A Survey of Chronic Pain Due to Spinal Dural Arteriovenous Fistulae

Prognosis and outcome of chronic pain after spontaneous spinal epidural hematoma

OBJECTIVE

Chronic pain is a common symptom experienced by patients after spontaneous epidural hematoma (SSEH), and it seriously affects their quality of life. The outcome and prognosis of chronic pain after SSEH are rarely reported. Thus, we conduct this study to present the outcomes and explore prognostic factors of chronic pain in patients with SSEH.

METHODS

We retrospectively reviewed patients diagnosed with SSEH and invited them to complete the American Spinal Injury Association (ASIA) and Neuropathic Pain Symptom Inventory (NPSI) scales. Pearson χ2 and binary logistic regression were used to explore prognostic factors related to chronic pain after SSEH.

RESULTS

A total of 55 patients were reviewed; 21 patients (38.2%) were lost to follow-up, 3 patients (5.4%) died, and 31 patients (56.4%) completed the scales, with a mean follow-up time of 20.6 ± 17.3 months. The ASIA and NPSI results showed significant improvement after surgery. Pearson χ2 showed that timely surgery (≤ 12 h) was related to better outcomes (p < 0.05, Fisher test), and binary logistic regression revealed that patients with a preoperative NPSI score of 11-20 were prone to achieving significant pain relief (OR 23.67, 95%CI 1.11-503.48, p = 0.04).

CONCLUSION

Chronic pain is a common symptom during follow-up after SSEH, and timely intervention is suggested to obtain satisfactory outcomes. Patients who receive emergent surgery within 12 h or who have a preoperative NPSI score of 11-20 may achieve significant relief of chronic pain.

Clinical and neuroimaging findings of spinal dural arteriovenous fistulas: How to avoid misdiagnosis of this disease

OBJECTIVE

Spinal dural arteriovenous fistulas (DAVFs) are rare but can cause serious gait and micturition disturbances. Delays in diagnosis and treatment result in poor clinical outcomes; however, the process of misdiagnosis is unknown.

METHODS

Forty consecutive patients were retrospectively analyzed.

RESULTS

Thirty-one patients (78%) were initially misdiagnosed with lumbar spinal stenosis or other diseases, mostly by orthopedic surgeons, even though most patients (85%) had specific symptoms or characteristic neuroimaging findings of spinal DAVFs: they often presented with spastic gait (thoracic myelopathy), progressive ascending numbness that begins in the distal lower extremities (epicous syndrome), and urinary tract symptoms (conus medullaris syndrome); initial lumbar MRI showed T2 signal change in the conus medullaris and vascular flow voids around the cord. The median time from onset to treatment was longer in patients with a misdiagnosis than in those with the correct diagnosis (11 vs 4 months). In all patients, the fistula was completely obliterated by the direct microsurgical procedure; however, patients with a misdiagnosis had developed additional disabilities by the time a correct diagnosis was made (Aminoff-Logue gait grade of 3.6 ± 1.4 vs 2.1 ± 1.5 p = 0.013), and achieved markedly smaller improvements after the treatment (Aminoff-Logue gait grade of 3.0 ± 1.6 vs 1.1 ± 1.5, p = 0.006) than those with the correct diagnosis of spinal DAVFs.

CONCLUSIONS

When common spinal stenosis fail to explain the symptoms such as thoracic myelopathy, epiconus syndrome, and conus medullaris syndrome, the possibility of spinal DAVFs should be considered. If lumbar MRI shows conus medullaris lesions, thoracic MRI should be performed to confirm the diagnosis.

Health-related quality of life in patients with spinal dural arteriovenous fistulae

Neurological improvement in patients with spinal dural arteriovenous fistulae (SDAVF) is often partial even after adequate treatment. While treatment outcomes have been evaluated primarily on the basis of the postoperative changes in neurological deficits, outcome measures should also reflect the patient-reported outcome (PRO). We conducted a health-related quality of life (HRQOL) survey in 52 SDAVF patients; 33 (63.5%) completed the short-form 36 Health Survey (SF-36) questionnaire. They were 25 males and 8 females ranging in age from 47 to 85 years (mean age 70.0 years). The mean follow-up period was 95.6 months. We analyzed the completed questionnaires and examined the clinical factors associated with their HRQOL. After treatment, gait- and micturition disturbances persisted in 31 (93.9%) and 31 (93.9%) of our patients; 26 (78.8%) reported chronic leg pain. The SF-36 scores of treated SDAVF patients were significantly lower than the national average of 50 for all 8 sub-items in the questionnaire. The scores for physical functioning (PF) and role-physical (RP) were particularly low. With the exception of bodily pain (BP), there was a significant negative correlation between the Aminoff-Logue scale (ALS) scores for gait- and micturition and the sub-item scores. The score for BP showed a significant positive correlation with the scores for the 7 other SF-36 sub-items. The HRQOL of treated SDAVF patients was lower than the national average with respect to both physical and mental aspects. Persistent post-treatment pain and gait- and micturition disturbances were responsible for their lower HRQOL.