Surgical treatment of spontaneous spinal cerebrospinal fluid leaks

Restricted access

Object. Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension and may require neurosurgical intervention. In the present report the authors review their experience with the surgical management of spontaneous spinal CSF leaks.

Methods. Between 1992 and 1997, 10 patients with spontaneous spinal CSF leaks and intracranial hypotension were treated surgically. The mean age of the seven women and three men was 42.3 years (range 22–61 years). Preoperative imaging showed a single meningeal diverticulum in two patients, a complex of diverticula in one patient, and a focal CSF leak alone in seven patients. Surgical exploration in these seven patients demonstrated meningeal diverticula in one patient; no clear source of CSF leakage could be identified in the remaining six patients. Treatment consisted of ligation of the diverticula or packing of the epidural space with muscle or Gelfoam. Multiple simultaneous spinal CSF leaks were identified in three patients.

Conclusions. All patients experienced complete relief of their headaches postoperatively. There has been no recurrence of symptoms in any of the patients during a mean follow-up period of 19 months (range 3–58 months; 16 person-years of cumulative follow up). Complications consisted of transient intracranial hypertension in one patient and leg numbness in another patient.

Although the disease is often self-limiting, surgical treatment has an important role in the management of spontaneous spinal CSF leaks. Surgery is effective in eliminating the headaches and the morbidity is generally low. Surgical exploration for a focal CSF leak, as demonstrated on radiographic studies, usually does not reveal a clear source of the leak. Some patients may have multiple simultaneous CSF leaks.

Article Information

Address reprint requests to: Wouter I. Schievink, M.D., Barrow Neurosurgical Associates, 2910 North Third Avenue, Phoenix, Arizona 85013.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 2. Postcontrast CT myelography scan showing a CSF leak along the right T-12 nerve root.

  • View in gallery

    Case 10. Postcontrast CT myelography scans indicating a CSF leak along the right C-5 nerve root (arrows).

  • View in gallery

    Case 7. Postcontrast CT myelography scans indicating CSF leaks along the right C-2 nerve root (arrow at left) and along the right T-9 nerve root (arrow at right).

References

  • 1.

    Bell WEJoynt RJSahs AL: Low spinal fluid pressure syndromes. Neurology 10:5125211960Bell WE Joynt RJ Sahs AL: Low spinal fluid pressure syndromes. Neurology 10:512–521 1960

    • Search Google Scholar
    • Export Citation
  • 2.

    Garcia-Albea ECabrera FTejeiro Jet al: Delayed postexertional headache, intracranial hypotension and racket sports. J Neurol Neurosurg Psychiatry 55:9751992 (Letter)Garcia-Albea E Cabrera F Tejeiro J et al: Delayed postexertional headache intracranial hypotension and racket sports. J Neurol Neurosurg Psychiatry 55:975 1992 (Letter)

    • Search Google Scholar
    • Export Citation
  • 3.

    Hochman MSNaidich TPKobetz SAet al: Spontaneous intracranial hypotension with pachymeningeal enhancement on MRI. Neurology 42:162816301992Hochman MS Naidich TP Kobetz SA et al: Spontaneous intracranial hypotension with pachymeningeal enhancement on MRI. Neurology 42:1628–1630 1992

    • Search Google Scholar
    • Export Citation
  • 4.

    Hortan JCFishman RA: Neurovisual findings in the syndrome of spontaneous intracranial hypotension from dural cerebrospinal fluid leak. Ophthalmology 101:2442511994Hortan JC Fishman RA: Neurovisual findings in the syndrome of spontaneous intracranial hypotension from dural cerebrospinal fluid leak. Ophthalmology 101:244–251 1994

    • Search Google Scholar
    • Export Citation
  • 5.

    Lehman RAWStears JCWesenberg RLet al: Familial osteosclerosis with abnormalities of the nervous system and meninges. J Pediatr 90:49541977Lehman RAW Stears JC Wesenberg RL et al: Familial osteosclerosis with abnormalities of the nervous system and meninges. J Pediatr 90:49–54 1977

    • Search Google Scholar
    • Export Citation
  • 6.

    Marcelis JSilberstein SD: Spontaneous low cerebrospinal fluid pressure headache. Headache 30:1921961990Marcelis J Silberstein SD: Spontaneous low cerebrospinal fluid pressure headache. Headache 30:192–196 1990

    • Search Google Scholar
    • Export Citation
  • 7.

    Miles JPennybacker JSheldon P: Intrathoracic meningocele. Its development and association with neurofibromatosis. J Neurol Neurosurg Psychiatry 32:991101969Miles J Pennybacker J Sheldon P: Intrathoracic meningocele. Its development and association with neurofibromatosis. J Neurol Neurosurg Psychiatry 32:99–110 1969

    • Search Google Scholar
    • Export Citation
  • 8.

