Minimally invasive approach for the treatment of lumbar epidural arteriovenous fistulas with intradural venous reflux.
BACKGROUND
Vascular lesions of the spinal cord are increasingly recognized. The most common types of these lesions are dural arteriovenous fistulas (AVFs) whereas, extradural AVFs are a very rare type of spinal AVF and can be associated with either extradural or intradural venous reflux. This results in neurological deficits through congestive or compressive myeloradiculopathy. These lesions must be treated to allow stabilization or improvement of neurologic status, either by endovascular therapy or microsurgical interruption. However, because some patients are not amenable to endovascular treatment, surgery is often warranted, which usually involves hemi- or bilateral laminectomy following a midline approach with bilateral muscle stripping. The main drawback of this procedure is directly related to the morbidity of the approach. Although, minimally invasive approaches are likely to overcome this drawback, there is a lack of reported experience supporting their use for treating spinal dural AVFs.


METHODS
Two patients, aged 62 and 79 years old, presented with rapidly progressive myelopathy characterized by paraparesis and sphincter disturbance. Spinal magnetic resonance imaging showed spinal cord oedema with perimedullary flow voids in both cases. Digital subtraction angiography revealed extradural AVFs associated with perimedullary venous reflux. Endovascular therapy was not feasible. Both patients were treated with microsurgical interruption of the intradural vein through a non-expendable retractor. Complete exclusion was confirmed on postoperative angiography, resulting in resolution of spinal cord edema and improved neurological functional status at 2-year follow-up.


CONCLUSIONS
The minimally invasive surgical treatment of spinal AVFs with epidural venous reflux is safe and effective. This approach is a valuable alternative to endovascular therapy and the standard open microsurgical approach.
Division of neurosurgery, department of surgery, Notre Dame hospital, university of Montreal, Montreal, Quebec, Canada.
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Najjar
Division of neurosurgery, department of surgery, Notre Dame hospital, university of Montreal, Montreal, Quebec, Canada; Department of neurosurgery, Lille university hospital, 59000 Lille, France. Electronic address: Fahed.zairi@gmail.com.
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Zairi
Division of neurosurgery, department of surgery, Notre Dame hospital, university of Montreal, Montreal, Quebec, Canada.
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Sunna
Division of neurosurgery, department of surgery, Notre Dame hospital, university of Montreal, Montreal, Quebec, Canada.
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Weil
Division of neuroradiology, department of radiology, Notre Dame hospital, Montreal, Quebec, Canada.
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Estrade
Division of neuroradiology, department of radiology, Notre Dame hospital, Montreal, Quebec, Canada.
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Weill
Division of neurosurgery, department of surgery, Notre Dame hospital, university of Montreal, Montreal, Quebec, Canada.
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Shedid
D000368:Aged; D020785:Central Nervous System Vascular Malformations / Q000473:pathology / Q000601:surgery*; D004388:Dura Mater / Q000601:surgery*; D006801:Humans; D007796:Laminectomy / Q000379:methods; D008279:Magnetic Resonance Imaging / Q000379:methods; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D013116:Spinal Cord / Q000473:pathology / Q000601:surgery; D013118:Spinal Cord Diseases / Q000601:surgery; D014680:Veins / Q000601:surgery
Arteriovenous fistula; Draining vein; Microsurgery; Minimally invasive; Myelopathy