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Yu Z, Zhang HFZ, Wang YJ. Surgical treatment of mixed cervical spondylosis with spontaneous cerebrospinal fluid leakage: A case report. World J Clin Cases 2023; 11:7242-7247. [PMID: 37946769 PMCID: PMC10631428 DOI: 10.12998/wjcc.v11.i29.7242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 09/07/2023] [Accepted: 09/18/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Spontaneous cerebrospinal fluid (CSF) leaks associated with cervical spondylosis are rare. To our knowledge, only a few cases have been reported in which treatment is challenging and varies from case to case. Here, we review the literature and describe the surgical treatment of a 70-year-old woman who presented with a CSF leak due to a cervical spine spur. CASE SUMMARY A 70-year-old female patient who was treated for a cerebral infarction, presented with complains of weakness in the right lower extremity and a feeling of stepping on cotton. The patient underwent regular neck massage and presented with neck and right shoulder pain radiating to the right upper extremity one-month ago. Magnetic resonance imaging showed a strip of leaking cerebrospinal fluid posterior to the C1-4 vertebrae, and computed tomography showed a "sickle-shaped" disc prolapse with calcification in C4/5. We chose to perform an anterior cervical discectomy. When the prolapsed C4/5 disc was scraped, clear fluid leakage was observed, and exploration revealed a 1 mm diameter rupture in the anterior aspect of the dura mater, which was compressed continuously with cotton patties, with no significant cerebrospinal fluid leakage after 1 h. CONCLUSION Three months after surgery, the patient was asymptomatic and follow-up imaging demonstrated complete resolution.
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Affiliation(s)
- Zhong Yu
- Department of Emergency, Honghui Hospital, Xi’an Jiaotong University, Xi’an 710032, Shaanxi Province, China
| | - Hao-Fu-Zi Zhang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an 710032, Shaanxi Province, China
| | - Yan-Jun Wang
- Department of Emergency, Honghui Hospital, Xi’an Jiaotong University, Xi’an 710032, Shaanxi Province, China
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Farnsworth PJ, Madhavan AA, Verdoorn JT, Shlapak DP, Johnson DR, Cutsforth-Gregory JK, Brinjikji W, Lehman VT. Spontaneous intracranial hypotension: updates from diagnosis to treatment. Neuroradiology 2023; 65:233-243. [PMID: 36336758 DOI: 10.1007/s00234-022-03079-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks, which result in continued loss of CSF volume and multiple debilitating clinical manifestations. The estimated annual incidence of SIH is 5/100,000. Diagnostic methods have evolved in recent years due to improved understanding of pathophysiology and implementation of advanced myelographic techniques. Here, we synthesize recent updates and contextualize them in an algorithm for diagnosis and treatment of SIH, highlighting basic principles and points of practice variability or continued debate. This discussion includes finer points of SIH diagnosis, CSF leak classification systems, less common types and variants of CSF leaks, brain MRI Bern scoring, potential SIH complications, key technical considerations, and positioning strategies for different types of dynamic myelography. The roles of conservative measures, non-targeted or targeted blood patches, surgery, and recently developed endovascular techniques are presented.
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Affiliation(s)
- Paul J Farnsworth
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jared T Verdoorn
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Darya P Shlapak
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Derek R Johnson
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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3
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Beck J, Hubbe U, Klingler JH, Roelz R, Kraus LM, Volz F, Lützen N, Urbach H, Kieselbach K, Fung C. Minimally invasive surgery for spinal cerebrospinal fluid leaks in spontaneous intracranial hypotension. J Neurosurg Spine 2023; 38:147-152. [PMID: 36087332 DOI: 10.3171/2022.7.spine2252] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 07/18/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Spinal CSF leaks cause spontaneous intracranial hypotension (SIH). Surgical closure of spinal CSF leaks is the treatment of choice for persisting leaks. Surgical approaches vary, and there are no studies in which minimally invasive techniques were used. In this study, the authors aimed to detail the safety and feasibility of minimally invasive microsurgical sealing of spinal CSF leaks using nonexpandable tubular retractors. METHODS Consecutive patients with SIH and a confirmed spinal CSF leak treated at a single institution between April 2019 and December 2020 were included in the study. Surgery was performed via a dorsal 2.5-cm skin incision using nonexpandable tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach. The primary outcome was successful sealing of the dura, and the secondary outcome was the occurrence of complications. RESULTS Fifty-eight patients, 65.5% of whom were female (median age 46 years [IQR 36-55 years]), with 38 ventral leaks, 17 lateral leaks, and 2 CSF venous fistulas were included. In 56 (96.6%) patients, the leak could be closed, and in 2 (3.4%) patients the leak was missed because of misinterpretation of the imaging studies. One of these patients underwent successful reoperation, and the other patient decided to undergo surgery at another institution. Two other patients had to undergo reoperation because of insufficient closure and a persisting leak. The rate of permanent neurological deficit was 1.7%, the revision rate for a persisting or recurring leak was 3.4%, and the overall revision rate was 10.3%. The rate of successful sealing during the primary closure attempt was 96.6% and 3.4% patients needed a secondary attempt. Clinical short-term outcome at discharge was unchanged in 14 patients and improved in 25 patients, and 19 patients had signs of rebound intracranial hypertension. CONCLUSIONS Minimally invasive surgery with tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach is safe and effective for the treatment of spinal CSF leaks. The authors suggest performing a minimally invasive closure of spinal CSF leaks in specialized centers.
