骶部硬脊膜动静脉瘘的诊断与治疗

目的探讨骶部硬脊膜动静脉瘘（DAVFs）的临床和影像学特征以及手术治疗效果，以此提高对该病的认识和正确地处理。方法回顾性分析四川大学华西医院神经外科2018年1月—2023年1月收治的15例骶部DAVFs患者的临床资料。术前均行脊髓核磁共振成像（MRI）检查，所有患者均行脊髓血管造影以明确诊断。治疗方式采用手术切除或者介入栓塞。结果临床症状主要表现为双下肢无力14例（93%）；肢体感觉障碍12例（80%）；大小便功能障碍13例（86%），腰部或双下肢疼痛2例（13%）。所有患者均成功进行脊髓血管造影（包括双侧髂内动脉）明确了诊断。所有瘘口均位于L5-S3水平。手术治疗12例，介入栓塞3例。术后随访6～60个月（平均26.2个月）。症状改善13例（86%），稳定2例（14%），无症状加重患者。所有患者术后影像学检查未见残留或复发。结论骶部DAVFs临床少见，选择性脊髓血管造影必须包括双侧髂内动脉在内才能找到瘘口。术前MRI上发现腰骶段椎管内增粗的终丝静脉（FTV）是进一步确诊骶部DAVFs的重要依据。手术和介入对骶部DAVFs 的治疗均有良好的效果。

Objective To investigate the clinical and imaging features as well as surgical treatment outcomes of sacral dural arteriovenous fistulas(DAVFs), in order to improve the understanding and proper management of the disease. Methods The clinical data of 15 patients with sacral DAVFs admitted to Department of Neurosurgery, West China Hospital, Sichuan University from January 2018 to January 2023 were analyzed retrospectively. All patients underwent magnetic resonance imaging(MRI) examination of the spinal cord before the operation, and all patients underwent spinal angiography for proper diagnosis. Surgical resection or interventional embolization were used for treatment. Results The main clinical symptoms were weakness of both lower limbs in 14 cases(93%), limb sensory disturbance in 12(80%), urinary and bowel dysfunction in 13(86%), and lumbar or lower limb pain in 2(13%). All patients underwent spinal cord angiography(including bilateral internal iliac arteries) to confirm the diagnosis. The fistulas were located at the L5-S3 level. Surgical treatment was performed in 12 cases and interventional embolization in 3. The patients were followed up for 6 to 60 months(mean 26.2 months). The symptoms were improved in 13 cases(86%). Two patients(14%) were stable, and no patients had worsening symptoms. No residual or recurrence was found in all patients by postoperative imaging examination. Conclusions Sacral DAVFs are rare in clinical practice. Selective spinal angiography must include bilateral internal iliac arteries to find the fistulas. The presence of dilated filum terminale veins(FTV) in the lumbosacral spinal canal on preoperative MRI is an important basis for further diagnosis of sacral DAVFs. Both surgery and interventional therapy are effective for the treatment of sacral DAVFs.