Post-surgical functional outcomes in patients exhibiting different topographical variants of Lumber epidural varicose veins: a retrospective analysis

Abstract

Background:

Lumbar epidural varicose veins (LEVVs) are an uncommon yet clinically significant cause of lumbar radiculopathy, with an incidence between 0.067% and 1.2%. These venous dilations within the epidural space can compress neural structures, leading to pain and functional impairment. This study aimed to evaluate postoperative functional outcomes in patients with distinct topographical variants of LEVV – diffuse (DVV), local (LVV), and segmental (SVV) – across two time intervals to assess the evolution of clinical management and recovery trends.

Methodology:

A retrospective analysis was conducted using data from two distinct cohorts: Data Set A (1999–2005, n = 100) and Data Set B (2006–2020, n = 150). All patients had surgically confirmed LEVV and documented preoperative and 6-month postoperative functional assessments. Functional outcomes were measured using the Oswestry Disability Index. Descriptive statistics and inferential analyses (chi-square and paired t-tests) were performed using SPSS version 27, with statistical significance set at P < 0.05.

Results:

Functional outcomes differed significantly between the two time periods. In Data Set A, the mean disability score was 18%, with no significant association between varicose vein type (VVT) and functionality (P = 0.979). In contrast, Data Set B demonstrated a higher mean disability score of 41% and a significant association between VVT and functional status (P = 0.014). Activities most affected by vein type included sitting, sleeping, and sexual life preoperatively, as well as standing and sexual life postoperatively.

Conclusion:

Diffuse varicose veins were consistently associated with greater postoperative disability compared to local and segmental variants, emphasizing the prognostic relevance of anatomical classification in surgical outcomes. The findings underscore the need for tailored surgical strategies and standardized long-term follow-up to optimize functional recovery in LEVV patients. Further multicentric prospective studies are warranted to validate these observations and refine management protocols.

Introduction

Lumbar epidural varicose veins (LEVV) represent an uncommon but clinically significant cause of lumbar radiculopathy and back pain, with reported incidences ranging from 0.067% to 1.2% in spinal surgery patients^[1^]. These varices arise from pathological dilation of the internal vertebral venous plexus within the epidural space, often accompanied by secondary expansion of communicating veins that connect the external vertebral venous plexus and intervertebral channels^[2^]. When venous drainage becomes impaired due to factors such as inferior vena cava obstruction, venous valve incompetence, or elevated intra-abdominal pressure, blood stasis leads to venous engorgement and compression of adjacent neural structures^[3^]. Recent magnetic resonance imaging (MRI)-based studies have refined the understanding of the anatomical distribution of LEVV and its relationship to degenerative lumbar pathology, demonstrating improved diagnostic recognition with high-resolution imaging modalities^[4,5^].

HIGHLIGHTS

• We aim to analyze the classified effects of Lumber epidural varices on the post-operative functional status of the patient during two-time intervals.

• Classified effects of varices on post-operative functional status were significant for DSB, manifesting higher disabilities, particularly in patients with diffused varix pathology.

• The findings substantiate the role of varix type on the functionality status of patients, serving as a crucial factor in assessing and improving the clinical condition of patients.

Unlike congenital venous malformations, epidural varices involve the dilation of pre-existing normal veins rather than the formation of aberrant vascular networks. Clinically, this can produce nerve root irritation or compression, manifesting as low back pain, sensory loss, or radiculopathy^[4^]. Although systemic risk factors such as obesity, pregnancy, thrombosis, or pelvic masses may predispose individuals to venous congestion, LEVV are distinct from peripheral varicose veins of the lower limbs and must be interpreted within the context of spinal venous anatomy^[5^].

The epidural venous plexus is a complex, valveless network of longitudinal and transverse channels that provides collateral drainage between the spinal cord and the inferior vena cava. Because of its bidirectional flow, this plexus is highly susceptible to pressure changes in the thoracoabdominal cavity. Consequently, even mild obstruction or venous hypertension can cause dilation of the epidural veins, leading to mechanical compression of the dural sac or nerve roots^[6,7^].

Based on topographical distribution, LEVV can be classified into segmental (SVV), local (LVV), and diffuse (DVV) types^[8^]. Segmental varices typically involve intervertebral veins, causing localized root compression, while local varices are confined to short segments of the ventral or dorsal longitudinal trunks. Diffuse varices, in contrast, affect multiple epidural levels and often reflect elevated vena cava or iliac venous pressures. Surgical management, therefore, requires precise intraoperative assessment, with preservation of ventral longitudinal trunks to maintain collateral venous return^[9,10^].

