328 - T4 Arteriovenous Fistula with Superimposed Lumbar Radiculopathy: A Case Report

Case Diagnosis: T4 Arteriovenous fistula with superimposed lumbar radiculopathy.

Case Description: In 2020, a 59-year-old male with a history of cervical spondylosis presented with weakness in his right lower limb. After evaluation, a T4 arteriovenous (AV) fistula was identified and repaired in May 2022. However, by October 2022, his proximal right lower extremity weakness worsened, despite weekly therapies. His physical examination revealed 2/5 strength in hip flexor and abductor, 3/5 in quadriceps, and 4/5 in extensor hallucis longus/tibialis anterior. Additionally, there was a diminished right patellar reflex, indicative of a lower motor neuron pattern. An original MRI indicated right neuroforaminal stenosis at L2-3 and L3-4. Subsequent EMG results confirmed chronic neurogenic involvement at the right L2/3 level and suggested old right L4 and probable L3 radiculopathies. These findings raised the possibility of adjacent segment disease stemming from the AV fistula as the likely cause of his symptoms.

Discussions: Spinal AV fistulas are the most common spinal vascular malformations. They lead to elevated spinal venous pressure, chronic hypoxia, and myelopathy. Common symptoms include difficulty climbing stairs, gait disturbances, and exercise-induced pain. Initially, our patient presented with similar symptoms, which led to the diagnosis and treatment of the AV fistula. However, his return with a lower motor neuron pattern and EMG findings suggested superimposed lumbar radiculopathy, likely due to adjacent segment disease. This potential association between spinal AV fistulas and superimposed lumbar radiculopathy is not a documented sequelae of spinal AV fistulas.

Conclusions: Long-term consequences of spinal AV fistulas frequently involve no improvement in motor and sensory function, with sporadic documentation of continued myelopathy and bladder dysfunction. The evolving clinical presentation in our patient prompted an EMG investigation, which revealed lumbar radiculopathy secondary to the AV fistula. Additional research is essential to comprehend the relationship between spinal AV fistulas and superimposed lumbar radiculopathy.