2.1 | Case history and examination
A 77-year-old man with a history of lumbar spondylosis presented to our hospital complaining of progressive weakness and paresthesia in both lower limbs with gait impairment for 2 months. The patient had no history of spinal surgery or family history of any spinal disease. Neurological examination revealed no weakness (5/5) and decreased sensation (4/5) in the lower extremities and no vesicorectal involvement. Therefore, we suspected intermittent claudication due to lumbar spine disease.
Initial evaluation with unenhanced MRI of the lumbar spine revealed abnormal thoracic spinal cord extension in the T11–12 region, with increased fluid signal within the spinal cord (Fig. 1).
MRI of the thoracic spine showed abnormal thoracic spinal cord extension in the T7–L1 region, with increased fluid signal within the cord and numerous abnormally dilated vascular structures around the thoracic spine, consistent with SDAVF (Fig. 2).
A multiplanar reconstruction (MPR) image from multidetector row computed tomography angiography (MDCTA) showed vessel entanglement below the right Th11 pedicle (Fig. 3a). These vessels were connected to intraspinal tortuous vessels, suggesting perimedullary draining veins (Fig. 3b).
The patient underwent spinal angiography under local anesthesia. A left inguinal common femoral artery puncture was performed for vascular access using a 4-French sheath, and selective spinal angiography was initiated using a 4-French Shepherd hook catheter (Fig. 4a). Specific significant findings on angiography included a fistula supplied by the right Th11 radicular artery draining into the right Th11 radicular veins. Observation of slow emptying of the anterior spinal artery and slow filling of the spinal veins above spinal levels revealed venous hypertension. These findings were discussed with the orthopedic surgeon, neurologists, and neurosurgeons, and embolization was decided to treat the patient.