Neurosurgery. 2026;99(5):1172–1179
Neurological improvement was observed after both embolization and open surgery for spinal dural arteriovenous fistulas in this institutional series. However, anatomy strongly influenced treatment allocation, and the findings support individualized multidisciplinary selection rather than establishing therapeutic equivalence. Protecting spinal cord arterial supply remains a decisive consideration when choosing the route to fistula obliteration.
Study and key findings
The authors retrospectively reviewed 48 patients treated between 2012 and 2023. Twenty-nine underwent primary embolization and 19 underwent open surgery. Mean age was 63.8 years, and mean follow-up was 24.3 months. Frankel grade improved in 20.7% and 21.1%, respectively, while Nurick grade improved in 55.2% and 57.9%. No significant between-group difference in these improvement rates was detected.
Mean hospital stay was shorter after embolization, at 3.1 versus 5.3 days. Three embolization patients required subsequent fistula treatment, compared with none after surgery. This difference was not statistically significant in the small cohort.
Patients were initially referred for angiography with the intention of embolization. Surgery was selected when safe or complete embolization was unsuitable. In 16 of 19 surgical cases, the feeding circulation contributed to the artery of Adamkiewicz or another radiculomedullary artery. Embolization predominantly used n-butyl cyanoacrylate, while laminoplasty was the most frequent open exposure.
Interpretation and limitations
This was a small, retrospective, nonrandomized comparison with substantial anatomical selection. Thoracic lesions were more frequent in the surgical group, and operator experience could influence endovascular results. Limited statistical power and relatively coarse neurological scales constrain interpretation.
Follow-up was primarily clinical, with no routine MRI or angiography in patients showing sustained improvement. Consequently, symptomatic retreatment cannot be treated as a complete measure of residual or recurrent shunting. The study also cannot establish the superiority of an embolic agent from its small treatment subgroups.
Clinical takeaway
Detailed angiographic assessment should inform a joint surgical and endovascular decision. In this series, shared arterial supply to the spinal cord was a principal reason to choose surgery. The shorter initial admission after embolization must be weighed alongside anatomical suitability, operator expertise, and possible retreatment.
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