HOW I DO IT - SPINE Surgical ligation of spinal dural arteriovenous fistula Thomas Sorenson 1 & Enrico Giordan 2 & Delia Cannizzaro 3,4 & Giuseppe Lanzino 1 Received: 11 June 2017 /Accepted: 29 October 2017 # Springer-Verlag GmbH Austria 2017 Abstract Background Spinal dural arteriovenous fistulas (SDAVFs) are abnormal arteriovenous shunts between a radicular artery and the radicular vein, located in the dorsal surface of the dura sleeve, which drains in a retrograde manner into the coronal venous plexus of the spinal cord without an interposed capil- lary network. This result is a venous hypertension that reduces spinal cord perfusion and leads to ischemia and edema. Spontaneous resolution is extremely rare and, once symptom- atic, the typical course is further progression with increased neurological impairment. Therefore, once a fistula is diag- nosed, treatment is recommended. Method The fistula is placed at the level of intervertebral fo- ramen and surgical ligation is performed through a laminectomy. After dural opening, the area is inspected, and the arterialized vein is identified and ligated. Conclusions Laminectomy and arteriovenous fistula ligation is a safe and reliable approach for accessing and treating spinal dural arteriovenous fistulas. Keywords Arteriovenous spinal fistula . Spinal dural fistula treatment . Spinal arteriovenous shunt Relevant anatomy Arterial vascularization of the spinal cord is provided by an anterior spinal artery and two posterior spinal arteries, with a variable supply from medullary branches of the metameric radiculo-meningeal arteries. Venous drainage is provided by the longitudinal spinal veins linked together and to the epidu- ral network [1–3]. A spinal radicular branch supplying the dura and the nerve root as a radiculomeningeal artery is pres- ent at each segment and follows the course of the correspond- ing nerve root (Fig. 1). Spinal dural arteriovenous fistulas (SDAVFs) are predominantly located around the area of the intervertebral foramen within the dura, and arterial supply is provided via a posterior radiculomeningeal branch of the cor- responding segmental radicular artery that supplies the dura at every level [3–7]. Venous drainage consists of a posterior radicular vein, a tributary of the radiculomedullary vein, which coalesces with normal spinal cord venous drainage in a retrograde fashion. The venous outflow through the medul- lary vein and venous plexus is located on the dorsal surface of the spinal cord in 80–90% of the cases [2]. Description of the technique Position The patient is positioned prone on a Jackson table with care so as to minimize the degree of intraabdominal pressure. In pa- tients with high- or mid-thoracic dural arteriovenous fistulas, radiopaque markers are useful for facilitating intraoperative Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00701-017-3381-z) contains supplementary material, which is available to authorized users. * Giuseppe Lanzino lanzino.giuseppe@mayo.edu 1 Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA 2 Department of Neurologic Surgery, University of Padua, Padua, Italy 3 Department of Neurologic Surgery, Humanitas Clinical and Research Center, Mozzano, Italy 4 Department of Neurology, Psychiatry and Neurologic Surgery, Sapienza University, Rome, Italy Acta Neurochir https://doi.org/10.1007/s00701-017-3381-z