From Mystery to Cure – A Rare Case of Low Back Pain

Low back pain is a frequent complaint in neurology and orthopedic settings, with causes ranging from benign to serious. Spinal dural arteriovenous fistulas (AVFs), though rare, are a crucial differential diagnosis in patients presenting with atypical or rapidly progressive symptoms. We report the case of a 57-year-old woman with hypertension and hypothyroidism who presented with insidious low back pain radiating to both lower limbs. Initially misattributed to degenerative spine disease, her condition rapidly worsened over several days, progressing to bilateral lower limb weakness, sensory loss, and bladder and bowel dysfunction. Neurological examination revealed hypotonia, 2/5 motor strength in the lower limbs, hyperreflexia, and bilateral Babinski signs. Lumbar spine MRI showed only mild degenerative changes without cord compression. Due to the rapid neurological decline, spinal angiography was performed and identified a dural AVF originating from the right L4 lumbar artery. The patient underwent successful endovascular embolization using N-butyl cyanoacrylate. She experienced prompt improvement in autonomic function and gradual motor recovery, eventually regaining full neurological function. This case highlights the diagnostic challenge posed by lumbar dural AVFs and emphasizes the importance of early recognition and angiographic evaluation in atypical myelopathy. Timely embolization can result in excellent outcomes, preventing permanent neurological deficits.