Steinmetz Michael P, Chow Michael M, Krishnaney Ajit A, Andrews-Hinders Doreen, Benzel Edward C, Masaryk Thomas J, Mayberg Marc R, Rasmussen Peter A
Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
Neurosurgery. 2004 Jul;55(1):77-87; discussion 87-8. doi: 10.1227/01.neu.0000126878.95006.0f.
Spinal dural arteriovenous fistulae (Type I spinal AVMs) are the most common type of spinal vascular malformations. The optimal treatment strategy has yet to be defined, and endovascular embolization is being offered with increasing frequency. A 7-year single-institution retrospective review of outcome with surgical management of Type I spinal AVMs is presented along with a meta-analysis of existing literature.
For the institutional analysis, a retrospective review of all patients who underwent treatment at our institution for Type I spinal AVMs was performed. Between 1995 and the present (the time frame during which endovascular treatments were available), 19 consecutive patients were treated. Follow-up was performed by clinical examination or telephone interview, and functional status was measured by use of the Aminoff-Logue score. For the meta-analysis, a MEDLINE search between 1966 and the present was performed for surgical, endovascular, or combined treatment of spinal dural arteriovenous fistula. These series were included in a meta-analysis to evaluate success and failure rates, complications, and functional outcome. Specifically, embolization and microsurgery were compared.
For the institutional analysis, 18 of 19 patients were available for long-term follow-up after surgery. There were no surgical failures, but one complication was seen. Patients demonstrated a statistically significant improvement in gait and bladder function after surgery. For the meta-analysis, 98% of those patients treated with microsurgery had their dural arteriovenous fistulae successfully obliterated after the initial treatment, compared with only 46% with embolization, as judged by radiographic or clinical follow-up. 89% percent of patients demonstrated improvement or stabilization in neurological symptoms after surgical treatment. Few complications were demonstrated with either surgery or embolization.
At this point, surgery seems to be superior to embolization for the management of spinal dural arteriovenous fistula. The fistula is usually obliterated after the initial treatment, with few clinical or radiographic recurrences. The majority of patients either improve or stabilize after treatment. Few worsen, and the morbidity is minimal. It is reasonable to attempt initial embolization, especially at the time of the initial diagnostic spinal angiogram. The treating physicians and patients should be aware of the high chance of recurrence, and patients may ultimately require surgery or repeat embolization. After endovascular therapy, patients are committed to repeat angiography and probably embolization. For these reasons, it is the authors' opinion that surgery should be used as the first-line therapy for spinal dural arteriovenous fistulae.
脊髓硬脊膜动静脉瘘（I型脊髓动静脉畸形）是最常见的脊髓血管畸形类型。最佳治疗策略尚未明确，而血管内栓塞治疗的应用频率正日益增加。本文呈现了对I型脊髓动静脉畸形手术治疗结果的一项为期7年的单机构回顾性研究，并对现有文献进行了荟萃分析。
对于机构分析，对在本机构接受I型脊髓动静脉畸形治疗的所有患者进行了回顾性研究。在1995年至当前（可进行血管内治疗的时间段）期间，连续19例患者接受了治疗。通过临床检查或电话访谈进行随访，并使用阿明诺夫 - 洛格评分来衡量功能状态。对于荟萃分析，对1966年至当前期间关于脊髓硬脊膜动静脉瘘的手术、血管内或联合治疗进行了MEDLINE检索。这些系列研究被纳入荟萃分析，以评估成功率和失败率、并发症及功能结果。具体而言，对栓塞治疗和显微手术进行了比较。
对于机构分析，19例患者中有18例在手术后可进行长期随访。无手术失败情况，但出现了1例并发症。患者术后步态和膀胱功能有统计学意义上的显著改善。对于荟萃分析，根据影像学或临床随访判断，显微手术治疗的患者中有98%在初始治疗后硬脊膜动静脉瘘成功闭塞，而栓塞治疗的患者中这一比例仅为46%。89%的患者在手术治疗后神经症状得到改善或稳定。手术或栓塞治疗均显示很少有并发症。
目前，对于脊髓硬脊膜动静脉瘘的治疗，手术似乎优于栓塞治疗。瘘通常在初始治疗后闭塞，临床或影像学复发很少。大多数患者治疗后病情改善或稳定。很少有病情恶化，且发病率极低。尝试初始栓塞治疗是合理的，尤其是在初次诊断性脊髓血管造影时。治疗医生和患者应意识到复发的高可能性，患者最终可能需要手术或重复栓塞治疗。血管内治疗后，患者需要进行重复血管造影，可能还需要重复栓塞治疗。基于这些原因，作者认为手术应作为脊髓硬脊膜动静脉瘘的一线治疗方法。
