The hybrid operation based on microsurgery assisted by intraoperative spinal angiography in patients with spinal dural arteriovenous fistula: a series of 45 cases from multicenter research.

Background: To assess the clinical effects of hybrid surgery, which includes spinal angiography-assisted microsurgery, in the treatment of spinal dural arteriovenous fistulas (SDAVF).

Methods: We retrospectively reviewed 45 patients who underwent hybrid Spinal dural arteriovenous fistula (SDAVF) resection between September 2019 and June 2022. The hybrid surgery involved intraoperative digital subtraction angiography (DSA) of the spinal vessels to determine the source of the blood-supplying artery, location of the fistula and draining vein, indocyanine green fluorescence (ICG)-assisted microsurgical resection of the fistula, and postoperative DSA to verify therapeutic efficacy. The Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Visual Analog Scale (VAS), Barthel score, modified Rankin Scale (mRS) and modified Aminoff-Logue score (key indicator) were used to assess the clinical effects of SDAVF resection.

Results: A series of 45 patients with SDAVF were successfully treated with hybrid surgery without fistula recurrence. There were no intraoperative complications related to spinal angiography, and none of the patients died. Postoperatively, two patients experienced clinical deterioration of spinal cord function, which manifested as bilateral lower extremity paralysis and bladder sphincter dysfunction. Postoperatively, improvement in mALS scores was observed in 16 cases (35.6%) within 1-2 days, 12 cases (26.7%) at 1 week, and 7 cases (15.6%) at 6 months. No SDAVF recurrence was detected in the spinal MRA examination 6 months after surgery. When compared with preoperative mALS scores, 35 cases (77.8%) showed significant improvement in symptoms, 8 cases (17.8%), remained unchanged, and 2 cases (4.4%) deteriorated. Compared with the preoperative scores, the postoperative mALS score was significantly decreased [postoperative vs. preoperative: 2(1,3) vs. 3(2,4)], HAMD score [(12.2 ± 5.5) vs. (19.6 ± 6.3)], HAMA score [(15.6 ± 5.5) vs. (20.5 ± 6.5)], and VAS score [3(2,5) vs. 5(4,8)]. Conversely, Barthel scoresshowed significant increase [(74.6 ± 8.7) vs. (67.8 ± 9.2)] (P < 0.05). However, the mRS scores were lower than preoperatively [1(1,2) vs. 2(1,2.5)], but the difference was not statistically significant (P > 0.05). There was a significant increase in "good" neurological outcomes at follow-up compared with preoperative function (62.2% vs. 33.3%) (P = 0.023).

Conclusion: Hybrid surgery is a safe and effective treatment for patients with SAVF, which is beneficial for improving anxiety, depression, spinal cord, and neurological function, and relieving pain. However, the treatment of patients with SDAVF is a complex, long-term process requiring further multidisciplinary interventions, including clinical care, psychosocial interventions, and neurorehabilitation.