Spinal dural fistulas are rare but important disorders treated by neurovascular neurosurgeons.
They are much less common than brain arteriovenous malformation and even less common than dural fistulas of the brain, themselves rare lesions. Typically presenting in older individuals, these lesions can mimic spinal degenerative stenosis with several distinguishing features. Insidious weakness out of proportion to pain are hallmarks of spinal fistulas and can be used to differentiate this disorder from degenerative disease.
MRI with contrast is the usual diagnostic as the enhancement and bright signal on T2-weighted imaging reveals spinal cord venous congestion from inappropriate arterial input. Both endovascular embolization and microsurgical clipping are relatively safe and effective treatment with the degree of recovery correlated with the duration and severity of symptoms. It is my practice to attempt embolization as a first line of therapy. If this is either not accomplished or the fistula is not closed significantly and clinical symptoms persist as happens on occasion, surgical ligation is performed.