Functional Outcomes After Endovascular Versus Open Surgical Approach for Treatment of Spinal Dural Arteriovenous Fistula

BACKGROUND AND OBJECTIVES: Treatment of symptomatic spinal dural arteriovenous fistulas (SDAVF) reduces spinal cord injury and prevents irreversible neurological deficits. It remains unclear whether endovascular embolization vs open surgical treatment of SDAVF is associated with better neurological outcomes. We aimed to compare neurological outcomes between patients who underwent endovascular embolization vs open surgical treatment as primary treatment of SDAVF. METHODS: Patients who underwent endovascular embolization or open surgical treatment as primary treatment of SDAVFs at our institution between 2012 and 2023 were retrospectively identified. The primary outcome assessed was neurological status measured using the Frankel grade and Nurick classification systems. Outcomes at final follow-up were compared with preintervention neurological status. RESULTS: A total of 48 patients (63.8 ± 11.1 years, 75.0% men) met study inclusion criteria. Endovascular embolization was performed in 29 patients, and open surgical treatment was performed in 19 patients. Baseline neurological function was similar for both treatment groups. At final follow-up, similar rates of Frankel (20.7% vs 21.1%, P > .999) and Nurick grade (55.2% vs 57.9%, P > .999) improvement were observed in endovascular vs open surgical treatment groups. Patients who underwent endovascular embolization had a shorter hospital stay (3.1 ± 2.3 vs 5.3 ± 1.8 days; mean difference = 2.2 days, 95% CI 0.93-3.42, P = .001). Reintervention for symptomatic SDAVF was required for 3 (10.3%) patients who underwent endovascular embolization and 0 (0.0%) patients who underwent open surgical treatment ( P = .267). CONCLUSION: Both endovascular embolization and open surgical treatment significantly improved neurological symptoms among patients with SDAVF, and similar neurological outcomes were achieved at final follow-up. Although high recurrence rates have been reported with endovascular treatment, they may be similar to open surgery in the hands of experienced operators. Treatment selection should be guided by multidisciplinary discussion of patient-specific risk factors.