gms | German Medical Science

Objective: Although spinal dural arteriovenous fistulas (SDAVF) are the mostly encountered vascular malformations of the spinal cord, their preferred and optimal treatment remains controversial. Thus, based on experience with the largest series of microsurgically treated SDAVF and analysis of the longest postoperative follow-up interval of patients with SDAVF reported so far, the purpose of this study was to characterize the treatment and outcome data of patients operated on SDAVF and to define the role and importance of microsurgery in the management of SDAVF.

Methods: Between 1990 and 2005, 110 SDAVF in 107 patients (84 males, 23 females) were angiographically confirmed and microsurgically treated at our department. The mean patient age at surgery was 60 years (range, 23 to 86 years). The presenting symptoms were consistent with progressive myelopathy (106/107) or included isolated back pain (1/107). Thoracic (69/110) location was predominant followed by the lumbar (31/110), sacral (6/110) and cervical (4/110) site. During surgery, 1/110 concurrent perimedullary fistula was identified and subsequently occluded. 107/107 patients were available for short-term examination (within 3 months), 62/107 patients for hitherto long-term follow-up evaluation (5 to 20 years) postoperatively. The clinical outcome was assessed using the Aminoff-Logue scale.

Results: During short-interval follow-up, 79/107 patients improved neurologically, no clinical change was seen in 26/107 patients, 2/107 patients got worse after surgery. 51/62 patients available for long-term evaluation remained improved (46/62) or stabilized (5/62), 11/62 patients subsequently deteriorated postoperatively. Surgery-related complications included 3/107 wound healing disturbances, 2/107 subcutaneous accumulations of CSF and 1/107 spinal epidural haematoma, requiring reoperation in 2/107 cases. A second operation because of residual and recanalized (5/107) or dual SDAVF (3/107) was indicated in 8/107 cases.

Conclusions: Microsurgical obliteration of SDAVF as a facile, immediate, secure and definite therapeutic option prevents progressive neurological deterioration and results in persistent clinical improvement and favourable long-term outcome in the majority of patients. Complications associated with surgery, reoperations and recurrences are exceptional. Therefore, microsurgery appears to be an ideal therapeutic approach and should act the leading role in the treatment of SDAVF.