title: Minimally invasive intradural spinal dural arteriovenous fistula ligation.
abstract: BACKGROUND
  Dural arteriovenous fistulas (DAVFs) have traditionally been approached through a bilateral laminectomy procedure with intradural exploration and ligation of the fistulae. A minimally invasive approach for DAVF ligation may be associated with fewer complications and a shorter recovery than the traditional laminectomy procedure. Our objective was to determine the feasibility, safety, and efficacy of intradural DAVF ligation via the use of a minimally invasive microsurgical technique.
  
  
  METHODS
  Seven patients with thoracolumbar DAVFs were microsurgically treated with a minimally invasive technique. The procedure entailed localization with the use of fluoroscopy followed by a midline 2.2-cm skin opening. Exposure was facilitated by the use of a tubular retractor. Intradural access was obtained after hemilaminectomy, and the fistula was identified and ligated. Dural closure was facilitated by the use of self-closing nitinol clips. The incidence of postoperative complications, blood loss, and length of hospital stay were reviewed.
  
  
  RESULTS
  Each patient tolerated the procedure well. There were no intraoperative or postoperative complications. Specifically, there were no new neurological deficits and no cerebrospinal fluid leaks. Each patient was ambulatory within 18 hours with only mild incisional back pain. Mean length of stay was 1.6 days. One-year follow-up demonstrated obliteration of the fistula with improvement or stabilization of neurological deficits in all cases.
  
  
  CONCLUSIONS
  The minimally invasive approach for intradural ligation of DAVFs appears to be a reasonable alternative to bilateral full laminectomies. Although no direct comparison with the more extensive bilateral laminectomy approach has been performed, our initial experience suggests that this novel approach may reduce blood loss and length of hospital stay.
authors.affiliation: Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, Arizona, USA. Electronic address: patel.naresh@mayo.edu.
authors.forename: Naresh P
authors.initials: NP
authors.lastname: Patel
authors.forename: Barry D
authors.initials: BD
authors.lastname: Birch
authors.forename: Mark K
authors.initials: MK
authors.lastname: Lyons
authors.forename: Stacie E
authors.initials: SE
authors.lastname: DeMent
authors.forename: Gregg A
authors.initials: GA
authors.lastname: Elbert
mesh_terms: D000368:Aged; D000768:Anesthesia, General; D020785:Central Nervous System Vascular Malformations / Q000601:surgery*; D004388:Dura Mater / Q000601:surgery*; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D007796:Laminectomy; D008026:Ligation; D008136:Longevity; D008297:Male; D008866:Microsurgery; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000188:drug therapy / Q000453:epidemiology; D016896:Treatment Outcome