A posterior cervical laminectomy  for avm (arteriovenous malformation) is generally performed to remove an avm  from within or surrounding the spinal cord.  The patient is lying on their abdomen, with their head in a Mayfield head holder (pins in a clamp hold the head in place).  A linear incision is made in the back of the neck, in a vertical (up and down) manner.  The surgeon will then dissect down, through the subcutaneous tissues, to the fascia (firm membrane) overlying the spinous processes ( bones protruding from the back of the spine).  The surgeon will then pull the muscle away from the bones, exposing the extent of the roof of the spinal canal on both sides.  Generally, under microscopic vision, the surgeon will drill or bite away the laminae (the bone covering the spinal cord).  At this point, the dura, which is a tough membrane covering the cord, is opened.  The avm may be seen involving or surrounding the cord, or it may be buried within the spinal cord.   Following the removal of as much avm as possible, the surgeon will close the spine.  The dura will be closed with suture.  The surgeon will then close the various muscle and skin layers with suture, and the skin with suture or staples.  The wound is then dressed in a sterile manner.

Procedure Risks

Posterior  cervical laminectomy with avm removal has substantial risks, depending on the type and location of avm.    Since this procedure is relatively uncommon, your surgeon will describe the risks specific to the type of avm you have.  These can be broken down into two categories, 1) those related to the operative site, and 2) those related to the risks of anesthesia. 

Risks related to the operative site: 

Surgical Exposure:  The patient is placed in a prone position (on their abdomen), with the head fixed in Mayfield head pins.  This is a clamp which fixes the head in position.  This is an extremely safe device, but there can be potential lacerations in the skin,  as well as infection.  In this position, there can be pressure sores, pressure injuries to nerves, and injury to the eyes as a result of pressure to them.
During surgical dissection, injury to muscle surrounding the spine can occur.

Spinal Cord/Nerve Root injuries: If there is any injury to the spinal cord or nerve roots, the consequences may involve loss of sensation, increased burning sensation, paralysis, weakness, loss of bowel, bladder, sexual function.  There may be a spinal fluid leak postoperatively, as the covering of the cord (dura) is widely opened during the procedure to gain access to the avm.  Although the surgeon will attempt to remove as much of the avm as possible, there may be a small or large amount of avm left behind.     Control of the diaphragm responsible for breathing, eminates from the upper cervical spinal cord.  If this area is damaged, the patient may need a permanent tracheostomy (hole in the windpipe), to provide a diversion of the route air takes to enter the lungs.  A feeding tube may also be needed, postoperatively.

General Risks:  These include such general difficulties, such as bleeding, infection, stroke, paralysis, coma and death.  The scar on the neck may be tender, or may heal in an unpleasant manner.  There is also the possibility that the surgery may not relieve the symptoms for which the procedure was performed.  The problem for which the surgery was performed may recur, requiring additional surgery in the future.  In addition, although every attempt is made to protect all areas of the body from pressure on nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases.

Risks of Anesthesia: Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion, if it given.

 

Post-operative care:

You may be required to wear a soft or firm cervical collar postoperatively.  There shall be no bending, twisting, or heavy lifting for several weeks after surgery.  Physical therapy may or may not be implicated.  Your doctor will gradually ease your work restrictions, depending on your progress. 

Remember to keep the wound dry and clean.  Notify your surgeon of any drainage or temperatures greater than 101 Fahrenheit.

You may experience some continuing incisional pain and occasional spasms in the back of your neck from time to time.    There are several steps you can take which will help speed your recovery as well as give you the best chance for a successful outcome.

1. Immediately upon discharge, contact our office and set up an appointment for staple removal is one has not already been set up.
2. Wear the collar given to you by your surgeon.  It should be worn continuously except when showering or shaving, unless instructed otherwise by your surgeon.
3. Do no drive until cleared with your physician.
4. Avoid riding in a car more than 50 miles.
5. When shaving, avoid tilting your neck back.  When washing your hair, do it in the shower and not in the sink.
6. Begin an exercise program of walking to gain strength.
7. Lift nothing heavier than one pound (one quart of milk).
8. No jogging, weight lifting, or other heavy exercise for now.
9. Do not raise your arms above your head.
10. You may shower with the incision covered.
11. You may engage in sexual relations.
12. In doing any activity in which you notice an increased amount of neck, shoulder or arm pain, STOP.  Your body is telling you that you are doing too much.
13. If you notice any swelling, redness or opening of the incision, notify your surgeon immediately.  If any clear or purulent fluid drains from your neck, notify your surgeon immediately.
14. If you develop  fever or a stiff neck, notify your surgeon immediately.
15. If you have any questions, please do not hesitate to call your surgeon.
16. Take your temperature at 4:00 PM daily until clips/sutures are removed.
17. Take your medications as prescribed by your physician.
18. It takes 6-18 months for a nerve to heal.  You may have numbness, tingling, creepy crawly sensations or fleeting pain during this time.