Microsurgical Ligation of Spinal Dural Arteriovenous Fistula

Spinal dural arteriovenous fistulas are a reversible cause of progressive thoracic myelopathy, for which definitive treatment requires complete disconnection of the pathological arteriovenous shunt. We demonstrate microsurgical clip occlusion and disconnection of a right T4 spinal dural arteriovenous fistula using indocyanine green (ICG) videoangiography and intraoperative neuromonitoring. Following T4-T5 laminectomy, the fistulous point was identified near the right T4 nerve root exit zone, with ICG confirming arterialized venous drainage. A clip was placed immediately adjacent to the dural fistulous point, and repeat ICG demonstrated obliteration of the shunt. The draining vein was subsequently coagulated and divided, with stable somatosensory and motor evoked potentials throughout the procedure. Precise angiographic localization and disconnection as close as possible to the dural fistulous point are critical to minimize residual shunting, vascular recruitment, and recurrence. ICG videoangiography and neuromonitoring provide valuable intraoperative confirmation for safe and definitive microsurgical treatment.