A 46-year-old male was admitted to our institute due to a history of progressive paraparesis for 2 weeks. Eight months earlier, he experienced severe left buttock pain radiating to left leg for 2 weeks. He was admitted to other private hospital and underwent discectomy L5-S1. Five months later, he suffered from right leg pain and urinary retention. He went back to the same private hospital and underwent revised surgery with spinal fusion L5-S1. Two weeks before hospitalization, he developed progressive paraparesis and constipation. He was unable to walk more than about 100 m. The patient went to another private hospital and was transferred to Prasat Neurological Institute for further investigation and proper treatment after performing MRI of the lumbosacral and thoracic spine. The neurological examination revealed the evidence of spastic paraparesis (muscle strength 3/5) and the lack of pinprick sensation below T10 level, impairment of proprioception, hyperreflexia, and presence of Babinski's sign in the lower extremities. The previous series of MRI of the lumbosacral and thoracic spine were retrospectively reviewed and revealed spinal canal stenosis and bilateral lateral recesses stenosis at L5-S1 level due to moderate diffuse annular disc bulging with moderate enlargement of facet joints and thickening of the ligamentum flavum []. There was an abnormal hyperintense T2 signal with patchy enhancement representing spinal cord congestion extending from the conus medullaris to the level of T4 with subtle perimedullary flow voids along ventral and dorsal cord surfaces [Figures and ]. Magnetic resonance (MR) myelography also showed “worm-like” appearance of the area from thoracic level to the conus medullaris []. MR angiography (MRA) of the thoracolumbar spine demonstrated early opacification of perimedullary venous plexus along anterior and posterior surfaces of spinal cord []. Furthermore, there was a curvilinear flow void, probably the dilated vein of the filum terminale, running from lower lumbar level to the conus medullaris []. Spinal angiography demonstrated SDAVF at the level of L5-S1, probably located on the left S1 nerve root sleeve, which is supplied by the left lateral sacral artery (LSA) originating from the internal iliac artery with venous drainage through the dilated radicular vein into the dilated vein of the filum terminale [Figure and ]. The artery of Adamkiewicz arose from the left L2 lumbar artery and left T9 intercostal artery. Transarterial embolization with N-butyl-cyanoacrylate (NBCA) through the left LSA was successfully performed with NBCA filling across the fistula into the proximal draining vein []. The patient had gradually improved until being the ability to walk independently 3 months later. His bowel and bladder controls had completely regained. Six months after the embolization, follow-up MRI of the thoracolumbar spine also confirmed completely regression of spinal cord congestion [].
A 53-year-old man with no significant past medical history was admitted to our hospital because of pain in the lower-extremities and gait disturbance. His gait disturbance noticed by his family when he was 30 years of age. At age 51, he was found to have a spinal lipoma at a neighboring hospital and was referred to our institution. His lower extremity pain and gait disturbance worsened while he was under observation and he was admitted for further examination. Manual muscle testing revealed lower limb paresis that was more pronounced on the right side. The patellar tendon reflex was not exaggerated on either side, but the Achilles tendon reflex was hyperactive and the Babinski sign was positive on both sides. There was no evidence of bladder or bowel disturbance, and the lumbar JOA score was 10/29. MRI of the spine revealed a spinal lipoma at the L2/3 level and a flow void dorsal to the spinal cord at the level of the conus medullaris (Fig. ). MRA revealed tortuous blood vessels within the spinal lipoma, as in Case 1 (Fig. ). Subsequent angiography revealed an arteriovenous shunt from the right second lumbar artery. The radiculopial artery entered the spinal canal from its ventral aspect to form a arterio-venous shunt within the lipoma. A vein from the shunt region drained into the juxtamedullary vein within the spinal canal, and formed a congestion of the venous circulation (Fig. ).\nDiagnosis was sAVF arising within the spinal lipoma, and embolization and possible surgery was scheduled. First, embolization was performed for the second lumbar artery, the feeding artery for the shunt. A xylocaine test at the feeding artery showed transient depression of MEP (as in Case 1) in the right leg muscles. However, we carried out embolization therapy as we judged the risk would be low as long as embolization was confined solely within the shunt. Because of the presence of multiple feeding arteries, the minor feeder was embolized with a coil first and then N-butyl-cyanoacrylate was injected through one of the main feeders into the shunt zone to occlude it. This did not achieve complete embolization, and surgical excision was deemed necessary. The shunt-containing lipoma was resected as far as possible. An abundance of blood vessels was confirmed within the lipoma. Intraoperative angiography confirmed there was no remaining shunt after the resection.\nAfter surgery, lower limb pain and muscle strength were improved on both sides. At 1month after surgery, lumbar JOA score was 14/29. At 1 year, angiographic examination showed no vascular abnormalities. Although the patient’s low back pain and leg numbness persisted, muscle strength and ADL score were improved. His lumbar JOA score was further improved to 17/29.