Diagnostic, clinical management, and outcomes in patients with spinal dural arteriovenous fistula

Abstract

Background: Spinal dural arteriovenous fistulas (SDAVFs) are rare spinal vascular malformations, but account for 70 to 80% of all spinal arteriovenous malformations. SDAVFs can be treated either surgically or endovascularly, with surgical treatment appearing to lead to higher closure rates. Our aim was to analyze the demographic data, diagnostic history, treatment characteristics and clinical short- and long-term outcomes.

Methods: The medical records of 81 patients who underwent surgical (n = 70, 86.4%) and endovascular (n = 11, 13.6%) treatment for SDAVF at a university hospital between 2002 and 2023 were retrospectively analyzed.

Results: SDAVF was observed more frequently in men than women (61, 75.3% vs. 20, 24.7%) with a mean age of 63.5 ± 12.7 years and a mean duration of symptoms to diagnosis of 12.0 ± 12.8 months. The most common first symptom was gait disturbance (36, 44.4%), followed by sensory disturbance (24, 29.6%). The location of the fistula point was most common in the lower thoracic region (36, 44.5%), followed by the lumbar region (23, 28.4%). Incomplete or failed occlusion of the fistula occurred in 8 patients (9.9%), with 6 patients (7.4%) undergoing further treatment either surgically or endovascularly. Treatment- or hospital-related complications were observed in 16 patients (19.8%). A single-level laminectomy was the most common approach (31, 44.3%), followed by single-level hemilaminectomy (28, 40.0%), and unilateral interlaminar fenestration (11, 15.7%). Back pain or radiculopathy was observed in 58% of patients (47/81) pre-treatment and had already decreased to 24.7% at hospital discharge (p < 0.001). No significant differences were observed in sensory disturbances (p = 0.681). The median of American Spinal Injury Association motor score (ASIA-MS) was 94 [82.5-100] at admission, 98 [86.5-100] at hospital discharge, 100 [90-100] at the first, second, and third follow-up (p = 0.019). The median modified Aminoff-Logue scale (mALS) was 5 [2-7] at admission, 3 [1-6] at hospital discharge, 2 [1-5] at the first follow-up, 2 [0.5-5] at the second follow-up and 2 [1-7] at the third follow-up (p = 0.006).

Conclusions: SDAVF occurs predominantly in men in the 6th decade of life and can be safely and effectively treated surgically and endovascularly, improving symptoms such as pain and motor deficits, gait disturbances as well as bowel and bladder dysfunction, but not sensory disturbances.

Keywords: SDAVF; spinal angiography; spinal arteriovenous malformation; spinal cord edema; spinal dural fistula; surgical treatment.

Figure 1

Flow charts. This figure shows our flow charts for diagnosis of spinal dural arteriovenous fistula (SDAVF). MRI, magnetic resonance imaging; MRA, magnetic resonance angiography; DSA, digital subtraction angiography.

Figure 2

First symptom occurring in SDAVF. This figure shows first symptom occurring in patients with spinal dural arteriovenous fistula (SDAVF).

Figure 3

Short and long-term outcomes of pain in patients with SDAVF. This figure shows short- and long-term outcomes of pain in patients with spinal dural arteriovenous fistula (SDAVF).

Figure 4

Short- and long-term outcomes of sensory disturbances in patients with SDAVF. This figure shows short- and long-term outcomes of sensory disturbances in patients with spinal dural arteriovenous fistula (SDAVF).

Figure 5

Short- and long-term outcomes of American spinal injury association motor score (ASIA-MS) in patients with SDAVF. This figure shows short- and long-term outcomes of ASIA-MS in patients with spinal dural arteriovenous fistula (SDAVF). ASIA, American Spinal Injury Association; MS, motor score.

Figure 6

Short- and long-term outcomes of modified aminoff-logue scale (mALS). This figure shows short- and long-term outcomes of modified Aminoff-Logue Scale (mALS) in patients with spinal dural arteriovenous fistula (SDAVF).

Figure 7

Short- and long-term outcomes of urination (U) aminoff-logue scale (U-ALS). This figure shows short- and long-term outcomes of urination (U) Aminoff-Logue Scale (U-ALS) in patients with spinal dural arteriovenous fistula (SDAVF).

Figure 8

Short- and long-term outcomes of gait (G) aminoff-logue scale (G-ALS). This figure shows short- and long-term outcomes of gait (G) Aminoff-Logue Scale (G-ALS) in patients with spinal dural arteriovenous fistula (SDAVF).

Figure 9

Short- and long-term outcomes of defaecation (D) aminoff-logue scale (D-ALS). This figure shows short- and long-term outcomes of defaecation (D) Aminoff-Logue Scale (D-ALS) in patients with spinal dural arteriovenous fistula (SDAVF).