Morgalla Matthias Hubert, Ernemann Ulrike, Gawlowski Jan, Deininger Martin, Bitzer Michael, Grote Ernst H
Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany.
Surg Neurol. 2004 Apr;61(4):347-52. doi: 10.1016/j.surneu.2003.05.002.
We report on a patient with the combination of a peridural and a perimedullary spinal fistula, which manifested consecutively. The clinical course and diagnostic steps reveal important observations helpful in the management of this pathology.
A 61-year-old male patient presented with a six-month history of progressive weakness of the lower limbs. Magnetic resonance imaging revealed edema and dilated spinal veins of the lower thoracic spinal cord. Spinal angiography confirmed the diagnosis of spinal dural fistula at level T9 on the left. The patient underwent surgery and the fistula was surgically excised. Two months after initial improvement, the clinical symptoms of lower limb weakness recurred. On re-angiography a spinal perimedullary fistula was found at level T7 that was not apparent on the previous angiogram and on the postoperative control angiogram. The patient underwent surgery again, and the second fistula was also excised. The clinical symptoms subsequently improved.
The interesting point in this case was the rare combination of a peridural and a perimedullary spinal fistula. They presented consecutively and could not be identified simultaneously on the first angiogram. Only after closure of the first fistula did the second become apparent. We believe that this may be a result of a postoperative pressure change in the venous system of the cord. After closure of the first fistula, the arterio-venous (AV) shunt of the second fistula developed gradually. The possibility of a second fistula should be considered in the presence of persistent edema of the cord on magnetic resonance imaging (MRI) and subsequent clinical deterioration.
我们报告一例先后出现硬膜外和髓周脊髓瘘的患者。临床病程和诊断步骤揭示了有助于处理这种病变的重要观察结果。
一名61岁男性患者，有6个月下肢进行性无力病史。磁共振成像显示下胸段脊髓水肿和脊髓静脉扩张。脊髓血管造影证实左侧T9水平存在脊髓硬脊膜瘘。患者接受了手术，瘘管被手术切除。初始症状改善两个月后，下肢无力的临床症状复发。再次血管造影时，在T7水平发现了一个髓周脊髓瘘，该瘘在之前的血管造影和术后对照血管造影中均未显示。患者再次接受手术，第二个瘘管也被切除。随后临床症状改善。
该病例的有趣之处在于硬膜外和髓周脊髓瘘的罕见组合。它们先后出现，在首次血管造影时无法同时识别。只有在第一个瘘管闭合后，第二个瘘管才变得明显。我们认为这可能是脊髓静脉系统术后压力变化的结果。第一个瘘管闭合后，第二个瘘管的动静脉分流逐渐形成。当磁共振成像（MRI）显示脊髓持续水肿且随后出现临床恶化时，应考虑存在第二个瘘管的可能性。
