Comparative Effectiveness of Surgery, Embolization, and Radiosurgery for Intramedullary Glomus Arteriovenous Malformations: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES: – Spinal glomus arteriovenous malformations are rare intramedullary vascular lesions that can cause progressive myelopathy. Treatment strategies include microsurgical resection, endovascular embolization, and stereotactic radiosurgery. However, comparative effectiveness data remain limited, and previous meta-analyses are outdated. This study systematically compares the clinical and radiographic outcomes of surgery, embolization, and radiosurgery in the treatment of spinal glomus arteriovenous malformations.METHODS: – A systematic review and meta-analysis were conducted in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines. Four electronic databases were searched for English-language reports with ≥3 patients and intervention-specific outcome data. Pooled proportions were calculated using random-effects models for 4 endpoints: (1) complete nidus obliteration, (2) partial obliteration, (3) neurologic symptom improvement, and (4) treatment-related complications. Subgroup analyses compared surgery with vs without preoperative embolization. Meta-regression evaluated temporal trends in treatment efficacy.RESULTS: – Thirty-six studies comprising 462 patients were included. Patients underwent surgery (51%), embolization (35%), or radiosurgery (14%). Complete obliteration was most likely to occur after surgery (77%), compared with embolization (39%) and radiosurgery (16%) (P <.001). No significant differences were found between treatment modalities in partial obliteration (P =.19), symptom improvement (P =.94), or complication rates (P =.35). Among surgical patients, preoperative embolization did not affect the rate of complete obliteration (P =.55). Meta-regression demonstrated an increase in complete obliteration rates after embolization over time.CONCLUSION: – A surgical strategy (resection ± preoperative embolization) yielded the highest obliteration rate in selected, typically compact lesions, without an increased risk of complications compared with embolization or radiosurgery. These rates, particularly for radiosurgery, may increase with longer follow-up lengths. Improvements in embolization techniques over time suggest a growing role for endovascular therapy, particularly as an adjunct to surgery. However, heterogeneity in lesion classification limits the ability to draw definitive treatment recommendations. Standardized diagnostic and outcome reporting frameworks are needed to guide future studies.