Open surgical ligation of a thoracic spinal epidural arteriovenous fistula causing thoracic myelopathy: illustrative case

BACKGROUND: Spinal epidural arteriovenous fistulas (eAVFs) are rare spinal vascular malformations characterized by an abnormal connection from the paraspinal and paravertebral system to the epidural venous plexus. This contrasts with the more frequently seen spinal dural AVF, where the fistula is entirely intradural. Although endovascular repair is commonly performed for spinal eAVF, few cases require open surgical ligation. OBSERVATIONS: The authors present a case of a 74-year-old male with progressive thoracic myelopathy secondary to a spinal eAVF. Thoracic magnetic resonance imaging (MRI) showed intramedullary T2 signal hyperintensity from T8 to T12. Spinal angiography revealed a primary arterial supply from the right T11 segmental artery and minor supply from the left T11 branches with drainage into the ventral epidural space. The patient underwent T11–12 laminectomy and complete right T11–12 facetectomy for ligation of the fistula with T11–L1 fusion. A postoperative spinal angiogram showed resolution of the fistula. Postoperatively, the patient’s myelopathy improved, and MRI showed a decrease in T2 cord intensity. LESSONS: Spinal eAVFs are rare lesions that differ from the more commonly seen intradural dural AVF in that the abnormal connection is in the epidural space, and they are often associated with a dilated epidural venous pouch. Treatment involves endovascular, open surgical, or combined approaches.