to occiput and C1)
• Intraoperative CSF leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord
• Postoperative weakness or numbness or continued pain
• Postoperative wound infection
• Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
• Prolonged hospitalization due to invasiveness of surgery and other comorbidities/iatrogenic infection
Prognosis
• Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities
• PT and OT will be needed postoperatively, immediately and as outpatient to regain strength
• Brace/collar is used for 8 weeks after discharge to immobilize to increase rate of healing
1.3.2 Cervical Vascular Lesion Treatment for Arteriovenous Malformation (AVM) (Vertebral Pathology)
Symptoms and Signs (AVM)
• Dilated arteries and veins with dysplastic vessels
• Subarachnoid hemorrhage
• Neck pain and loss of mobility due to neck pain
• Pain in moving shoulders
• Meningism (neck rigidity, photophobia, and headache)
• Myelopathy
• Seizure
• Ischemic injury to cervical
• Increased sweating around cervical vascular lesion
• Hemorrhaging
• Inability to conduct fine motor skills with hands
Surgical Pathology
• Cervical vascular benign/malignant lesions
Diagnostic Modalities
• Angiography:
– Preoperative spinal angiography
– Intraoperative indocyanine green (ICG) angiography
• CT of cervical spine with and without contrast (can rule out acute hemorrhage)
• MRI of cervical spine with and without contrast
Differential Diagnosis:
• Fibromuscular dysplasia (FMD):
– Craniocervical FMD
• Spinal AVM (see ▶Fig. 1.17 and ▶Fig. 1.18):
– Intradural-intramedullary (hemorrhaging common)
◦ Glomus (Type II) (see ▶Fig. 1.19 and ▶Fig. 1.20)
◦ Juvenile (Type III)
– Intradural-extramedullary
– Conus medullaris
– Metameric
– Extradural
– Cavernoma
– Capillary telangiectasia
• Spinal dural arteriovenous fistula (AVF, Type I) (see ▶Fig. 1.21):
– Intradural-extramedullary
◦ Perimedullary AVF (Type IV)
– Intradural-intramedullary
– Extradural
• Vertebral sarcoidosis
• Dissection syndromes:
– Cervical internal carotid artery
– Extracranial vertebral artery
Treatment Options
• Conservative observation
• Radiation treatment:
– Conventional radiation: not very effective therapy
Fig. 1.17 (a–g) Radiology revealed an upper cervical intradural arteriovenous fistula (AVF) with an aneurysm in a teenage girl. Several feeding vessels were identified at the fistula. The fistula was surgically treated after reducing its blood flow by placing a coil in the main feeding artery. (Source: Operative procedure. In: Macdonald R, ed. Neurosurgical Operative Atlas: Vascular Neurosurgery. 3rd ed. Thieme; 2018).
Fig. 1.18 (a–e) Radiology revealed a cervical diffuse intramedullary arteriovenous malformation (AVM) in a teenage boy. Feeding vessels were identified to be from the anterior spinal artery and muscular branches. (Source: Relevant anatomy and classification. In: Spetzler R, Kalani M, Nakaji P, eds. Neurovascular Surgery. 2nd ed. Thieme; 2015).
Fig. 1.19 (a, b) Preoperative angiography revealed an unresectable type 2 cervical arteriovenous malformation (AVM). Postoperative angiography (24 months) demonstrates successful treatment of nidus via stereotactic radiosurgery. (Source: Stereotactic radiosurgery of spinal arteriovenous malformations. In: Nader R, Berta S, Gragnanielllo C, et al, eds. Neurosurgery Tricks of the Trade: Spine and Peripheral Nerves. 1st ed. Thieme; 2014).
