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.
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.