Endovascular treatment for acute paraplegia after epidural steroid injection in a patient with spinal dural arteriovenous malformation

Case report

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Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal arteriovenous malformations. Type 1 spinal arteriovenous malformations are defined by the presence of radiculomeningeal feeders that drain into intradural veins. Patients with these lesions frequently present with chronic myelopathy, which is most often caused by venous hypertension. The authors present the case of a 69-year-old man with acute paraparesis following a lumbar epidural injection, resulting from a previously undiagnosed SDAVF. The patient initially reported right lower-extremity weakness and paresthesias and was referred to an orthopedic practice. His pain and weakness were exacerbated with ambulation. Reevaluation at 4 months was remarkable for groin, mild low-back, and buttock pain. The patient received a right L5–S1 interlaminar epidural steroid injection and became acutely weak. He presented to the emergency department 3 hours after the injection. Once MRI of the lumbar and thoracic spine had been performed, the neurosurgery service was consulted, and it was decided to proceed with emergent spinal angiography with the intent to embolize the fistula. An emergent spinal angiogram was obtained, revealing 2 arterial pedicles emanating from the right T-5 and T-6 radicular arteries. Transarterial embolization was thought to be the most rapid way to potentially obliterate the fistula. The patient exhibited immediate improvement in neurological function, and by 6 hours postprocedure, his neurological function was near normal. He was ambulatory and released to home 3 days after the embolization procedure.

Abbreviation used in this paper:SDAVF = spinal dural arteriovenous fistulas.

Article Information

Address correspondence to: Adam S. Arthur, M.D., M.P.H., Semmes-Murphey Clinic, 6325 Humphreys Boulevard, Memphis, Tennessee 38120. email: aarthur@semmes-murphey.com.

Please include this information when citing this paper: published online July 6, 2012; DOI: 10.3171/2012.6.SPINE11835.

© AANS, except where prohibited by US copyright law.

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Figures

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    Sagittal T2-weighted MR images obtained from T-7 through the conus demonstrating epidural flow voids and signal change.

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    Spinal angiograms showing the right T-6 (left) and right T-5 (right) pedicles.

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    Postembolization angiogram showing no residual filling.

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    Six-week follow-up MR image demonstrating some flow voids, but cord is not effaced and signal change is minimal.

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