Spinal epidural arteriovenous fistula with an intraosseous shunt arising in a compression fracture vertebra: illustrative case

Spinal epidural arteriovenous fistulas (SEAVFs) with intraosseous shunts are rare, and their underlying pathophysiological mechanisms remain unclear. A female in her 70s presented with rapidly progressive weakness in both lower extremities and urinary retention. Lumbar spine magnetic resonance imaging revealed spinal cord edema and flow voids due to venous dilation and compression fractures of the L1 and L2 vertebral bodies. Spinal angiography revealed ventral and dorsal somatic branches of the lumbar arteries at L1 and L2 flowing into the shunt. High-resolution cone-beam computed tomography revealed a shunt within the compression-fractured vertebral body bone of L2. The intravertebral shunt blood flowed into the ventral epidural venous plexus (VEVP) and returned into the perimedullary vein (PMV). Transarterial embolization was performed using N-butyl cyanoacrylate and Onyx-18 for feeder L1 and feeder L2, respectively. Onyx-18 was injected from the VEVP into the PMV, and complete occlusion of the shunt was achieved. The patient showed symptomatic improvement postoperatively. Vertebral compression fractures are common but rarely associated with SEAVFs. https://thejns.org/doi/10.3171/CASE2457.