title: Multimodality treatment of conus medullaris arteriovenous malformations:  2 decades of experience with combined endovascular and microsurgical treatments.
abstract: BACKGROUND
  Conus medullaris arteriovenous malformations (AVMs) are rare, challenging spinal vascular lesions that cause progressive debilitating myeloradiculopathy. Only sporadic reports of conus AVMs have been published.
  
  
  OBJECTIVE
  To better define the presentation, prognosis, and optimal treatment of these lesions, we present the first case series of conus AVMs, reflecting over 2 decades of experience with a multimodality endovascular and surgical approach.
  
  
  METHODS
  We retrospectively reviewed the charts of 16 patients with a conus AVM evaluated at our institution from 1989 to 2010. For each patient, the following clinical data were collected: age, sex, symptoms, angiographic findings, type of treatment, complications, degree of angiographic obliteration, recurrence at follow-up, and need for re-treatment. Ambulatory status, Frankel Grade, motor function, and bladder/bowel function were assessed before treatment, at discharge, and at last follow-up.
  
  
  RESULTS
  All 16 patients were treated. Eight (50%) patients underwent embolization followed by microsurgical resection, and 8 (50%) underwent microsurgical resection only. The rate of complete angiographic obliteration was 88%. At last follow-up (mean, 70 months), 43% of patients neurologically improved, 43% were stable, and 14% worsened in comparison with before treatment. During follow-up, 3 recurrences were detected, including the only 2 instances of long-term neurological decline. In the absence of recurrence, all patients ambulatory before treatment remained ambulatory at follow-up, whereas 75% of the initially nonambulatory patients regained the ability to walk.
  
  
  CONCLUSIONS
  Although conus AVMs are challenging to treat, excellent long-term outcomes are possible with a multimodality approach. Recurrence is associated with long-term neurological decline and calls for close follow-up.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Wilson
authors.forename: Adib A
authors.initials: AA
authors.lastname: Abla
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Uschold
authors.forename: Cameron G
authors.initials: CG
authors.lastname: McDougall
authors.forename: Felipe C
authors.initials: FC
authors.lastname: Albuquerque
authors.forename: Robert F
authors.initials: RF
authors.lastname: Spetzler
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001164:Arteriovenous Fistula / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000601:surgery*; D008137:Longitudinal Studies; D008279:Magnetic Resonance Imaging; D008297:Male; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D012189:Retrospective Studies; D013116:Spinal Cord / Q000473:pathology* / Q000601:surgery; D016896:Treatment Outcome; D055815:Young Adult