Arteriovenous Fistula in a Nerve Root of the Cauda Equina Fed by a Proximal Radiculo-Medullary Artery

Abstract

While there have been a few reports on cases of intradural spinal arteriovenous fistula located on the filum terminale, no cases of its location in a nerve root of the cauda equina have been reported to date. We describe two such cases and describe the intraoperative findings. A 40-year-old man presented weakness of his left leg. Another 62-year-old man presented paraparesis dominantly in his left leg with urinary hesitation. In both cases, spinal T2-weighted magnetic resonance images showed edema of the spinal cord, indicating a flow void around it. Digital subtraction angiography disclosed an anterior radicular artery branching from the anterior spinal artery on the surface of the conus medullaris and a turnaround vein running in the opposite direction within the cauda equina. In the first patient, while the feeding artery running along a nerve root was detected, the draining vein and the fistula were not identified at first sight. An incision into the respective nerve root exposed their location within it. In the second patient, unlike the first case, the feeding artery and the fistula were buried in a nerve root, while the draining vein was running along the nerve's surface. In both cases, permanent clips were applied to the draining vein closest to the fistula. The recognition of a hidden fistulous point in a nerve root of the cauda equina is essential for successful obliteration of the fistula.