Surgical management of spinal dural arteriovenous fistulae: systematic review of current practices and open questions.

Background: Spinal dural arteriovenous fistulae(sDAVF) represent the most common spinal vascular malformation. Therapeutic strategies include both surgical and endovascular approaches. Surgical interruption of the fistula is crucial to prevent the onset and progression of neurological symptoms. Despite a range of surgical techniques, little research has evaluated their relative efficacy. This review aims to summarize the available surgical techniques and identify open questions for future research.

Methods: A systematic review was conducted on PubMed, Ovid, and Web of Science databases to identify surgically treated cohorts of sDAVF. Five commonly reported surgical steps were analyzed: type of approach, temporary clipping, shunt disruption method, fistulous vein management, and epidural vessel management. In addition, open questions lacking consensus or evidence were identified for pre, intra and postoperative stages.

Results: 63 of 115 analyzed cohorts described surgical techniques. The most commonly used approach was single-level laminectomy (52.4%). Temporary clipping was used in 11.1% of cases, while 15.9% of studies reported excision of intradural arterialized veins. There was wide variation in the methods used to close the fistula, with the most frequent being coagulation alone (27.5%). The management of epidural vessels was reported in 11.1% of studies. Sixteen major open questions were identified with a wide variety of technical nuances.

Discussion: Surgical treatment of sDAVF is not a standardized procedure but rather encompasses significantly different techniques. The lack of controlled trials leaves many questions unanswered, including optimal surgical strategies and the role of adjunct imaging and monitoring techniques. Further research is required to address these gaps and refine treatment protocols.