A 33-year-old male presented with a 2-year history of pain in the lumbosacral spine with progressive lower-limb weakness, urinary frequency, and incontinence. Symptoms intensified after exercise and prolonged standing. Lumbar spine MRI demonstrated a tethered cord at the L3 level, a filum terminale lipoma, and edema in the spinal cord. It also showed tortuous veins on the posterior surface of the spinal cord (Figures ).\nThe neurological examination revealed bilateral hip-joint flexion weakness (grade 4 according to modified Medical Research Council system), plantar flexion weakness (grade 3 according to modified Medical Research Council system), and reduced sensation in the S2–S3 dermatomes. The Babinski and Rossolimo signs were present bilaterally. Based on the clinical and radiological signs, a SDAVF was suspected. A DSA confirmed the SDAVF at the S2-S3 level, in the dura supplied by lateral sacral arteries and branches from the internal iliac arteries. Tortuous draining veins were present on the posterior surface of the entire spinal cord and terminated intracranially (Figures ).\nThe patient underwent three endovascular embolizations, each with a different agent. First, embolization was performed with Onyx™ 18, administered in two microcatheters. This treatment resulted in an occlusion of the fistula. The patient significantly improved, but due to poor penetration of the draining vein, after a few weeks, the fistula recanalized and symptoms returned.\nA second embolization was performed 4 months later. The vascular access to the fistula was more complicated. A 25% Phil™ injection was feasible only through the small sacral branches of the left internal iliac artery. This procedure achieved a significant reduction of flow through the fistula. Eighteen months later embolization of the fistula was attempted with diluted glue. Despite good occlusion of the fistula observed in a DSA, the tortuous vessels remained visible in the follow-up MRI (Figures ). The symptoms persisted, and the patient was qualified for surgical treatment.\nThe goal of surgery was to occlude the draining vein and the arterial feeder and to reduce the lipoma. With a median incision, the sacral canal was opened on the right side. The dura was thick, and there were multiple vessels filled with embolic agents. There was one large, bright-red vessel extradurally and one intradurally at the S2-S3 level. A clip was placed upon the arterialized vein intradurally for a couple of minutes. After that, the vessel changed color and the tension decreased. Both intra- and extradural vessels were coagulated. Afterwards, the lipoma was visualized and partially removed. The dura was sutured in a watertight fashion, and the wound was closed in layers.\nThe postoperative course was uneventful, and a few days later, the patient was discharged. After 6 months, a follow up MRI showed the absence of tortuous vessels on the posterior surface of the spinal cord and a significant reduction in the myelopathic changes (Figure ). On follow-up, the patient considerably improved, with no incontinence, some urinary frequency and mild weakness (grade 4 according to modified Medical Research Council system).
A 60-year-old female patient was admitted to the inpatient treatment section from the outpatient therapy wing of the physical medicine and rehabilitation department for the evaluation and treatment of impaired walking due to gradual weakening of the bilateral lower extremities that had lasted for three months. The patient seemed to have cognitive impairment, and did not have accurate memory of the trauma. However, according to the report of a family member, the patient had been medicated for cerebral infarction, hypertension, and osteoporosis, with no problems in ambulation and other activities of daily living before slipping down three months ago. After that, she had been in a bed ridden state and showed gait disturbance. Based on neurological examination, her mental status was alert, but her orientation, memory, calculation and other cerebral functions were generally impaired, whereas her speech was intact. In terms of the cerebellar function, there were no specific findings on both of the upper extremities, and the lower extremities could not be checked due to muscle weakness. Although an accurate evaluation of motor function was challenging during the manual muscle test, the upper extremities were found to be in normal range. For the lower extremities, the flexor and extensor of the hip and knee of both sides were in poor grade, and the dorsiflexor and plantarflexor of both ankle joints were degraded to trace grade level. There was no limitation in passive range of motion. In both lower extremities, the spasticity corresponded to the Modified Ashworth Scale I grade. Although accurate evaluation for sensory function was also difficult, the patient showed a relatively intact result in the pinprick test, but the proprioception and vibration sensation were impaired. Deep tendon reflex was normal for both upper extremities but increased in both lower extremities, and Barbinski's signs and ankle clonus were found on both sides. Results of the functional evaluation showed impossibility of independent ambulation. Although the activities of daily living using the upper extremities were possible, the patient needed considerable assistance in other areas. In terms of urinary function, urinary retention was observed, so we inserted a foley catheter since the patient was incapable of self-voiding. In addition, due to severe constipation, medication was provided and we helped defection with the use of glycerine enema, 2-3 per day as needed. The first lumbar vertebral body bursting fracture was found in the simple film taken at admission. From the magnetic resonance imaging (MRI) of the lumbar spine, the spinal dural arteriovenous fistula was found in the first lumbar vertebral body bursting fracture in addition to the shades of dilated vein in the periphery of the spines starting from the fifth thoracic vertebra to the cornus medullaris. As a result, the spinal cord edema was accompanied, and the specific findings of high signal, light shade of the spine were observed from the T2 weighted image (). Although electromyography and somatosensory evoked potential test were considered, we could not conduct them because of the patient's transfer to the neurosurgical department due to urgent need of arterial embolization. For more accurate location mapping of the spinal arteriovenous fistula, we conducted spinal vessel angiography and found that the arteriovenous fistula originated from the twelfth intercostal artery and first lumbar radicular artery. In addition, the spinal vein located on the anterior and posterior spine that continued to the cervical vertebra region was observed (). Since the artery of interest was not that large, we planned the embolization procedure employing glue (n-butyl cyanoacrylate) rather than the operation. After embolization of the number twelve right thoracic vertebrate intercostal artery and first lumber, the embolization of all fistula was followed. As a result, there was no venous plexus observed around the spine (), and the neurologic symptoms of the patient improved. The hip flexor and knee extensor improved to 'fair grade' and the ankle plantar flexor improved to 'poor grade'. Although we were not able to check the sensory function due to the patient's impaired cognition, big changes were not observed after the treatment. As a result of the post therapy follow-up using MRI to see the condition of spinal cord edema, we found that the spinal vein was dilated due to arteriovenous fistula not being found, as well as the spinal cord edema around the artery. Therefore, we were able to observe normal low signal intensity of the spinal cord from the T2 weighted image (). With the help of rehabilitation therapy including strengthening and endurance exercise of the lower extremities, gait training, and functional electrical stimulation to both tibialis anterior, the patient showed gradual improvement and could ambulate about 2-3 m. The urinary symptoms also improved and the patient was able to self-void after removal of the foley catheter following normal functioning results based on the urodynamic study. Bowel function also improved and the patient was capable of daily defecation.