Craniocervivcal Spinal Dural Arteriovenous Fistula Ligation via a Modified Suboccipital Craniectomy and C1 Laminectomy: Operative Video

Dural arteriovenous fistulas (dAVFs) are vascular malformations of the central nervous system that feature an arteriovenous shunt fed by dural arteries and can be intracranial or spinal.1-3 Spinal dAVFs are classically found at the nerve root sleeve.3 The arterial supply can often be predicted by the fistula location, whereas the symptomatology and risk of hemorrhage is determined by the venous drainage pattern.1-3 Craniocervical fistulas, a subset of dAVFs, may arise in association with the anterior condylar venous confluence or more dorsally in association with the transdural segment of the vertebral artery.1-3 This latter type of fistula typically has spinal venous drainage and may present with myelopathy from spinal cord venous congestion. We present a 61-year-old man who presented with a 2-week history of neck pain and paraparesis. Magnetic resonance imaging of the cervical spine revealed diffuse T2 hyperintensity of the cord from the pons to the level of the T1 vertebra. A computed tomography angiogram showed a possible dAVF at the craniocervical junction on the left. Because of the unclear nature of the patient's spinal cord lesion, a cerebral angiogram was performed. It confirmed a dAVF associated with the transdural segment of the left vertebral artery, with small dural feeders from the left vertebral artery and venous drainage into the anterior spinal vein. The patient underwent a modified suboccipital craniectomy and C1 laminectomy for dAVF ligation (Video 1). He was extubated postoperatively and discharged to a rehabilitation unit with improvement in lower extremity strength.