Arterio-venous malformations and back pain

Arterio-venous malformations inside or around the spinal cord can cause spinal cord compression, parenchymal hemorrhage, subarchnoid hemorrhage, or a combination of these phenomena. Symptoms may include a gradual progressive upward or upward and downward segmental neurologic deficit, radicular pain, or sudden back pain with an acute segmental neurologic deficit. It is diagnosed by means of MRI. Treatment: surgical or stereotactic radiosurgery, and also possible angiographic embolization.

Arterio-venous malformations are the most frequent vascular spinal anomalies. Most often they occur in the thoracic and lumbar regions in the posterior sections of the extramedullary space. The rest are localized in the cervical and upper-thoracic regions and more often intramedullary. Arterio-venous malformations can be small and local or occupy up to 50% of the spinal cord. They can squeeze or even dislodge the normal spinal parenchyma, or they can tear, causing focal or generalized hemorrhage.

Skin angiomas are sometimes located above the spinal arterio-venous malformations. Arterio-venous malformations usually squeeze the nerve roots, causing pain irradiating down to the innervation region of the affected root (radicular pain), or squeezing the spinal cord, causing a segmental neurological deficit gradually increasing or wave-like. Often there is symptomatology of the defeat of upper and lower motoneurons. Arterio-venous malformations can burst inside the spinal cord, causing sudden severe back pain and an acute segmental neurological deficit. Arterio-venous malformations of the upper parts of the spinal cord rarely cause subarachnoid hemorrhages, manifested by sudden and severe headache, neck stiffness, and decreased level of consciousness.

Arterio-venous malformations of the spinal cord can be an accidental finding in neuroimaging studies. Arterio-venous malformation can be suspected on the basis of clinical signs: unexplained segmental neurologic deficit or subarachnoid hemorrhage, especially in the presence of sudden severe back pain or median skin angiomas.

Surgical treatment of arterio-venous malformations is indicated if they pose a danger to the spinal cord, but good experience with microsurgical techniques is required. Stereotactic radiosurgery is useful for small arterio-venous malformations localized in areas difficult to access for surgery. Angiographic occlusion by embolization of the delivery artery often precedes surgery or stereotaxic surgery.

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