A 30-year-old female presented with a 10-year history of pain in the lumbosacral spine; she had had casual radiation to both lower limbs. After her first delivery, she developed back pain. The MRI demonstrated a tethered cord at the L4 level and a filum terminale lipoma. The MRI also showed tortuous veins on the spinal cord surface (Figure ). Nine years later, during the second pregnancy, she noted weakness and sensory loss, imbalance with urinary and fecal incontinence. On admission, she had bilateral plantar flexion weakness (grade 4 according to modified Medical Research Council system) and reduced sensation in the gluteal regions and legs, and plantar response. The Babinski and Rossolimo signs were present bilaterally. A repeat MRI revealed intraspinal T2 hyperintensive changes in the thoracic spine and conus (Figures ). Those changes were consistent with neurologic deficit and, after exclusion of inflammatory demyelinating diseases, based on a brain MRI and an aquaporin-4 antibody test, diagnosed as myelopathy. Due to described torturous veins on the spinal cord surface (Figure ), the patient underwent spinal digital subtraction angiography (DSA). The range of DSA was from the Th6 level to the coccygeal artery. The results did not reveal any vascular malformation. Therefore, the preliminary diagnosis was symptomatic TCS and filum terminale lipoma. In view of weakness and neurological deficit surgical spinal cord de-tethering, without lipoma resection was planned.\nThe sacral canal was opened with a median incision. The dura was thin and transparent. After a midline dura and arachnoid incision, a tumor was visualized that appeared to be a lipoma. It engulfed the filum terminale and spinal nerve roots caudally, to the S2 level. The S1 and S2 nerve roots were positioned lateral to the tumor. A thickened, tortuous, bright-red vessel was also noted on the filum terminale, running in the cranial direction. The external surface of the dura was explored bilaterally at the sacral level in search for a SDAVF. A clearly visible nidus was identified at the S3 level on the left side. An empirical test was performed to support this finding. A clip was placed on the arterialized vein, intradurally, for a few minutes. Then, the vessel on the filum terminale clearly changed color, from bright red into bluish gray, and its tension decreased. The SDAVF was then intradurally disconnected, and the nidus was extradurally coagulated. In addition, the filum terminale was cut, and samples of lipoma were taken for histology. The dura was sutured in a watertight fashion, and the wound was closed in layers.\nThe postoperative course was uneventful. A few days later, the patient was discharged. A follow-up MRI showed resolution of the myelopathic changes (Figures –). At the 1-year follow-up, the patient had considerably improved, with no incontinence or motor deficit.
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 [].