Despite increasing recognition of LEVV as a surgically relevant pathology, comparative data on postoperative functional outcomes among different anatomical subtypes remain limited^[5,11,12^]. Most available studies focus on case descriptions or surgical techniques without examining how specific topographical variants influence recovery. More recent literature has emphasized that early identification of segmental and diffuse venous variants using MRI and intraoperative evaluation is essential to minimize bleeding and neurological deficits^[13,14^].

The present retrospective study aims to evaluate and compare postoperative functional outcomes among patients with segmental, local, and diffuse LEVV. Two distinct time intervals (1999–2005 and 2006–2020) were analyzed to explore whether advances in imaging, microsurgical techniques, and perioperative care have improved functional recovery. By delineating the relationship between varix topography and postoperative outcomes, this study seeks to provide an evidence-based framework for individualized surgical decision-making in patients with lumbar epidural varices.

Methodology

Study setting and sample size

This retrospective study was conducted at a single tertiary neurosurgical center, ensuring consistency in diagnostic and surgical protocols across all cases. Data were retrieved from the institutional spinal surgery database for two distinct time periods: Dataset A (1999–2005) and Dataset B (2006–2020).

The required sample size was calculated using the standard normal distribution formula at a 95% confidence level (Z = 1.96) and a 5% margin of error (d = 0.05), yielding a statistically adequate number of cases to ensure the validity and reliability of the findings.

Patient selection and inclusion criteria

Patients were eligible if they had a surgically confirmed diagnosis of LEVVs, documented through intraoperative findings and preoperative imaging. Diagnostic confirmation relied on a combination of MRI and, for earlier cases, computed tomography myelography or venospondylography, depending on availability during the study period. MRI criteria included the visualization of serpiginous flow voids in the epidural space and the absence of disc or bony compression explaining symptoms.

Inclusion criteria required:

• Age ≥18 years,

• Complete documentation of preoperative and 6-month postoperative functional assessment (Oswestry Disability Index, ODI), and

• Operative confirmation of LEVV topography (segmental, local, or diffuse).

Exclusion criteria included:

• Prior lumbar surgery.

• Incomplete records or missing follow-up data, and

• Absence of intraoperative confirmation of epidural varices.

Surgical technique

All patients underwent microsurgical decompression and selective coagulation or excision of dilated epidural veins under general anesthesia. The approach involved midline laminectomy or hemilaminectomy with microscopic visualization of the affected venous plexus.

In segmental varices, the intervertebral veins at the symptomatic level were coagulated and transected.

• For local varices, limited excision of the ventral or dorsal longitudinal venous trunk was performed, while preserving collateral channels.

• In diffuse varices, only symptomatic segments were coagulated to maintain ventral longitudinal venous drainage and prevent postoperative venous congestion.

• No endovenous laser therapy or sclerotherapy was used; these techniques are not applicable to epidural venous plexuses.

Study instruments

Demographic data included patient age and sex. Functional status was evaluated using the ODI, which assesses 10 domains: pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, traveling, and sexual activity. Each item is scored from 0 to 5, yielding a total score between 0 and 50. Scores were converted into disability categories:

• 0–4 = No disability,

• 5–14 = Mild,

• 15–24 = Moderate,

• 25–34 = Severe, and

• 35–50 = Completely disabled.

Statistical analysis

Data analysis was performed using IBM SPSS Statistics version 27. Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables as frequencies and percentages. Data normality was assessed using the Shapiro–Wilk test.

• Paired t-tests (for normally distributed variables) or Wilcoxon signed-rank tests (for non-normal data) were used to compare pre- and postoperative ODI scores within each cohort.

• One-way Analysis of Variance (or Kruskal–Wallis test, where appropriate) compared outcomes among the three LEVV types (segmental, local, diffuse).

• Chi-square or Fisher’s exact tests were used to evaluate associations between categorical variables.

All statistical tests were two-tailed, with significance set at P < 0.05. Results were displayed in tables and figures, with 95% confidence intervals (CIs) where relevant.

Results

Dataset A (1999–2005)

A total of 100 patients were included in Dataset A. The majority were aged 36–55 years (60%), followed by 56–75 years (23%) and 16–35 years (17%) (Table 1). This distribution reflects a higher occurrence of lumbar epidural varices among middle-aged adults. Based on intraoperative classification, SVVs were the most frequent (65%), followed by LVV (27%) and DVV (8%) (Fig. 1).

Table 1.

Demographic features of Cohort.

