title: Recurrence Rates After Surgical or Endovascular Treatment of Spinal Dural Arteriovenous Fistulas: A Meta-analysis.
abstract: BACKGROUND
  There is an increasing tendency to treat spinal dural arteriovenous fistulas (SDAVFs) endovascularly despite the lack of clear evidence favoring embolization over surgery.
  
  
  OBJECTIVE
  To compare the initial failure and recurrence rates of primary treatment of SDAVFs by surgery and endovascular techniques.
  
  
  METHODS
  A meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standard was performed. All the English literature from 2004 onward was evaluated. From each article that compared the 2 treatment modalities, the odds ratio (OR) was calculated. Combined ORs were calculated with Review Manager 5.3 of The Cochrane Collaboration.
  
  
  RESULTS
  A total of 35 studies harboring 1112 patients were assessed. Initial definitive fistula occlusion was observed in 588 of 609 surgical patients (96.6%; 95% confidence interval [CI], 94.8-97.8) vs 363 of 503 endovascularly treated patients (72.2%; 95% CI, 68.1-75.9; P < .001). The combined OR from 18 studies that assessed both treatment modalities (730 patients) was 6.15 (95% CI, 3.45-11.0) in favor of surgical treatment. Late recurrence (13 studies, 480 patients) revealed an OR of 3.15 (95% CI, 1.66-5.96; P < .001) in favor of surgery. In a subgroup, recurrence was reported in 10 of 22 patients (45%) treated with Onyx vs 8 of 35 (23%) treated with n-butyle-2-cyanoacrylate (OR, 2.51; 95% CI, 0.75-8.37; P = .13).
  
  
  CONCLUSIONS
  Although hampered by inclusion of poor quality studies, this meta-analysis shows a definite advantage of primary surgical treatment of SDAVF over endovascular treatment in initial failure rate and late recurrences. The often-used argument that endovascular techniques have improved and therefore outweigh surgery is not supported by this meta-analysis.
authors: From the Departments of *Neurosurgery, ‡Radiology, and §Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
authors: Nicolaas A
authors: NA
authors: Bakker
authors: Maarten
authors: M
authors: Uyttenboogaart
authors: G J
authors: GJ
authors: Luijckx
authors: Omid S
authors: OS
authors: Eshghi
authors: Aryan
authors: A
authors: Mazuri
authors: Jan D M
authors: JD
authors: Metzemaekers
authors: Rob J M
authors: RJ
authors: Groen
authors: J Marc C
authors: JM
authors: Van Dijk
mesh_terms: D020785:Central Nervous System Vascular Malformations / Q000601:surgery*; D057510:Endovascular Procedures / Q000379:methods; D006801:Humans; D019635:Neurosurgical Procedures / Q000379:methods; D012008:Recurrence; D012189:Retrospective Studies; D013122:Spinal Diseases / Q000601:surgery*; D016896:Treatment Outcome