Anterior Approach Combined with Endoscopic Fluorescence Video Angiography for a Cervical Perimedullary Arteriovenous Fistula

Background: Perimedullary arteriovenous fistulas (pAVFs) of the anterior cervical spinal cord are rare and difficult to eradicate by surgery because of the limitations of the approach routes. Because of the anatomic relationships, an anterior approach with corpectomy can provide direct observation. However, a narrow corridor to the lesion is the drawback of this approach. Therefore, to overcome this limitation, we introduced angled endoscopes integrated with fluorescence video angiography to observe the real-time blood flow. Case Description: A 47-year-old woman was incidentally found to have a pAVF fed by multiple radicular arteries, and she underwent direct surgery via the anterior approach. Although observation of the entire lesion was difficult with the microscope alone, the introduction of the angled endoscope made it possible to observe the lateral portion of the spinal cord hidden behind the dura mater. Furthermore, endoscopic fluorescein video angiography visualized residual fine feeding arteries that were then electrocoagulated, which contributed to complete obliteration of the shunt. Conclusions: The anterior approach with endoscopic assistance is a reasonable strategy for the treatment of ventrally located cervical pAVFs. Furthermore, integration of a fluorescence video angiography system with the endoscope enables confirmation of the complicated real-time hemodynamics of the pAVFs, contributing to reliable treatment. © 2020 Elsevier Inc.