Angiographic and Surgical Aspects of Spinal Cord Vascular Anomalies

Abstract

In 1961, a report concerning vascular anomalies of the spinal cord by Svien and one of the present authors (1) made the point that myelography was the only roentgenographic method which consistently demonstrated the lesion and concluded that the results of surgical treatment were less than satisfactory. Laminectomy and decompression alone, or in conjunction with local ligation and excision or coagulation of the abnormal vessels, not only did not improve the neurologic status of any patient but caused a deterioration in almost half of those so treated. Just before and after that study, several cases were reported (2–7) in which vascular anomalies of the cord had been opacified and identified by angiographic methods. These were sporadic cases, and angiography was not logically and systematically applied to the evaluation of a group of patients with this condition until Djindjian and his associates (8) began their work in 1962. The recent monograph of these French investigators gave in detail their roentgen and angiographic findings and also described a rational surgical approach to the lesion, in which the supplying vessels were ligated. Salutary results were seen in a number of cases. It is the purpose of this presentation to recount our experience with 13 cases studied since 1963 and to encourage more widespread use of angiography and surgery in the management of spinal cord vascular lesions. Material and Clinical Data The 13 patients are included here because all presented with similar neurologic signs and symptoms and were studied to demonstrate the presence of a vascular anomaly of the spinal cord. Eleven were found to have such an anomaly; one patient had an ependymoma of the cauda equina, and the remaining one had no demonstrable spinal cord lesion. There were 8 males and 5 females, ranging in age from ten to sixty-two years. Only 3 were more than fifty years old. All had experienced pain in the back and progressive weakness and numbness of the legs for a number of months or years. Seven were confined to a wheel chair because of inability to walk. Some dysfunction of the urinary bladder or bowel was noted by all patients except one. Neurologic examination revealed the presence of upper motor neuron signs and an objective or subjective sensory level in all. The spinal fluid protein was elevated in all cases in which it was measured, and in 4 instances erythrocytes were encountered in the spinal fluid. Other laboratory tests were not particularly helpful. Conditions considered in the differential diagnosis, in addition to vascular anomaly of the spinal cord, were protruded intervertebral disk, multiple sclerosis, spinal cord tumor, and hysteria. Roentgenologic Aspects Routine roentgenograms of the spinal column yielded little helpful diagnostic information in these cases. Positive-contrast myelography preceded and led to angiography in all.