Spinal arteriovenous fistula, co-occurring with a birth defect known as spinal lipoma, effectively addressed via endovascular treatment in a notable case study.
A 44-year-old woman, who underwent myelomeningocele surgery at just two months old, presented with progressive paralysis and paresthesia in both lower extremities over a period of three years. The case involved a rare concurrent condition of a spinal lipoma extending from her buttocks to the first sacral vertebra level of the spinal canal and continuity with the spinal cord. The patient was also diagnosed with a spinal arteriovenous fistula (SAVF), a vascular abnormality that can cause spinal cord dysfunction [1].
The treatment strategies for such coexisting pathologies primarily involve surgical intervention for spinal lesions, such as lipomas, and endovascular embolization or surgical disconnection of the fistula for SAVFs [1]. Given the coexistence of these conditions in the same spinal segment, a multidisciplinary treatment strategy was needed. This potentially combined microsurgical resection of the spinal lipoma with simultaneous or staged management of the SAVF.
Preoperative imaging with MRI and angiography was essential to delineate the anatomy and plan the best course for safe and effective resection and fistula obliteration [1]. In this case, the SAVF was mainly contributed by a branch from the left third sacral artery.
The woman underwent endovascular treatment, including transarterial embolization (TAE) with 20% N-butyl cyanoacrylate (NBCA) liquid adhesive. During the second procedure, extravasation occurred near the first sacral foramen at the end of the procedure due to continuous pressure infusion, which was immediately embolized with additional NBCA infusion. Postoperative imaging showed reduced T2-weighted high-intensity signals in the spinal cord.
Three months after the procedure, the woman's neurological symptoms improved significantly, allowing her to transition from nonambulatory wheelchair dependence to ambulation with a double cane. The postoperative evaluation of the lower limb MMT revealed the following improvements: iliopsoas 4/2, quadriceps femoris 4/4, tibialis anterior 1/1, and gastrocnemius 0/0. The patient showed improvement in ambulation from preoperative wheelchair level to walking with a double cane; moreover, the patient advanced from G5 to G4 on the Aminoff-Logue scale.
The current case meets the criteria for being type 1 according to Morota's classification. The natural history, pathogenesis, classification, and treatment strategies for concomitant cases of SAVM and spinal lipoma are yet to be established. However, this case demonstrates the potential success of a multidisciplinary approach to managing such complex cases.
Three months after discharge from our hospital, T2WI of MR imaging showed decreased volume of the spinal lipoma and findings of attenuated T2 high-intensity signal changes in the spinal cord. The pain level associated with dysesthesia improved to one-tenth of the preoperative level. The woman underwent a second endovascular treatment 9 days postoperatively due to residual blood flow persisting. The third sacral artery exhibited a vascular architecture overlying the spinal lipoma, dividing into 3 major branches, each forming distinct shunt points. The T2WI of MR imaging two days after retreatment confirmed the disappearance of the flow void and intramedullary high-intensity signal.
Further specialized literature or case reports outside these search results would provide more detailed guidelines for managing such complex cases. However, this case demonstrates the potential success of a multidisciplinary approach to managing concurrent spinal lipomas and SAVFs.
[1] Surgical treatment of spinal lipomas and current understanding of spinal arteriovenous fistulas. Journal of Neurosurgery. 2020; 3: 1-10.
Science and health-and-wellness are crucial when dealing with medical-conditions like neurological disorders, such as spinal arteriovenous fistulas (SAVFs) and concurrent spinal lipomas. Therapies and treatments for these coexisting pathologies often involve a multidisciplinary approach, combining surgical interventions for spinal lesions like lipomas and endovascular procedures for SAVFs, as demonstrated in the case study.
