Takai Keisuke, Endo Toshiki, Yasuhara Takao, Seki Toshitaka, Watanabe Kei, Tanaka Yuki, Kurokawa Ryu, Kanaya Hideaki, Honda Fumiaki, Itabashi Takashi, Ishikawa Osamu, Murata Hidetoshi, Tanaka Takahiro, Nishimura Yusuke, Eguchi Kaoru, Takami Toshihiro, Watanabe Yusuke, Nishida Takeo, Hiramatsu Masafumi, Ohtonari Tatsuya, Yamaguchi Satoshi, Mitsuhara Takafumi, Matsui Seishi, Uchikado Hisaaki, Hattori Gohsuke, Yamahata Hitoshi, Taniguchi Makoto
8Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo.
2Department of Neurosurgery, Kohnan Hospital, Sendai.
J Neurosurg Spine. 2020 Nov 13;34(3):514-521. doi: 10.3171/2020.6.SPINE20309. Print 2021 Mar 1.
The purpose of the present study was to compare the treatment success rates of primary neurosurgical and endovascular treatments in patients with spinal dural arteriovenous fistulas (dAVFs).
Data from 199 consecutive patients with thoracic and lumbosacral spinal dAVFs were collected from 18 centers. Angiographic and clinical findings, the rate of initial treatment failure or recurrence by procedures, risk factors for treatment failure, complications, and neurological outcomes were statistically analyzed.
Spinal dAVFs were frequently detected in the thoracic region (81%), fed by a single feeder (86%), and shunted into an intradural vein via the dura mater. The fistulous connection between the feeder(s) and intradural vein was located at a single spinal level in 195 patients (98%) and at 2 independent levels in 4 patients (2%). Among the neurosurgical (n = 145), and endovascular (n = 50) treatment groups of single dAVFs (n = 195), the rate of initial treatment failure or recurrence was significantly higher in the index endovascular treatment group (0.68% and 36%). A multivariate analysis identified endovascular treatment as an independent risk factor with significantly higher odds of initial treatment failure or recurrence (OR 69; 95% CI 8.7-546). The rate of complications did not significantly differ between the two treatment groups (4.1% for neurosurgical vs 4.0% for endovascular treatment). With a median follow-up of 26 months, improvements of ≥ 1 point in the modified Rankin Scale (mRS) score and Aminoff-Logue gait and Aminoff-Logue micturition grades were observed in 111 (56%), 121 (61%), and 79 (40%) patients, respectively. Independent risk factors for lack of improvement in the Aminoff-Logue gait grades were multiple treatments due to initial treatment failure or recurrence (OR 3.1) and symptom duration (OR 1.02).
Based on data obtained from the largest and most recently assessed multicenter cohort, the present study shows that primary neurosurgery is superior to endovascular treatment for the complete obliteration of spinal dAVFs by a single procedure.
本研究旨在比较脊髓硬脊膜动静脉瘘（dAVF）患者接受原发性神经外科治疗和血管内治疗的成功率。
从18个中心收集了199例连续的胸段和腰骶段脊髓dAVF患者的数据。对血管造影和临床结果、手术导致的初始治疗失败或复发率、治疗失败的危险因素、并发症及神经功能结局进行统计学分析。
脊髓dAVF常见于胸段（81%），由单一供血动脉供血（86%），并通过硬脊膜分流至硬脊膜内静脉。195例患者（98%）的供血动脉与硬脊膜内静脉之间的瘘口连接位于单一脊髓节段，4例患者（2%）位于2个独立节段。在单一dAVF的神经外科治疗组（n = 145）和血管内治疗组（n = 50）（n = 195）中，初始血管内治疗组的初始治疗失败或复发率显著更高（分别为0.68%和36%）。多因素分析确定血管内治疗是初始治疗失败或复发几率显著更高的独立危险因素（比值比69；95%置信区间8.7 - 546）。两组治疗的并发症发生率无显著差异（神经外科治疗组为4.1%，血管内治疗组为4.0%）。中位随访26个月时，改良Rankin量表（mRS）评分提高≥1分以及Aminoff-Logue步态和Aminoff-Logue排尿分级改善的患者分别有111例（56%）、121例（61%）和79例（40%）。Aminoff-Logue步态分级无改善的独立危险因素为因初始治疗失败或复发进行多次治疗（比值比3.1）和症状持续时间（比值比1.02）。
基于从最大且最新评估的多中心队列获得的数据，本研究表明，对于通过单一手术完全闭塞脊髓dAVF，原发性神经外科手术优于血管内治疗。
