case_images: PMC11029105_01
case_images: Left. Sagittal T2-weighted magnetic resonance imaging of the cervical and upper thoracic spine. Right. Axial T2-weighted magnetic resonance imaging centered behind the C2, C3, and C4 vertebral bodies. Red arrows. Dural fold originating at C1 and terminating at C7 bisecting the spinal cord at the C3-4 level
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case_images: The spinal cord was found to be bisected at the C3-4 level from a posterior dural fold originating at C1 and terminating at C7 [Figure 1].
case_images: Sagittal T2-weighted magnetic resonance imaging of the cervical and upper thoracic spine. Red arrow. Plum line from the center of the spinal cord demonstrating the extent of laminectomy which must be performed for adequate spinal cord decompression
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case_images: T3. The goal was to release the dura, allowing the spinal cord to shift backward into the region affected by dural ectasia. To determine the stopping point for the laminectomy, a vertical plumb line was drawn on a sagittal MRI image, guiding the removal of the lamina obstructing the cord's transition from cervical to thoracic regions [Figure 2].
case_images: (a) Postoperative sagittal T2-weighted magnetic resonance imaging of the cervical and upper thoracic spine showing decompression and migration of the spinal cord posteriorly. (b) Axial T2-weighted magnetic resonance imaging of the cervical at the C2 level. Blue arrow. Large arterialized epidural vein not noted on prior imaging. Red arrow. Spinal cord now significantly compressed by arterialized epidural vein which was allowed to expand secondarily to cervical decompression. (c) Axial T2-weighted magnetic resonance imaging of the cervical at the C7 level. Yellow arrow. Empty spinal canal. Green arrow. Posteriorly migrated spinal cord post laminectomy
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case_images: However, the lower spinal cord was completely decompressed, having migrated posteriorly beyond the spinal column [Figure 3].
case_images: Mid-phase left vertebral artery digital subtraction angiography demonstrating retrograde flow into the right vertebral artery to the arteriovenous fistula. Red arrow. Multilevel vertebral artery to epidural vein fistula with large draining arterialized epidural vein centrally
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case_images: This necessitated the complete sacrifice of the V2 segment of the vertebral artery through catheter-based embolization with coils [Figure 4].
case_images: Sagittal and Anteroposterior (AP) postoperative X-rays showing posterior cervical instrumentation from C2 to T4 with 4 rod rigid fixation and coil sacrifice of the V2 segment of the right vertebral artery. Metal mesh can be seen on the AP view protecting the posteriorly migrated spinal cord
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case_images: In addition, a dorsal metal mesh was positioned to serve as a protective barrier over the spinal cord during potential future posterior cervical procedures in this area [Figure 5].