Microsurgical Resection of a Spinal Cord Pial Arteriovenous Fistula: 2-Dimensional Operative Video

Abstract

We present a patient who was diagnosed 20 yr prior to current presentation with a spinal arteriovenous malformation. This patient had a 10-yr history of worsening back pain (and underwent lumbar fusion), urinary dysfunction leading to 3-yr dependence on intermittent catheterization, lower extremity paresthesias and pain, and progressive weakness with multiple falls, leading to walker then wheelchair dependence for mobility. Magnetic resonance studies showed extensive thoracic cord expansion and edema with enlarged spinal cord surface veins and flow voids extending from spinal levels T6 to the conus medullaris. Partial embolization at an outside institution elicited transient symptom improvement. Repeated spinal angiogram demonstrated persistent T10 pial arteriovenous fistula (AVF) supplied by the posterior spinal artery arising from the right T11 segmental artery as well as by the anterior spinal artery from the left T10 segmental artery. Because additional embolization carried significant risk, we planned open surgery with fistula resection. Informed consent for the surgery and video recording was obtained. The patient was placed in the prone position, and a radial artery access was obtained for intraoperative angiogram. Following a posterior T9-T11 laminectomy and dural opening, a pial dissection was performed to expose the AVF. Intraoperative indocyanine green angiography was used to assist in identifying the feeders and major drainage of the AVF. Post-AVF resection, a formal intraoperative radial access spinal angiogram demonstrated complete resection of the lesion with no residual shunt or early venous drainage. The patient improved significantly and, on last follow-up, is ambulating without any assistive devices.

Intraoperative angiography during neurosurgical procedures on patients in prone, three-quarters prone, and park-bench positions: tertiary single-center experience with systematic review and meta-analysis

“…Twelve studies were conducted in Asia3 6 19–28, 11 studies in the United States7 8 29–37, and 3 in Europe38–40. The number of participants per study ranged from 1 to 30.…”

“…The most common intraoperative position was prone (85%), followed by three-quarters prone (8%), and park-bench (8%). IOA was performed with a portable C-arm in 18 studies3 6 7 19–22 24 25 29–32 34–38, in a hybrid operative room in 78 23 26–28 33 40, and in an adapted angiosuite in 139. Postoperative angiographic confirmation of the IOA findings was performed in seven studies3 20–22 29 32 39.…”

Trans-radial spinal angiography: A single-center experience

“…Haynes et al have previously described a series of four patients in whom they developed a trans-radial protocol for intraoperative spinal angiography, but they do not report on the routine use of this approach for outpatient diagnostic or interventional SpAn. 4,9 However, they did illustrate the advantages of trans-radial SpAn in patients who have been positioned prone for surgery. 4 The only prior report of a trans-radial spinal intervention comes from Orru et al who described a case of a sacral dural AVF that was treated via a radial approach due to difficulties with transfemoral approach.…”