Multidisciplinary Treatment of Cervical Spinal Cord Vascular Fistulae and Malformations: Experience Over 16 years

Paul W Detwiler MS, MD
Randall W Porter MD
Robert F Spetzler MD
Michael T Lawton, MD
Volker KH. Sonntag, MD
Cameron G. McDougall MD (Phoenix, AZ)

Introduction:

The management of arteriovenous fistulae and malformations affecting the cervical spinal cord (CAVM) can be more challenging than lesions in the thoracic and lumbar spine. In the latter case, most lesions are intradural dorsal fistulae that are easily treated with a laminectomy and interruption of the fistula. Methods: Over 16 years the senior author (RFS) has applied a multidisciplinary approach to the treatment of CAVMs in 17 patients (nine females, eight males). Their average age was 40 years (range, 14–75 years). The distribution of lesions was extradural (n=l), intradural–dorsal (n=2), intradural–ventral (n=2), extradural–intradural (n=3), and intradural–intramedullary (n=9). Sixteen patients underwent surgical procedures: laminectomy (n=B), laminoplasty (n=5), corpectomy/allograft fusion and plating (n=2), and far–lateral craniotorny with Cl and C2 hemilaminectomies. Seven patients were treated with transarterial embolization. Six patients underwent both surgery and embolization: preoperative (n=2) and postoperative (n=4).

Results:

Complete resection was achieved in 13 cases; four required postoperative embolization. Postoperative neurological status was the same (n=7), improved (n=6), or worse (n=4).

Conclusion:

These CAVMs were more aggressive clinically than is typical of those located in the thoracic and lumbar spine. The relative incidence of intradural–intramedullary and extradural–intradural lesions is the primary reason for this finding. Successful treatment requires obliteration of the lesion with prudent resection and or embolization. The best surgical approach is the one that gives the best visualization of the entire lesion and may require extensive bone removal and spinal reconstruction.