Spinal dural arteriovenous fistula is a vascular malformation that occurs in the spinal cord and can be a cause for myelopathy. This fistula is an arteriovenous shunt that is located in the dural matter between a spinal radicular artery and vein. It essentially causes arterial inflow into the venous system which causes increased pressure in venous congestion leading to intermedulary edema which results in cortischemia and infarction. Spinal dural arteriovenous fistula most commonly affects elderly males and are classically found in the thoracolumbar region with roughly 80% of lesions occurring between T6 and L2. The progression of weakness is slow and can be unilateral or bilateral. Some patients experience lower extremity numbness, tingling, radicular pain before they end up experiencing paraplegia. They also may experience bowel or bladder incontinence. This ailment often gets underdiagnosed because of the nonspecific clinical features and slow progression of the disease. Although microsurgery and endovascular embolization treatments have improved significantly in the last decade, many of these patients still are debilitated after these interventions and these patients are good candidates for aggressive inpatient rehabilitation. This case that I'll be presenting is in the setting of an academic acute inpatient rehabilitation hospital and this patient is an 87-year-old male with non-traumatic spinal cord injury due to spinal dural arteriovenous fistula. This patient had a history of hypertension, stage 4 prostate cancer, and lumbar spine degenerative joint disease. He presented the emergency department progressive weakness in both lower extremities and urinary continence over the course of six months. It was a slow progression. An MRI of the spine showed thoracodema and dilated vessels dorsal to the cord. Due to these findings that were indicative of a spinal dural AV fistula, a spinal angiogram was ordered and demonstrated a dural AV fistula at the level of T10. The patient underwent microsurgical intervention for a T10 spinal dural AV fistula disconnection by neurosurgery. He stabilized after surgery but continued to present with weakness in his lower extremity and urinary continence. He required two-person assist with bed mobility and sit to stand transfers due to continued weakness. He was deemed a candidate for rehabilitation and was transferred to an acute inpatient rehabilitation hospital. Spine sagittal T2. The findings include diffuse multilevel intramedullary hyperintensity indicative edema and also prominent intradural extramedullary flow voids in posterior portion of the extramedullary region. And these are both findings that are concerning for dural AV fistula. Upon arrival at the acute inpatient rehabilitation hospital, the patient had an ENSKY exam that was performed to document his level of lesion. He was found to be a L1 Asia C. During his course of rehab, the patient demonstrated improvement balance, strength and coordination as evident by an increase in stand pivot transfers from maximum assistance to minimum assistance. He improved sit to stand to moderate assistance and supine to sit to moderate assistance as well. He continued to be limited by endurance and weakness and was recommended to continue physical therapy and occupational therapy at home. The acute inpatient rehabilitation team also educated the patient and his family on changes after spinal cord injury including neurogenic bladder and bowel management. Internal dural arteriovenous fistula is a rare cause of vascular related non-traumatic spinal cord injury. These patients typically have a slow progression of weakness over the course of several months that can be accompanied by bladder or bowel incontinence. It is these vague symptoms that can cause a significant delay in the diagnosis and surgical treatment leading to a poor prognosis for these individuals. This case demonstrates not only how imperative a prompt diagnosis is, but also the importance of integrating acute inpatient rehabilitation to improve function. To our knowledge, there are only a few documented cases incorporating a physiatrist role in this setting.

Spinal dural arteriovenous fistula

vascular malformation

myelopathy

elderly males

slow progression of weakness