Demographic categories	DSA (1999-2005) n (%)	DSB (2006-2020) n (%)
Age
a. 16-35	17 (17)	20 (13.3)
b. 36-55	60 (60)	81 (54)
c. 56-75	23 (23)	49 (32.7)
VVT
a. LVV	27 (27)	38 (25.3)
b. SVV	65 (65)	99 (66)
c. DVV	8 (8)	13 (8.6)

DSA: Data set A; DSB: Data set B; VVT, Varicose vein type; LVV, Local varicose vein; SVV, Segmental varicose vein; DVV, Diffused varicose vein

Figure 1.

Comparative Analysis of Varicose Vein Type Classification Between Data Set A (1999–2005) and Data Set B (2006–2020).

The mean preoperative ODI was 48.3 ± 0.34, which improved significantly to 17.2 ± 1.03 at 6 months post-surgery (P < 0.001) (Table 2, Fig. 2). Improvement was observed across all varix types, and no significant association was found between varix topography and postoperative ODI (P = 0.979). This indicates that, in the earlier period, surgical decompression provided comparable functional recovery regardless of anatomical subtype.

Table 2.

Pre-and post-operative functionality status in DSA and DSB.

	Functionality status	Mean ± SD	P-value
DSA	Before surgery	48.27 ± 0.338	<0.001
	After surgery	17.15 ± 1.03
DSB	Before surgery	41.0 ± 0.608	<0.001
	After surgery	31.5 ± 0.922

Figure 2.

Mean Disability Scores Associated with Varicose Vein Types in Data Set A (1999–2005) and Data Set B (2006–2020).

Dataset B (2006–2020)

Dataset B included 150 patients, offering a larger and more demographically diverse sample. The majority were aged 36–55 years (54%), followed by 56–75 years (33%) and 16–35 years (13%) (Table 1). As in Dataset A, segmental varices remained predominant (66%), followed by local (25%) and diffuse (9%) types (Fig. 1). The mean preoperative ODI was 41.0 ± 0.61, which improved to 31.5 ± 0.92 postoperatively (P < 0.001), reflecting significant functional recovery (Table 2).

Unlike Dataset A, a significant association between varix type and functional outcomes was identified (P = 0.014). Patients with diffuse varices exhibited higher postoperative disability compared to local and segmental types.

Domain-level analysis (Supplemental Digital Content Table S1, available at: http://links.lww.com/IJSOPEN/A72) revealed that, before surgery, varix type significantly affected sitting (P = 0.006), sleep (P < 0.001), social life (P = 0.035), travel (P = 0.012), and sexual activity (P = 0.02). Postoperatively, significant differences persisted in standing (P = 0.025) and sexual life (P = 0.02), indicating that diffuse varices tend to produce broader and more persistent functional limitations (Fig. 3).

Figure 3.

Graphical representation of Pre-and post-operative functionality status in DSA and DSB.

Comparative functional outcomes between datasets

Comparison between both cohorts demonstrates that surgical intervention consistently improved functional status across the two decades (Fig. 4). However, the patterns of recovery differed.

Figure 4.

Functional association with VVT from DSA.

In Dataset A, functional improvement was uniform across varix types, suggesting that the early microsurgical approaches were effective for all subtypes. In Dataset B, the significant relationship between varix type and outcome indicates that anatomical complexity and disease severity began to influence postoperative recovery.

These findings may reflect advancements in imaging, better detection of diffuse venous involvement, and evolving surgical precision over time. The higher mean disability in Dataset B suggests that more complex or advanced cases are now being operated on, highlighting the need for individualized surgical planning and rehabilitation strategies (Fig. 5).

Figure 5.

Functional association with VVT from DSB.

Detailed item-wise ODI domain results are provided in Supplemental Digital Content Table S1, available at: http://links.lww.com/IJSOPEN/A72; Supplemental Digital Content Table S2, available at: http://links.lww.com/IJSOPEN/A73.

Discussion

The present study evaluated and compared postoperative functional outcomes in patients with LEVVs across two decades, providing a temporal and anatomical perspective on how venous topography influences recovery. The findings demonstrate a clear evolution in patient outcomes, with Dataset B (2006–2020) showing a substantially higher mean disability score (41%) than Dataset A (1999–2005) (18%). This trend suggests that, in recent years, patients undergoing surgery for LEVV presented with more advanced or diffuse venous pathology, possibly reflecting enhanced diagnostic precision, shifting case selection, and evolving surgical practices. This aligns with contemporary reports showing that more severe venous pathology is increasingly recognized in complex spinal cases^[15–18^].

