A Rare Case of Vertebral Intraosseous Arteriovenous Fistula with Large Epidural Venous Varices and Vertebral Collapse: Multimodal Imaging and Treatment Options.

Spinal arteriovenous fistulas (AVF) are uncommon spinal pathologies and the presence of exclusive intraosseous vertebral AVF is a rarity. Only a handful of cases are documented in the literature. We present a case of large vertebral intraosseous spinal AVF causing vertebral collapse with associated large epidural venous pouches causing compression and congestion of cauda equina nerve roots. We highlight the clinico-radiological features of this entity and the importance of endovascular embolization before surgery in the management of vertebral intraosseous AVF. A 22-year lady presented with complaints of low back ache that had radiation to the right lower limb. MRI and contrast enhanced CT of lumbosacral spine showed areas of L5 vertebral destruction with large vascular channels. These channels were in contiguity with multiple venous pouches present in the anterior epidural spaces. Catheter angiography showed these venous pouches draining into the paravertebral venous plexus. The intraosseous AVF was completely occluded by the techniques of transarterial embolization with glue. The symptoms showed significant reduction after embolization. Although extremely rare, spinal intraosseous AVFs can develop and cause symptoms like back ache, congestive myelopathy and compressive myelopathy. Endovascular embolization is useful for the cases of spinal intraosseous AVFs as the primary treatment method and can be used presurgery in patients requiring vertebral instrumentation for stabilisation of the spine.