Spinal Fistula Disconnection

If a patient develops a spinal dural arteriovenous fistula, damage to the spinal cord can occur. This condition causes high pressure blood from an artery to flow the wrong way into the veins that drain the spinal cord, causing damage over time. This can cause pain, numbness, bowel or bladder problems or even paralysis if left untreated over months or years. This surgery is performed to block this connection to prevent further damage and allow the spinal cord to heal.

First, a spinal angiogram will be done. This involves placing a needle into the artery of the thigh and injecting dye into each blood vessel branch at every level of the spine to find out where the fistula is located. Later, at surgery, x-rays are used to identify this exact point. An incision is made in the middle of the back over this area, and the muscles are lifted off the bones of the spine. The back of the spinal canal, called the lamina, is removed at one or more levels.  The spinal fluid sack is then opened. Using a microscope, the fistula is found where it comes into the spine, and a small clip is placed on it. Another angiogram is done showing that blood is not going the wrong way into the spinal cord anymore. The fistula is then cut, the sack of spinal fluid is sewn shut and the back muscles and skin are closed with stitches and/or staples. Sometimes the bone (the lamina) are reattached with small plates and screws, as well.

Back pain could occur from the part of the surgery on the skin, muscles and bones of the spine. This will generally improve with time but may benefit from postoperative physical therapy.

This surgery involves working around the spinal cord and/or nerves of the spine, so damage to them is possible, but rare. This could result in numbness, weakness or pain. The spinal fluid could leak out of the spinal fluid sack and require further treatment. Bleeding or infection are also risks of any surgery. It is possible that the fistula cannot be fully disconnected and further treatment may be needed.

Finally, some of the damage and symptoms from the fistula could be permanent and may not fully recover, even with a successful surgery. Most patients experience significant improvement in their symptoms after surgery as long as the fistula is discovered and treated in time.

If you take any blood thinners—for example, Coumadin, aspirin, Plavix, Xeralto, Eliquis or Ticlid—make sure your surgeon is aware of this medication as soon as possible. You will be given specific instructions regarding any need to discontinue or modify your current use of any blood-thinning medication. If necessary, your surgeon will get clearance from your cardiologist or other physician to ensure that this medication change is safe and appropriate for you based on your heart history, including prior heart attack, stent placement or open-heart surgery.

Stop taking aspirin-based products one week before surgery. Also, stop taking non-steroidal anti-inflammatory drugs, such as ibuprofen, Naprosyn, Naproxen, Advil and Motrin, at least one week before surgery.

Please do not eat or drink anything after midnight the day of your surgery. This includes water, coffee, chewing gum and hard candies. You may brush your teeth with toothpaste the morning of surgery.

Some daily medications may be taken the day of surgery with a sip of water. Medications that are appropriate to take the morning of surgery will be discussed with you by the hospital staff or your surgeon’s staff.

Smoking and alcohol use should be stopped before surgery.

Rehabilitation, either in a facility or outpatient, may be needed after surgery. This is both to recover from the surgery as well as to help the nerves heal after the fistula is repaired.

A lifting limit of 10 pounds is recommended after surgery for one month. Bending and twisting should be avoided and only light activity, such as going for walks, should be done. Stitches or staples will be removed 10 – 14 days after surgery. In most cases, showers can be resumed two days after surgery, or one day after drain removal if a drain is left after the procedure. Four to six weeks off of work should be expected at minimum.

Generally, any pain, numbness or weakness in the arms or legs that was present before surgery will improve over time afterward. Pain from the surgery will ease over the first few weeks. The surgery area should be checked every day for drainage, swelling, increasing redness or pain. Any worsening symptoms such as numbness, weakness or new bowel or bladder problems should be reported to your doctor.

After leaving the hospital, physical therapy is not necessary for most patients. Your best therapy is walking, which increases blood flow to the spine and assists in the healing process. Try walking on a structured basis, slowly at first and progressing on a regular basis as your pain begins to lessen.

If your recovery is slower, you may need additional therapy after surgery. If needed, physical therapy will be discussed with you at your followup appointment.