Unilateral Knee Pain as Clinical Presentation of Spinal Dural Arteriovenous Fistula: A Case Report

脊髓硬膜動靜脈瘻管以單側膝關節疼痛為臨床表現：病例報告

林亮婷(Liang-Ting Lin) ； 孫淑芬(Shu-Fen Sun) ； 王志龍(Jue-Long Wang) ； 許培德(Pei-Te Hsu)

《台灣復健醫學雜誌》 40卷2期 (2012/06) Pp. 85-90

https://doi.org/10.6315/2012.40(2)04

摘要

脊髓硬膜動靜脈瘻管（spinal dural arteriovenous fistula）是很罕見的疾病，臨床表現多為脊髓病變（myelopathy），症狀多樣化且不具特異性，包含漸進性下肢無力，背痛，大小便功能異常或陽痿。初期常會延遲診斷，而以膝關節疼痛為主訴的案例更是少見。我們報告一名49歲，具有脊髓硬膜動靜脈瘻管病史並接受過兩次血管栓塞術治療的男性患者，因急性右側膝關節疼痛僵硬至復健科求診。病史詢問後發現無外傷病史，理學檢查發現雙側下肢出現上運動神經元現象（upper motor neuron sign）。膝關節相關影像學檢查含X光及軟組織超音波均無可解釋臨床症狀的結構性病變，下肢肌電神經檢查之結果無神經根或周邊神經病變，血管攝影顯示硬膜動靜脈瘻管復發，因此推論該病患右膝關節疼痛應為瘻管復發所造成脊髓病變之表現。早期診斷及早期治療有較好的預後，治療可以選擇血管栓塞術或脊椎手術。治療後約有三分之二的病人運動功能可恢復，但只有約三分之一的病人感覺異常會改善，此外疼痛的情形則可能一直持續，值得臨床醫師注意。（台灣復健醫誌2012；40(2)：85 - 90）

關鍵字

脊髓硬膜動靜脈瘻管（spinal dural arteriovenous fistula） ； 脊髓病變（myelopathy） ； 脊髓血管病變（spinal cord vascular malformation） ； 膝痛（knee pain）

並列摘要

Spinal dural arteriovenous fistula (SDAVF) is a rare disease. The principal clinical manifestation of SDAVF is myelopathy, with variable but nonspecific symptoms including progressive weakness of the lower extremities, back pain, bowel and bladder dysfunction, and impotence. Diagnosis is often delayed. Knee pain as the chief complaint of SDAVF is rare. The present case report describes a 49-year-old man with a history of SDAVF, for which he had twice received endovascular embolization, who presented with profound pain in the right knee when attending the study rehabilitation clinic. He had no history of trauma. Physical examination revealed upper motor neuron signs in bilateral lower extremities. Imaging studies of the right knee, including X-ray and sonography, revealed no structural lesion to which his clinical presentation could be attributed. Nerve conduction velocity and electromyography examination showed no evidence of radiculopathy or peripheral neuropathy. Digital subtraction angiography (DSA) identified recurrent SDAVF. It was, thus, believed that the patient's profound right knee pain was the presentation of persistent myelopathy caused by recurrent SDAVF. Early diagnosis and treatment of SDAVF can improve patient's prognosis. Treatment options include endovascular embolization and open spinal surgery. When treating patients with SDAVF, physicians should keep in mind that although two-thirds of these patients can experience motor recovery, only one-third show improvements in sensory disturbances, and pain might persist. (Tw J Phys Med Rehabil 2012; 40(2): 85 - 90)

並列關鍵字

spinal dural arteriovenous fistula ； myelopathy ； spinal cord vascular malformation ； knee pain