Surgical Treatment of Spinal Dural Arteriovenous Fistulas
Surgical Treatment of Spinal Dural Arteriovenous Fistulas
Of the 214 craniospinal AVM/AVF seen at our institution over the last 8 years, 19 (9%) were spinal, of which 15 (79%) were Type I spinal AVFs (see Table 1 for the SDAVF classification scheme). Patient characteristics including age, sex, presenting symptoms, and Aminoff-Logue Disability score (Table 2), as well as SDAVF location, were analyzed. Eleven of the fistulas were surgically obliterated, and all patients had at least 1 month of postoperative follow-up and were evaluated for Aminoff-Logue score, strength, sensation, paresthesias, and bowel/bladder function. Institutional review board approval for the study was obtained from the Brigham and Women's Hospital.
Any patients with myelopathic symptoms are selected to undergo surgery unless contraindicated by medical comorbidities. Also selected to undergo surgery were asymptomatic or minimally symptomatic patients with MRI evidence of progressive T2 signal abnormality in the spinal cord or a progressive increase in the prominence of intradural flow voids.
All patients in the series underwent preoperative DSA. In the operating room, the level of the fistula was localized with cross-table C-arm fluoroscopy, and standard 1− to 2-level laminectomies were performed without significant disruption of the facet joints. Because access to the fistula can be typically achieved via a relatively narrow laminectomy, special care was taken to not destabilize the bony elements. The dura was opened to create a working intradural surgical window. The fistula was identified, typically by tracing a dorsal arterialized vein into a nerve root sleeve, and the fistula was then obliterated at the artery-vein connection either by coagulation and ligation or by using an aneurysm clip. Under direct microscopic vision, indocyanine green dye was administered to ensure disconnection of the fistula. The wound was closed in a standard fashion. Patients subsequently underwent formal digital subtraction angiography either the same day or the day after surgery.
Methods
Study Design
Of the 214 craniospinal AVM/AVF seen at our institution over the last 8 years, 19 (9%) were spinal, of which 15 (79%) were Type I spinal AVFs (see Table 1 for the SDAVF classification scheme). Patient characteristics including age, sex, presenting symptoms, and Aminoff-Logue Disability score (Table 2), as well as SDAVF location, were analyzed. Eleven of the fistulas were surgically obliterated, and all patients had at least 1 month of postoperative follow-up and were evaluated for Aminoff-Logue score, strength, sensation, paresthesias, and bowel/bladder function. Institutional review board approval for the study was obtained from the Brigham and Women's Hospital.
Selection Criteria
Any patients with myelopathic symptoms are selected to undergo surgery unless contraindicated by medical comorbidities. Also selected to undergo surgery were asymptomatic or minimally symptomatic patients with MRI evidence of progressive T2 signal abnormality in the spinal cord or a progressive increase in the prominence of intradural flow voids.
Surgical Technique
All patients in the series underwent preoperative DSA. In the operating room, the level of the fistula was localized with cross-table C-arm fluoroscopy, and standard 1− to 2-level laminectomies were performed without significant disruption of the facet joints. Because access to the fistula can be typically achieved via a relatively narrow laminectomy, special care was taken to not destabilize the bony elements. The dura was opened to create a working intradural surgical window. The fistula was identified, typically by tracing a dorsal arterialized vein into a nerve root sleeve, and the fistula was then obliterated at the artery-vein connection either by coagulation and ligation or by using an aneurysm clip. Under direct microscopic vision, indocyanine green dye was administered to ensure disconnection of the fistula. The wound was closed in a standard fashion. Patients subsequently underwent formal digital subtraction angiography either the same day or the day after surgery.
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