    Mokri PParisi JEScheithauer BWet al: Meningeal biopsy in intracranial hypotension: meningeal enhancement on MRI. Neurology 45:180118071995Mokri P Parisi JE Scheithauer BW et al: Meningeal biopsy in intracranial hypotension: meningeal enhancement on MRI. Neurology 45:1801–1807 1995

    • Search Google Scholar
    • Export Citation
  • 9.

    Pannullo SCReich JBKrol Get al: MRI changes in intracranial hypotension. Neurology 43:9199261993Pannullo SC Reich JB Krol G et al: MRI changes in intracranial hypotension. Neurology 43:919–926 1993

    • Search Google Scholar
    • Export Citation
  • 10.

    Paulson GWKlawans HL Jr: Benign orgasmic cephalgia. Headache 13:1811871974Paulson GW Klawans HL Jr: Benign orgasmic cephalgia. Headache 13:181–187 1974

    • Search Google Scholar
    • Export Citation
  • 11.

    Philip NAndrac LMoncla Aet al: Multiple lateral meningoceles, distinctive facies and skeletal anomalies: a new case of Lehman syndrome. Clin Dysmorphol 4:3473511995Philip N Andrac L Moncla A et al: Multiple lateral meningoceles distinctive facies and skeletal anomalies: a new case of Lehman syndrome. Clin Dysmorphol 4:347–351 1995

    • Search Google Scholar
    • Export Citation
  • 12.

    Pleasure SJFriedman JKo NUet al: Diencenphalic herniation as a result of spontaneous intracranial hypotension (SIH). Neurology 48:A260A2611997 (Abstract)Pleasure SJ Friedman J Ko NU et al: Diencenphalic herniation as a result of spontaneous intracranial hypotension (SIH). Neurology 48:A260–A261 1997 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 13.

    Pyeritz REFishman EKBernhardt BAet al: Dural ectasia is a common feature of the Marfan syndrome. Am J Hum Genet 43:7267321988Pyeritz RE Fishman EK Bernhardt BA et al: Dural ectasia is a common feature of the Marfan syndrome. Am J Hum Genet 43:726–732 1988

    • Search Google Scholar
    • Export Citation
  • 14.

    Rando TAFishman RA: Spontaneous intracranial hypotension: report of two cases and review of the literature. Neurology 42:4814871992Rando TA Fishman RA: Spontaneous intracranial hypotension: report of two cases and review of the literature. Neurology 42:481–487 1992

    • Search Google Scholar
    • Export Citation
  • 15.

    Renowden SAGregory RHyman Net al: Spontaneous intracranial hypotension. J Neurol Neurosurg Psychiatry 59:5115151995Renowden SA Gregory R Hyman N et al: Spontaneous intracranial hypotension. J Neurol Neurosurg Psychiatry 59:511–515 1995

    • Search Google Scholar
    • Export Citation
  • 16.

    Schievink WIEbersold MJAtkinson JLD: Roller-coaster headache due to spinal cerebrospinal fluid leak. Lancet 347:14091996 (Letter)Schievink WI Ebersold MJ Atkinson JLD: Roller-coaster headache due to spinal cerebrospinal fluid leak. Lancet 347:1409 1996 (Letter)

    • Search Google Scholar
    • Export Citation
  • 17.

    Schievink WIMeyer FBAtkinson JLDet al: Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg 84:5986051996Schievink WI Meyer FB Atkinson JLD et al: Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg 84:598–605 1996

    • Search Google Scholar
    • Export Citation
  • 18.

    Schievink WIReimer RFolger WN: Surgical treatment of spontaneous intracranial hypotension associated with a spinal arachnoid diverticulum. Case report. J Neurosurg 80:7367391994Schievink WI Reimer R Folger WN: Surgical treatment of spontaneous intracranial hypotension associated with a spinal arachnoid diverticulum. Case report. J Neurosurg 80:736–739 1994

    • Search Google Scholar
    • Export Citation
  • 19.

    Schievink WITorres VE: Spinal meningeal diverticula in autosomal dominant polycystic kidney disease. Lancet 349:122312241997 (Letter)Schievink WI Torres VE: Spinal meningeal diverticula in autosomal dominant polycystic kidney disease. Lancet 349:1223–1224 1997 (Letter)

    • Search Google Scholar
    • Export Citation
  • 20.

    Spelle LBoulin APierot Let al: Spontaneous intracranial hypotension: MRI and radionuclide cisternography findings. J Neurol Neurosurg Psychiatry 62:2912921997 (Letter)Spelle L Boulin A Pierot L et al: Spontaneous intracranial hypotension: MRI and radionuclide cisternography findings. J Neurol Neurosurg Psychiatry 62:291–292 1997 (Letter)

    • Search Google Scholar
    • Export Citation
  • 21.

    Weitz SRDrasner K: Spontaneous intracranial hypotension: a series. Anesthesiology 85:9239251996Weitz SR Drasner K: Spontaneous intracranial hypotension: a series. Anesthesiology 85:923–925 1996

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 253 253 20
Full Text Views 195 171 2
PDF Downloads 117 104 1
EPUB Downloads 0 0 0

PubMed

Google Scholar