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How I do it: surgery for spinal arteriovenous malformations

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Abstract

Background

Spinal arteriovenous malformations (AVM) are rare lesions. They may present with intramedullary hemorrhage or edema, often inducing severe neurological deficits. Active treatment of spinal AVMs is challenging even for experienced neurosurgeons.

Method

Anticipation of anatomy and AVM angiocharacteristics from preoperative imaging is key for successful treatment. Information gathered from MRI and DSA has to be then matched to intraoperative findings. This is a prerequisite for reasonably safe and structured lesion removal.

Conclusion

We provide a structured approach for surgical treatment of spinal AVMs, supplemented by high-resolution video and imaging material.

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Abbreviations

ASA:

Anterior spinal artery

AVM:

Arteriovenous malformation

CSF:

Cerebrospinal fluid

EVT:

Endovascular treatment

ICG:

Indocyanine green

LMWH:

Low molecular weight heparin

PSA:

Posterior spinal arteries

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Key points

1. If a vascular malformation of the spinal cord is suspected, at least MRI and DSA should be performed to confirm the diagnosis.

2. The key to treatment is to understand preoperative MRI and DSA images outlining the anatomy and angioarchitecture of the AVM.

3. Based on images, neurological exam and patient characteristics, decide whether to treat and if surgery is the correct modality.

4. After the dura has been opened, the first step is to find and recognize pre-identified angiographical structures in situ, by inspection and ICG-angiography.

5. Take sufficient time to understand the anatomy: What is part of the nidus and needs to be taken out and what is not part of the pathology and needs to be preserved?

6. Take down major feeders first to reduce the bleeding risk and ease AVM dissection, then subsequently close other feeders.

7. Dural closure should be watertight, laminoplasty may be preferable to laminectomy.

8. Start mobilization and physiotherapy immediately postoperatively, followed by neurorehabilitation.

9. Preexisting neurological deficits may be (transiently) worsened after surgery and only long-term follow-up will show the final result of the treatment.

10. We advocate performing DSA after surgery and MRI after 3 to 6 months, to verify AVM obliteration and regression of edema.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland

    Tobias Rossmann, Michael Veldeman, Rahul Raj & Martin Lehecka

  2. Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria

    Tobias Rossmann

  3. Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany

    Michael Veldeman

Authors
  1. Tobias Rossmann
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  2. Michael Veldeman
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  3. Rahul Raj
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  4. Martin Lehecka
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Tobias Rossmann, Michael Veldeman, and Rahul Raj. The first draft of the manuscript was written by Tobias Rossmann, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Tobias Rossmann.

Ethics declarations

Ethics approval

The research project was conducted following the principles outlined in the Declaration of Helsinki. Anonymized presentation of a single case does not require an ethics approval by the local university hospital review board.

Informed consent

The patient provided written informed consent for the use of imaging data and operative video.

Conflict of interest

The authors declare no competing interests.

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This study has not been presented previously.

Supplementary information

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Rossmann, T., Veldeman, M., Raj, R. et al. How I do it: surgery for spinal arteriovenous malformations. Acta Neurochir 165, 1447–1451 (2023). https://doi.org/10.1007/s00701-023-05598-3

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  • DOI: https://doi.org/10.1007/s00701-023-05598-3

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