Sivakumar Walavan, Zada Gabriel, Yashar Parham, Giannotta Steven L, Teitelbaum George, Larsen Donald W
Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90089, USA.
Neurosurg Focus. 2009 May;26(5):E15. doi: 10.3171/2009.2.FOCUS098.
Spinal dural arteriovenous fistulas (DAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy, yet remain inefficiently diagnosed lesions. Over the last several decades, the treatment of spinal DAVFs has improved tremendously due to improvements in neuroimaging, microsurgical, and endovascular techniques. The aim of this paper was to review the existing literature regarding the clinical characteristics, classification, and endovascular management of spinal DAVFs.
A search of the PubMed database from the National Library of Medicine and reference lists of all relevant articles was conducted to identify all studies pertaining to spinal DAVFs, spinal dural fistulas, and spinal vascular malformations, with particular attention to endovascular management and outcomes.
The ability to definitively treat spinal DAVFs using endovascular embolization has significantly improved over the last several decades. Overall rates of definitive embolization of spinal DAVFs have ranged between 25 and 100%, depending in part on the embolic agent used and the use of variable stiffness microcatheters. The majority of recent studies in which N-butyl cyanoacrylate or other liquid embolic agents were used have reported success rates of 70-90%. Surgical treatment remains the definitive option in cases of failed embolization, repeated recanalization, or lesions not amenable to embolization. Clinical outcomes have been comparable to surgical treatment when the fistula and draining vein remain persistently occluded. Improvements in gait and motor function are more likely following successful treatment, whereas micturition symptoms are less likely to improve.
Endovascular embolization is an increasingly effective therapy in the treatment of spinal DAVFs, and can be used as a definitive intervention in the majority of patients that undergo modern endovascular intervention. A multidisciplinary approach to the treatment of these lesions is required, as surgery is required for refractory cases or those not amenable to embolization. Newer embolic agents, such as Onyx, hold significant promise for future therapy, yet long-term follow-up studies are required.
脊髓硬脊膜动静脉瘘（DAVFs）是最常见的脊髓血管畸形，可能是脊髓病的重要病因，但仍是诊断效率低下的病变。在过去几十年中，由于神经影像学、显微外科和血管内技术的进步，脊髓DAVFs的治疗有了巨大改善。本文旨在综述关于脊髓DAVFs的临床特征、分类和血管内治疗的现有文献。
检索美国国立医学图书馆的PubMed数据库以及所有相关文章的参考文献列表，以识别所有与脊髓DAVFs、脊髓硬脊膜瘘和脊髓血管畸形相关的研究，特别关注血管内治疗及结果。
在过去几十年中，使用血管内栓塞术明确治疗脊髓DAVFs的能力有了显著提高。脊髓DAVFs的明确栓塞总体成功率在25%至100%之间，部分取决于所使用的栓塞剂以及可变硬度微导管的使用。最近大多数使用氰基丙烯酸正丁酯或其他液体栓塞剂的研究报告成功率为70%至90%。在栓塞失败、反复再通或病变不适合栓塞的情况下，手术治疗仍是最终选择。当瘘管和引流静脉持续闭塞时，临床结果与手术治疗相当。成功治疗后步态和运动功能更有可能改善，而排尿症状改善的可能性较小。
血管内栓塞术在脊髓DAVFs的治疗中是一种越来越有效的疗法，并且可以作为大多数接受现代血管内介入治疗的患者的确定性干预措施。由于难治性病例或不适合栓塞的病例需要手术治疗，因此需要采用多学科方法来治疗这些病变。新型栓塞剂，如Onyx，在未来治疗中具有很大前景，但需要长期随访研究。
