复合手术治疗硬脊膜外动静脉瘘合并硬脊膜动静脉瘘1例 并文献复习

目的 总结硬脊膜外动静脉瘘（SEDAVF）合并硬脊膜动静脉瘘（SDAVF）的复合手术治疗经验。方法 回顾性分析复合手术治疗的1例SEDAVF合并SDAVF的临床资料，并结合文献分析。结果 首先经动脉途径进行ONYX胶栓塞，因胶弥散效果不佳，仅封堵供血动脉，瘘口及引流静脉仍可显影；然后，开放性手术烧灼硬脊膜外扩张迀曲的静脉丛血管，但未剪开硬脊膜探查，术后7 d因并存SDAVF加重血流动力学改变并引起症状加重，再次行介入栓塞时处理SDAVF。术后6个月随访双下肢肌力恢复至4级，大小便功能正常。结论 SEDAVF处理的关键在于闭塞瘘口及近端引流静脉，对于合并的SDAVF，可选择介入治疗。单纯SEDAVF，可选择开放性手术灼闭硬脊膜外扩张迂曲的静脉湖；SEDAVF合并SDAVF，可先行介入栓塞瘘口，解除脊髓静脉高压综合征及硬脊膜外静脉湖压迫症状；如仍末治愈，可行开放手术灼闭硬脊膜外扩张迀曲的静脉湖，解除对脊髓的压迫。

Hybrid operation for spinal epidural arteriovenous fistula: report of one cese and literature review

Objective To explore the clinical manifestations, diagnosis and treatment of spinal epidural arteriovenous fistula (SEDAVF) associated with spinal dural arteriovenous fistula (SDAVF). Methods The clinical data of one patient with SEDAVF associted with SDAVF treated with hybrid operation were retrospectively analyzed, and the literatures were reviewed. Results First, ONYX glue was used to embolize the fistula via arterial approach. Due to the poor dispersion effect of the glue, only the blood supply artery was occluded, and the fistula and draining vein could still be seen on the DSA images. Then, the open operation was used to cauterize the spinal epidural expansion of the tortuous venous plexus, but the spinal dura mater was not cut for exploration. Seven days after the operation, the symptoms were aggravated due to the coexisting SDAVF, and the endovascular embolization was used to embolize the SDAVF. The follow-up at 6 months showed that the muscle strength of both lower limbs was recovered to grade 4 and the defecation function was normal. Conclusions The key to SEDAVF treatment is to occlude the fistula and the proximal draining vein, and the interventional therapy can be selected for the coexisting SDAVF. For simple SEDAVF, open surgery can be used to cauterize the tortuous venous lake of the spinal epidural. For SEDAVF associated with SDAVF, the interventional treatment can be first used to embolize the fistula to relieve the symptoms caused by spinal venous hypertension and the compression of the epidural venous lake. If it is still not cured, open surgery can be used to cauterize and occlude the venous lake of the spinal epidural expansion to relieve the compression on the spinal cord.