e。单体位手术伴术中转位血管造影治疗复杂脊柱动静脉病变：一个病例系列

IF 2.5 Q3 Medicine

North American Spine Society Journal Pub Date : 2025-07-01 DOI:10.1016/j.xnsj.2025.100654

Guan-Tze Liu MD , Chao-Hung Kuo MD, PhD , Li-Yu Fay MD

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引用次数: 0

摘要

脊柱动静脉病变，包括动静脉畸形（AVMs）和动静脉瘘（AVFs），是罕见但复杂的血管异常。某些亚型，如硬膜外avm合并硬膜内引流或硬膜内avf抵抗血管内治疗，对诊断和治疗构成重大挑战。目的术中经股动脉入路血管造影有助于实时评估病变，但需要患者重新定位，这可能效率低下。本研究探讨单体位手术入路合并术中转位血管造影治疗复杂脊柱动静脉病变的可行性。研究设计/设置患者接受椎板切除术减压，选择性固定，然后在术中换位动脉造影和术中神经生理监测（IONM）下进行病变闭塞。所有手术均在俯卧位进行，腘窝区为血管通路做好准备。通过左腘动脉插入诊断导管进行术中实时成像。病例1:48岁男性，表现为进行性双侧下肢麻木和尿潴留。MRI发现左侧T9层有血管病变。术中转位血管造影证实在左侧T9-T10椎间孔有AVM，由左侧第9根动脉硬膜内静脉引流。手术切除在IONM下进行，并在术中垂体血管造影的帮助下进行。病例2:71岁女性，急性双侧下肢无力、麻木（肌力2/5）。MRI显示硬膜内血管呈蛇形，脊髓背侧受压于T8-T11水平。脊髓血管造影证实脊髓硬脊膜AVF有右第8胸节段动脉供血。患者在相同的方案下接受病变切除和脊髓减压。病例3:53岁女性报告间歇性左下肢无力，最近恶化。MRI显示硬膜内血管呈蛇形，脊髓水肿，T11-L1硬膜内髓外血流空洞。脊髓血管造影证实在左L1腰动脉有脊髓硬膜AVF伴髓周静脉充血。由于可及性差且风险高，血管内闭塞术被认为是不可行的。患者在相同的方案下接受了T12和L1椎板切除术进行减压和AVF闭塞。结果：3例患者术中神经生理信号均得到保留或改善。术中转位血管造影在硬膜切开前病变定位中起着至关重要的作用。闭塞后，实时血管造影证实远端供血动脉血流充足，无残留病变。术后MRI和DSA证实病变完全切除和硬膜内蛇形血管溶解。所有病例脊髓水肿均有所消退。病例1和病例3报告持续轻度麻木，但病例1尿潴留完全消失，而病例2和病例3下肢无力几乎完全改善。结论本研究强调了脊髓动静脉病变治疗的复杂性。单体位手术入路结合术中转位血管造影提供了多种术中优势，包括增强病变定位和实时血流评估，同时避免了俯卧位经股动脉入路的挑战。精细的手术计划和先进的术中监测技术是优化复杂的脊柱血管手术结果的关键。FDA器械/药物状态本摘要不讨论或包括任何适用的器械或药物。

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P30. A single-position surgery with transpopliteal intraoperative angiography for complex spinal arteriovenous lesions: a case series

BACKGROUND CONTEXT

Spinal arteriovenous lesions, including arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs), are rare but complex vascular anomalies. Certain subtypes, such as extradural AVMs with intradural drainage or dural AVFs resistant to endovascular treatment, pose significant diagnostic and therapeutic challenges.

PURPOSE

Intraoperative angiography via a transfemoral approach is useful for real-time lesion evaluation but requires patient repositioning, which can be inefficient. This study examines the feasibility of a single-position surgical approach incorporating transpopliteal intraoperative angiography for managing complex spinal arteriovenous lesions.

STUDY DESIGN/SETTING

Patients underwent laminectomy for decompression, with optional fixation, followed by lesion obliteration under transpopliteal intraoperative angiography and intraoperative neurophysiological monitoring (IONM). All procedures were performed in the prone position, with the popliteal area prepped for vascular access. A diagnostic catheter was introduced through the left popliteal artery for real-time intraoperative imaging.

PATIENT SAMPLE

Case 1: 48-year-old male presented with progressive bilateral lower limb numbness and urinary retention. MRI identified a vascular lesion at the left T9 level. Transpopliteal intraoperative angiography confirmed an AVM at the left T9-T10 intervertebral foramen, fed by the left 9th radicular artery with intradural venous drainage. Surgical excision was performed under IONM and with the assistance of transpopliteal intraoperative angiography. Case 2: 71-year-old female presented with acute bilateral lower limb weakness and numbness (muscle power 2/5). MRI revealed serpentine intradural vessels and dorsal spinal cord compression at the T8-T11 level. Spinal angiography confirmed a spinal dural AVF with a feeder from the right 8th thoracic segmental artery. The patient underwent lesion removal and spinal cord decompression under the same protocol. Case 3: 53-year-old female reported intermittent left lower limb weakness that had recently worsened. MRI showed serpentine intradural vessels, spinal cord edema, and intradural extramedullary flow voids at T11-L1. Spinal angiography confirmed a spinal dural AVF at the left L1 lumbar artery with engorged perimedullary veins. An attempted endovascular obliteration was deemed unfeasible due to poor accessibility and high risk. The patient underwent T12 and L1 laminectomy for decompression and AVF obliteration under the same protocol.

OUTCOME MEASURES

N/A

METHODS

N/A

RESULTS

All three patients demonstrated preserved or improved neurophysiological signals intraoperatively. Transpopliteal intraoperative angiography played a crucial role in lesion localization before durotomy. After obliteration, real-time angiography confirmed adequate flow in the distal cord-supplying arteries and the absence of residual lesions. Postoperative MRI and DSA confirmed complete lesion removal and resolution of serpentine intradural vessels. Spinal cord edema showed regression in all cases. Cases 1 and 3 reported persistent mild numbness, but case 1 experienced complete resolution of urinary retention, while lower limb weakness in cases 2 and 3 showed near-total improvement.

CONCLUSIONS

This study highlights the complexity of managing spinal arteriovenous lesions. The single-position surgical approach integrating transpopliteal intraoperative angiography provided multiple intraoperative benefits, including enhanced lesion localization and real-time flow assessment, while avoiding the challenges of transfemoral access in the prone position. Meticulous surgical planning and advanced intraoperative monitoring techniques are crucial for optimizing outcomes in complex spinal vascular surgeries.