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.