Operative Planning

• Review imaging: magnetic resonance imaging (MRI), myelography (optional), spinal angiography

Embolization

• Embolization as sole intervention associated with high rate of recurrence
  
• In patients with acute neurologic decline without hemorrhage (Foix-Alajouanine syndrome), embolic occlusion of fistula at conclusion of diagnostic selective angiogram prior to surgery may prevent further deterioration
  
• Give dexamethasone postembolization to reduce swelling

Routine Equipment

• Laminectomy instruments
  
• High-speed drill (optional)
  
• Microsurgical instruments

Special Equipment

• Consider neurophysiological monitoring of somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs)

Operating Room Set-up

• Open-frame spinal table or electric table with bolsters or Wilson frame
  
• Ensure ability to obtain anteroposterior and lateral radiographs to confirm operative levels
  
• Headlight
  
• Loupes (optional)
  
• Bipolar and Bovie cautery
  
• Microscope with bridge

• General anesthesia
  
• Arterial line for blood pressure monitoring
  
• Intravenous antibiotics (cefazolin 2 g or vancomycin 1 g for adults) should be given 30 minutes prior to incision
  
• Minimize halogenated inhalational agents and nitrous oxide if monitoring SSEPs and MEPs

Positioning

• Patient prone
  
• Open-frame spinal table or electric table with bolsters or Wilson frame
  
• Ensure ability to obtain anteroposterior and lateral radiographs to confirm operative levels
  
• For lesions at T6 or above, pad arms well and tuck along sides; for more distal lesions, abduct shoulders and flex elbows 90 degrees
  
• Secure head with foam mask, Gardner-Wells tongs with 15 lb of inline traction, or Mayfield head holder
  
• If using foam mask, ensure no ocular pressure

Sterile Scrub and Prep

• As for posterior cervical or posterior thoracic approach

Incision

• Center midline linear incision over levels of the lesion to permit exposure one level proximal and one level distal to the lesion

Laminectomy

• Bilateral subperiosteal exposure to medial facet joints bilaterally
  
• Perform bilateral laminectomies from one level proximal to one level distal to the dural arteriovenous fistula (AVF)
  
• Do not violate facet joints (may lead to postoperative kyphotic deformity)
  
• Wax bone edges, obtain meticulous epidural hemostasis

Dural Opening

• Open dura in midline
  
• Secure edges of dura to paraspinal muscles with 4–0 silk tacking sutures