Evolution in functional outcomes

In both datasets, significant improvement in postoperative functionality was observed (P < 0.001), confirming that surgical decompression effectively restores functional capacity. However, only Dataset B demonstrated a significant association between varicose vein type (VVT) and postoperative function (P = 0.014). This finding highlights a contemporary trend in which anatomical complexity – particularly DVV – has become a critical determinant of recovery. Patients with DVV exhibited greater residual disability compared to those with SVVor LVV varices, echoing previous studies that linked diffuse venous congestion with persistent radiculopathy and poorer functional restoration^[19–22^]. The higher disability scores in Dataset B likely reflect both increased disease complexity and changing surgical profiles, as diffuse venous networks are often associated with elevated epidural pressure, chronic nerve compression, and extensive collateralization. These factors make complete decompression surgically challenging, explaining why functional improvement, although significant, was comparatively lower in the later cohort. These findings support the growing consensus that individualized surgical planning based on venous topography can improve outcomes^[14,23,24^].

Anatomical and pathophysiological correlates

Our results emphasize the need to recognize the distinct hemodynamic and anatomical behavior of epidural varices. In diffuse forms, venous dilation typically extends beyond a single segment and may involve bilateral epidural spaces or paravertebral veins, contributing to chronic congestion and higher venous reflux pressures^[25–28^]. These changes are consistent with our earlier observations, where DVV patients exhibited markedly higher rates of radicular pain (92%) than LVV (73%) or SVV (35%) cohorts. The resultant venous hypertension and myopathic changes likely explain the greater postoperative disability seen in DVV^[29,30^].

Similar to Wong et al., our findings suggest that conventional decompressive surgery alone may be insufficient for diffuse venous variants, as residual venous engorgement often persists postoperatively^[31^]. The limited radicality of surgical correction and the presence of caval hypertension may further reduce functional recovery, reinforcing the need for more targeted venous decompression or hybrid microsurgical approaches in such cases.

Clinical implications

The emerging correlation between VVT and functional outcome underscores the importance of individualized surgical planning based on anatomical subtype. Comprehensive preoperative imaging, such as MR venography or contrast-enhanced MRI, can delineate venous architecture more precisely, allowing surgeons to anticipate potential complications and tailor their approach accordingly.

Moreover, advances in surgical visualization and hemostatic control should be matched with personalized postoperative rehabilitation, particularly for patients with diffuse lesions who remain at risk for chronic pain, sleep disturbances, and sexual dysfunction. Integrating these anatomical insights into clinical decision-making may enhance long-term recovery and quality of life. Long-term follow-up studies also demonstrate that residual venous congestion may contribute to persistent disability, underscoring the need for standardized postoperative monitoring^[27^].

Limitations

This study has certain limitations inherent to its retrospective design, including potential bias in patient selection and incomplete standardization of postoperative assessments between eras. The reliance on historical data may have introduced variability in surgical techniques, anesthesia methods, and follow-up duration. Additionally, the absence of long-term follow-up data limits the interpretation of chronic outcomes such as recurrence or delayed disability. These limitations emphasize the need for prospective, multicenter studies to validate these findings and establish standardized protocols for LEVV management.

Conclusion

This retrospective two-decade analysis provides novel evidence that the anatomical subtype of LEVVs significantly influences postoperative functional recovery. While surgical techniques have evolved and consistently improved functionality overall, patients with diffuse varices exhibited higher postoperative disability, indicating that venous architecture plays a decisive role in the outcome. The observed rise in mean disability from 18% (1999–2005) to 41% (2006–2020) suggests a shift toward treating more complex or advanced cases.

These findings advocate for comprehensive preoperative assessment, anatomically guided surgical strategies, and tailored rehabilitation protocols to optimize outcomes. Future prospective research should focus on the long-term functional trajectory of LEVV subtypes and evaluate novel techniques aimed at addressing diffuse venous congestion, thereby refining clinical guidelines and improving patients' quality of life.

Ethical approval

Ethical approval was obtained from the Institutional Review Board (IRB Approval No. [N661]), and all procedures complied with the Declaration of Helsinki. Informed consent for inclusion and data use was obtained from all participants or their legal guardians. All data were anonymized prior to analysis to maintain confidentiality. The research complied with national and international ethical standards for retrospective studies involving human participants.

Consent

Informed written consent was taken from patient prior to initiation of this project.

Sources of funding

None.

Author contributions

All authors have equal contributions.

Conflict of interest disclosure

None.

Research registration unique identifying number (UIN)

None.

Guarantor

Bipin Chaurasia.

Provenance and peer review

None.