SPINAL DURAL ARTERIOVENOUS-FISTULAS - A PLEA FOR NEUROSURGICAL TREATMENT

Spinal dural arteriovenous fistulas are the most common type of arteri ovenous malformation involving the spinal cord, especially in middle-a ged men. We report 21 patients with this malformation who had signs an d symptoms of myelopathy. The diagnosis was established by selective s pinal angiography in patients whose neurological deficits, myelograms or magnetic resonance tomographies suggested the presence of a spinal arteriovenous fistula. They were treated by microsurgical coagulation of the fistula nidus located in the dura and intradural division of th e draining vein. Twenty patients improved neurologically following sur gery, one remained unchanged. Complete obliteration of all lesions was verified by intra-operative microvascular Doppler sonography and in 3 cases by postoperative angiography. There were only a few minor and t ransient complications after surgery: one neurological deterioration w here venous thrombosis was suspected, one cerebrospinal fluid accumula tion and, in one case a transient wound healing impairment. Two patien ts had to be operated on again. In one case with difficult localizatio n of a fistula at the L5/S1 level, the fistula was still visible in th e postoperative angiogram. In another patient, a spinal epidural haema toma occurred a few hours after surgery. We conclude that microsurgica l treatment of spinal dural arteriovenous fistulas is a safe, fast, si mple and effective method of treating these lesions. However, recovery after surgical management was often incomplete because the diagnosis was established too late and the patient already presented with severe and long-lasting deficit. Thus, the main problem remains a diagnostic and not a surgical one.