Lumbar spinal epidural arteriovenous fistula with perimedullary venous drainage after endoscopic lumbar surgery

Abstract

Spinal epidural arteriovenous fistulas (AVFs) with perimedullary venous drainage are rare. This report describes a case of lumbar epidural AVF in a patient with a history of endoscopic lumbar discectomy at the same level 8 years prior to presenting with progressive myelopathy secondary to retrograde venous reflux into the perimedullary vein. A 69-year-old man presented with progressive lower extremity weakness and sensory disturbance and loss of sphincter control 8 years after endoscopic lumbar discectomy for a disc herniation at L4-5 level. Magnetic resonance imaging showed spinal cord edema and dilated intradural perimedullary vessels. Spinal angiography revealed an epidural AVF at the site of the previous endoscopic lumbar surgery with intradural perimedullary venous drainage. The fistula was successfully occluded via endovascular transarterial embolization, and the patient had stabilization of his neurological deficits. Lumbar spinal epidural AVFs, especially those associated with iatrogenic trauma, are rare. Endoscopic surgical procedure can occlude the epidural venous plexus and disturb venous drainage, thereby inducing local venous hypertension and leading to epidural AVF with perimedullary venous drainage. This type of pathology should be considered within the differential diagnosis of delayed neurological deterioration after spinal surgery.

Keywords: Endoscopic lumbar surgery; epidural arteriovenous fistula; perimedullary venous drainage; transarterial embolization.

Figure 1.

Images from the patient upon admission. Sagittal T2-weighted MR image at the lumbar (a) and the lower thoracic (b) spine shows hyperintensity within the cord (arrowhead) and shows the presence of multiple flow voids on the surface of the cord (arrows). Sagittal (c) and axial (d) enhanced-CT shows a venous pouch in the posterior L4 vertebral body and shows dilated vessels (arrowhead). The AVF draining to the perimedullary vein (white arrow) at the L1 level through intradural vein (black arrow) (c).

Figure 2.

Selective angiography of the dorsal somatic branch (black arrows) of the right (a) and left (b) radicular artery at the level of L4 shows epidural AVFs with an epidural venous pouch (arrowhead) draining through the intradural vein into the perimedullary vein (white arrows). Transarterial embolization with NBCA was performed via the dorsal somatic branch of the right radicular artery (black arrow) (c). Complete obliteration of the fistula is seen after embolization (d).

Figure 3.

Sagittal (a) and axial (b) CT after embolization shows glue cast in the ventral epidural pouch (arrowhead). Sagittal T2-weighted MR image showing disappearance of the spinal cord swelling and showing multiple flow voids on the spinal cord (c).