Spinal manifestations of spontaneous intracranial hypotension

Clinical article

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Object

The goal of the study was to elucidate the spinal manifestations of spontaneous intracranial hypotension.

Methods

The authors reviewed the medical records and imaging studies of 338 consecutive patients with spontaneous intracranial hypotension who were evaluated at their institution between 2001 and 2010.

Results

Twenty patients (6%; mean age 35.8 [range 16 to 60 years]; 5 males and 15 females) had convincing signs or symptoms referable to the spinal cord or spinal nerve roots. The spinal manifestations consisted of radiculopathy in 11 patients (unilateral in 8 and bilateral in 3), myelopathy in 8 patients, and bibrachial amyotrophy in 1 patient. The cervical spine was involved in 12 patients, the thoracic spine in 5, and the lumbosacral spine in 3. The spinal symptoms were positional in only 3 patients. The spinal manifestations occurred around the time of the headache onset in 16 patients, and months to years after the positional headache had resolved in 4 patients. A large extrathecal CSF collection causing compression of the spinal cord or nerve root was responsible for the spinal manifestations in the majority of patients. Treatment of the spinal CSF leak resulted in resolution of the spinal manifestations along with the headache, except for those in the patient with bibrachial amyotrophy.

Conclusions

Spinal manifestations are uncommon in cases of spontaneous intracranial hypotension, occurring in about 6% of patients, but myelopathy and radiculopathy involving all spinal segments do occur. Unlike the headache, the spinal manifestations usually are not positional and are caused by mass effect from an extradural CSF collection.

Abbreviation used in this paper:ALS = amyotrophic lateral sclerosis.

Article Information

Address correspondence to: Wouter I. Schievink, M.D., Department of Neurosurgery, Cedars-Sinai Medical Center, 8631 West Third Street, Suite 800E, Los Angeles, California 90048. email: SchievinkW@cshs.org.

Please include this information when citing this paper: published online November 2, 2012; DOI: 10.3171/2012.10.SPINE12469.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Cervical myelopathy and radiculopathy in spontaneous intracranial hypotension. Postmyelography CT scans (A, B, and E) and axial T2-weighted MR images (C, D, and F) showing extensive extrathecal CSF collections in 5 patients with a cervical myelopathy (A–E) and a disc herniation in 1 patient with a cervical myelopathy (F) who also had multiple spinal meningeal diverticula. Postmyelography CTs (G, H, and J) and axial T2-weighted MR image (I) demonstrating extensive extrathecal CSF collections in 4 patients with a cervical radiculopathy, and an MR myelogram (K) showing multiple spinal meningeal diverticula in a patient with a left C-7 radiculopathy. Note how the C-7 nerve root is one of the few not affected by meningeal diverticular formation (K, black arrow).

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    Bibrachial amyotrophy in spontaneous intracranial hypotension. Preoperative (left) and postoperative (right) sagittal T2-weighted MR images revealing resolution of a large ventral extrathecal CSF collection in a patient who presented with ALS-like symptoms.

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    Thoracic myelopathy and radiculopathy in spontaneous intracranial hypotension. Axial T2-weighted MR images (A and B) showing extensive extrathecal CSF collections in 2 patients with a thoracic myelopathy. Postmyelography CT scans (C and D) and axial T2-weighted MRI (E) demonstrating extensive extrathecal CSF collections in 3 patients with a thoracic radiculopathy.

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    Lumbosacral radiculopathy in spontaneous intracranial hypotension. Preoperative MR myelogram (A) showing extensive CSF leaks along several lumbar nerve roots. Preoperative MR myelogram (B) and axial T2-weighted MR image (C) revealing lumbosacral dural ectasia in 2 patients with Marfan syndrome.

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