腰椎术后硬脊膜动静脉瘘合并腰椎间盘突出1例报道并文献复习

Acquired spinal dural arteriovenous fistula after lumbar surgery associated with lumbar disc herniation:a case report and literature review

目的报道1例腰椎术后硬脊膜动静脉瘘(SDAVF)合并腰椎间盘突出病例,并结合文献探讨脊柱手术后SDAVF合并腰椎间盘突出和/或腰椎管狭窄症患者的临床表现、影像学特征及治疗措施。方法回顾性分析1例65岁男性腰椎手术10年后SDAVF形成合并腰椎间盘突出患者的临床资料。在中国知网、万方数据、维普及PubMed等数据库中,以“脊髓硬脊膜动静脉瘘”“脊髓硬脊膜动静脉畸形”“腰椎间盘突出”“腰椎管狭窄症”,以及“spinal dural arteriovenous fistula”“spinal dural arteriovenous malformation”“lumbar disc herniation”“spinal stenosis”为中、英文关键词,检索2022年1月前有关脊柱手术后SDAVF合并腰椎间盘突出和/或腰椎管狭窄症的相关文献,共纳入9篇(9例)英文文献。结合本文病例的诊治过程,总结该类疾病的临床及影像学特点、发生机制和治疗策略。结果本文1例65岁男性10年前于外院行L4/5椎间盘切除术,本次入院行L2/3髓核切除术,术后患者突发双下肢无力伴感觉异常。脊髓血管造影见右侧L4节段SDAVF形成,行瘘口介入栓塞治疗后症状明显缓解,随访18个月结果为临床治愈。结合文献报道的9例,共10例脊柱手术后SDAVF合并腰椎间盘突出和/或腰椎管狭窄症患者,均为男性,年龄27~76(53.8±14.9)岁。其中,9例SDAVF发生于原手术区域,1例发生于原手术邻近区域。临床表现为进行性下肢运动、感觉异常及括约肌功能障碍,亦可有慢性腰背部疼痛、间歇性跛行、鞍区感觉异常等不典型症状。MRI显示脊髓肿胀,T2WI高信号改变,增强扫描可见特征性的“虫蚀样”血管流空影。10例患者中,3例行介入治疗、4例行手术治疗、3例行介入联合手术治疗,治疗后随访患者临床症状均有不同程度改善。结论脊柱术后SDAVF同时合并腰椎间盘突出和/或腰椎管狭窄症在临床十分罕见,患者临床表现为典型或不典型的神经功能障碍,有误诊或漏诊可能;其影像学特征具有特异性,可作为诊断的主要依据,早期诊断并积极行介入或手术治疗阻断动静脉瘘口,有望最大限度地恢复患者的神经功能状态。

Objective This study aimed to describe a rare case of acquired spinal dural arteriovenous fistula(SDAVF)after lumbar surgery associated with lumbar disc herniation and clinical manifestations.Imaging features and treatment measures of SDAVF patients with lumbar disc herniation and/or lumbar spinal stenosis after spinal surgery were discussed combined with the literature.Methods The clinical data of a 65-years-old male who had a history of lumbar discectomy 10 years ago was retrospectively analyzed.He was diagnosed with acquired SDAVF associated with lumbar disc herniation.Pieces of literature about SDAVF associated with lumbar disc herniation and/or spinal stenosis before January 2022 were searched in CNKI,Wanfang,Weipu,and PubMed database using"脊髓硬脊膜动静脉瘘","脊髓硬脊膜动静脉畸形","腰椎间盘突出","腰椎管狭窄症",and"spinal dural arteriovenous fistula","spinal dural arteriovenous malformation","lumbar disc herniation","spinal stenosis"as keywords.Nine English literature on nine cases were included.The clinical and imaging characteristics,mechanism of this disease,and treatment strategy of nine cases in the literature combined with this case were summarized.Results A 65-year-old male patient,with a history of L4/5 discectomy at an outside institution 10 years ago,suffered from sudden weakness of both lower limbs with sensory abnormalities after L2/3 discectomy and fenestration.Spinal angiography showed the formation of SDAVF supplied by the right L4 radicular artery,and the symptoms were significantly relieved after interventional embolization of the fistula.Results of follow-up for one and a half years were clinically cured.A total of 10 cases of acquired SDAVF with lumbar disc herniation and/or spinal stenosis were involved,including nine reported cases and a case in this paper.All patients were males,with ages ranging from 27-76(53.8±14.9)years old.Among them,nine patients had SDAVF in the previous surgical area and one in the nearby region.The clinical symptoms were progressive lower extremity weakness,sensory disturbance,and sphincter disturbance.In addition,the atypical symptoms,such as chronic low back pain,claudication,and saddle anesthesia were observed.MRI demonstrated swelling and increased T2-weighted signal in the spinal cord,enhanced MRI can find a"moth-eaten"flow void sign.Among them,three,four,and three patients underwent endovascular embolization,surgery,and embolization combined with surgery,respectively.After treatment,the clinical symptoms were relieved for all patients by various degrees.Conclusion SDAVF combined with lumbar disc herniation and/or lumbar spinal stenosis after spinal surgery is very rare in clinical practice.The clinical manifestations of patients are typical or atypical neurological dysfunction,with possible misdiagnosis or missed diagnosis.The imaging features of the disease are specific and can be used as the main basis for diagnosis.Early diagnosis and active intervention or surgical treatment to block the arteriovenous fistula are expected to maximize the recovery of the patient's neurological function.