric distention can produce IVC obstruction that can trigger engorgement of the EVP, causing root compression and radiculopathy. This is largely attributed to the fact that Batson’s EVP is a valveless network connected to the IVC, pelvic veins, and azygos system through multiple intersegmental branches traversing the intervertebral foramina adjacent to the spinal nerve roots.[2,6]

Engorgement of the IVC results in Sciatica

IVC compression (caused by hypercoagulable states, vascular thrombosis, obesity, vascular agenesis, malignant intra-abdominal mass, or pregnancy) or thrombosed epidural varices can compress spinal nerve roots resulting in radiculopathy [Table 1].[1-9] However, only rarely does IVC obstruction result in engorgement of the EVP leading to symptoms/signs mimicking a lumbar disc herniation and/or spinal stenosis. In Paksoy and Gormus out of 9640 patients, the MRI showed that only 13 (0.13%) patients had epidural engorged veins due to IVC obstruction or occlusion leading to sciatica/radiculopathy.[6,8]

Table 1:

Cases that exemplify different causes of engorgement of the EVP.

Here, we reported a clear case of IVC obstruction leading to significant engorgement of the lumbar EVP resulting in neurological radiculopathy.

CONCLUSION

Here, we have described a unique iatrogenic complication of gastric balloon placement resulting in compression of the IVC and engorgement of the lumbar EVP responsible for lumbar radiculopathy.