Clinical Features and Surgical Treatment of Spinal Dural Arteriovenous Fistulas

DOI 1 Citations 41 References
  • Okuda Teruaki
    Department of Orthopedic Surgery, Hiroshima Mitsubishi Hospital
  • Fujimoto Yoshinori
    Department of Orthopaedic Surgery, Hiroshima University, Faculty of Medicine
  • Oka Shinichi
    Department of Orthopaedic Surgery, Hiroshima University, Faculty of Medicine
  • Ikuta Yoshikazu
    Department of Orthopaedic Surgery, Hiroshima University, Faculty of Medicine
  • Nishikawa Koichiro
    Department of Orthopedic Surgery, Hiroshima City Hospital

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  • 脊髄硬膜動静脈瘻の診断と治療

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Abstract

Objective : Spinal dural arteriovenous fistula (D-AVF) are rare, and mainly occurs in the thoracolumbar junction. Due to slow progress of symptoms, versatile symptoms of dysesthesia, weakness, and muscle atrophy in the lower limbs, accurate diagnosis is often delayed in many cases. In the current study, the diagnosis and treatment methods for spinal D-AVF were analyzed in terms of characteristic preoperative symptoms, the correlation between sensory disturbances and magnetic resonance imaging (MRI), and the factors that infuluenced the postoperative results.<br>Materials and Methods : Of the 10 spinal D-AVFs, those with the lesion in the cervical or upper thoracic levels were excluded, and the remaining seven patients, five men and two women, were included in the current study. The mean age of these patients at the time of operation was 64 years old. The duration of symptoms was from 6 months to 5 years (mean 3 years), and the mean postoperative period was 2 years and 6 months. Before operation, MRI were used to show the intramedullary high intensity zone (HIZ), and selective spinal angiography (SSA) was carried out to detect a feeder of spinal D-AVF. T2-weighted MRI indicated high signal intensity from the midthoracic area to the conus of the spinal cord. SSA and the intraoperative findings indicated D-AVF were fed by the T7 intercostal artery to the L2 lumbar artery.<br>Operative Procedure : A posterior approach was used in the operation to identify the location of the D-AVF. The intradural portion of the fistula was clipped for 15 minutes under spinal cord monitoring using evoked spinal cord potentials. When clipped, arterial pulsative sounds of dorsal coronary vein disappeared under Doppler examination. After the integrity of spinal cord function was confirmed by the unchanged potentials, the D-AVF was coagulated and excised.<br>Results and Conclusions : The Japanese Orthopaedic Association (JOA) score improved from 4.8 preoperatively to 6.5 postoperatively with an improvement rate of 31%. Paroxismal weakness and aggravation of the symptoms in the lower extremities after bathing or drinking are preoperative characteristic symptoms that were useful for the diagnosis. The region showing intramedullary HIZ extended proximal to the sensory disturbance level, which was considered to have made the differentiation of this disease from other thoracolumbar diseases difficult. HIZ disappeared in 6 cases after operation, suggest that spinal cord edema was the underlying pathology of the HIZ in these cases. Pre-operative severity of symptoms influenced the post-operative result. The postoperative result seems to be also influenced by the level of the lesion, duration of gait disturbance, and type of palsy.

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