- 期刊
脊椎硬膜動靜脈廔管：病例報告
Spinal Dural Arteriovenous Fistula : A Case Report
摘要
脊椎硬膜動靜脈廔管是屬於脊椎動靜脈畸形的類型之一，病人一開始的症狀常是多變且無特異性，因此早期診斷不易。主要症狀是感覺障礙與肌肉無力，病人可能會同時合併上下運動神經元病變的症狀。造成症狀的原因可能為出血、直接壓迫、血栓形成、或靜脈壓力上升等。病程多為漸進性變差，有時有些症狀會出現波動性。治療方式為栓塞與手術。 本病例為65歲男性，因兩下肢漸進性僵硬與麻痺持續六個月而至本院復健部求診。經肌電圖診斷懷疑為壓迫性胸椎脊髓病□，故接受磁振攝影檢查，但結果正常。不久因同時出現上下運動神經元病變的症狀，由神經內科診斷為肌萎縮性脊髓側索硬化而給予Riluzole治療。但病人雙下肢肌力逐漸變差，且有數次因腹壓增加而導致症狀波動性的變化。後來又合併大小便失禁，經多次住院檢查及門診追蹤，曾經分別診斷為脊髓炎與星細胞瘤而給予類固醇及放射線治療，但症狀仍漸漸惡化。今年七月，病患接受第三次磁振攝影，疑為胸椎硬膜動靜脈廔管，經血管攝影確定診斷後，給予栓塞治療並配合復健治療，整體進步情形令人滿意。 脊椎動靜脈畸形的診斷不易，須與許多疾病作鑑別。由於核磁攝影初期的變化可能不明顯，因此對高度懷疑的患者應儘早做血管攝影，以利早期診斷與治療。本病例報告一位病患，雖然被延遲診斷，但經由栓塞治療及適當而完整的復建計劃，病人的功能及生活品質仍獲得滿意的結果。
關鍵字
脊椎硬膜動靜脈廔管並列摘要
A case of delayed diagnosis of spinal dural arteriovenous fistula is presented. A 65-year-old male presented to our clinic for progressive stiffness and numbness over bilateral lower limbs for 6 months. Neurological examination was suggestive of thoracic spinal cord lesion with signs of both upper and lower motor neuron disorders. Electromyographic examination showed evidence of denervation and re-innervation in the bilateral paraspinal muscles of middle thoracic level. Magnetic resonance imaging (MRI) of the spine revealed trivial changes, but they were neglected initially. Because of clinical fluctuation and progressive deterioration, he was treated as early parkinsonism, stroke, amyotrophic lateral sclerosis, transverse myelitis and astrocytoma respectively, but in vain. Two years after the initial MRI, follow-up study demonstrated engorged vessels and secondary ischemic change of the spinal cord resulting from venous hypertension. Thoracic dural arteriovenous fistula was highly suspected and was confirmed by the following angiography. After embolization, his condition stabilized and has gradually improved. With participation in a comprehensive rehabilitation program, he significantly improved in functional mobility and self-care. Spinal dural AVM is often misdiagnosed early in their clinic and image presentation. Appropriate embolization therapy along with an aggressive rehabilitation program will help to prevent progressive disability.