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Affiliation(s)
| | | | | | | | | | | | - Niklas Lützen
- 2Neuroradiology, Medical Center, University of Freiburg, Freiburg; and
| | - Horst Urbach
- 2Neuroradiology, Medical Center, University of Freiburg, Freiburg; and
| | - Kristin Kieselbach
- 3Interdisciplinary Pain Center, Medical Center, University of Freiburg, Freiburg, Germany
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Barber SM, Sofoluke N, Reardon T, Mongelluzzo G, Weiner GM, Hofstetter C, Telfeian A, Konakondla S. Full Endoscopic Repair of Spontaneous Ventral Cerebrospinal Fluid Leaks in the Spine: Systematic Review of Surgical Treatment Options and Illustrative Case. World Neurosurg 2022; 168:e578-e586. [PMID: 36243360 DOI: 10.1016/j.wneu.2022.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/11/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Spontaneous spinal cerebrospinal fluid (CSF) leaks are a rare entity that can lead to intracranial hypotension and associated headaches, meningismus, and patient debility. Surgical treatment may be necessary for patients who do not respond to conservative management. Surgical repair of CSF leaks located in the ventral thoracic spine traditionally require an invasive, open approach. METHODS We describe the case of a patient with a ventral thoracic spontaneous spinal CSF leak associated with a ventral bony osteophyte successfully treated with spinal endoscopy. We also provide a systematic review of the literature to better understand outcomes of this approach. RESULTS A total of 55 patients were included in the systematic review. The study designs found in the literature review included case reports (66.7%), retrospective cohorts (22.2%), and prospective cohorts (11.1%). Of the studies reporting data, 50% of studies stated they used an open posterior approach to the dural defect, while 37.5% reported using an open anterior approach to the pathology. Only 1 (12.5%) study reported using an endoscope. Most studies (62.5%) used primary closure of the dura in their technique, while 37.5% reported using a local tissue graft (fat or muscle) or a dural sealant for their closure technique, and 25% of studies reported using a dural substitute for their closure technique. Overall mean clinical follow-up was 19.8 months. CONCLUSIONS The endoscopic approach described here for treatment of this rare entity allows for removal of bony spicules/osteophytes and dural repair without the morbidity associated with traditional open dorsolateral or ventrolateral approaches.
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Affiliation(s)
- Sean M Barber
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Nelson Sofoluke
- Geisinger Neuroscience Institute, Geisinger Health, Danville, USA
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, USA
| | | | - Gregory M Weiner
- Geisinger Neuroscience Institute, Geisinger Health, Wilkes-Barre, Pennsylvania, USA
| | - Christoph Hofstetter
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Albert Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Kewlani B, Garton ALA, Hussain I, Chazen JL, Robbins MS, Baaj AA, Greenfield JP. Intracranial hypotension due to ventral thoracic dural tear secondary to osteophyte complex: resolution after transdural thoracic microdiscectomy with dural repair. Illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21615. [PMID: 36273860 PMCID: PMC9379770 DOI: 10.3171/case21615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intracranial hypotension (IH) manifests with orthostatic headaches secondary to cerebrospinal fluid (CSF) hypovolemia. Common iatrogenic etiologies include lumbar punctures and spinal surgery. Although much rarer, structural defects such as osteophytes and herniated calcified discs can violate dural integrity, resulting in CSF leak. OBSERVATIONS The authors reported the case of a 32-year-old woman who presented with progressively worsening orthostatic headaches. During an extensive examination, magnetic resonance imaging of her thoracic spine revealed a cervicothoracic ventral epidural collection of CSF, prompting a dynamic computed tomography myelogram, which not only helped to confirm severe cerebral hypotension but also suggested underlying pathology of a dorsally projecting disc osteophyte complex at T2–3. Conservative and medical management failed to alleviate symptoms, and a permanent surgical cure was eventually sought. The patient underwent a transdural thoracic discectomy with dural repair, which resulted in resolution of her symptoms. LESSONS Clear guidelines regarding the management strategy of IH secondary to disc osteophyte complexes are yet to be established. A thorough literature review noted only 24 reported cases between 1998 and 2019, in which 13 patients received surgery. There is a 46% symptom resolution rate with conservative management, lower than that for iatrogenic etiologies. For patients in whom conservative management failed, surgical intervention proved effective in resolving symptoms, with a success rate of 92.3%.
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Affiliation(s)
- Bharti Kewlani
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, NewYork Presbyterian Hospital, New York, New York
- Department of Neurological Surgery, Beaumont Hospital, Dublin, Ireland
| | - Andrew L. A. Garton
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, NewYork Presbyterian Hospital, New York, New York
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, NewYork Presbyterian Hospital, New York, New York
| | - J. Levi Chazen
- Departments of Interventional Radiology and Diagnostic Radiology and
| | - Matthew S. Robbins
- Neurology, Weill Cornell Medical Center, NewYork Presbyterian Hospital, New York, New York; and
| | - Ali A. Baaj
- Department of Neurological and Orthopaedic Surgery, University of Arizona—Banner Health System, Phoenix, Arizona
| | - Jeffrey P. Greenfield
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, NewYork Presbyterian Hospital, New York, New York
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Spontaneous Spinal Cerebrospinal Fluid Leak: Review and Management Algorithm. World Neurosurg 2021; 150:133-139. [PMID: 33798778 DOI: 10.1016/j.wneu.2021.03.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 01/03/2023]
Abstract
Spontaneous spinal cerebrospinal fluid (CSF) leak is a condition that commonly presents with debilitating positional headaches. Often, the cause of the leak is located in the spine. Although often cured with conservative management, including epidural blood patching, a subset of patients are refractory to this initial management. Determining the focal location of the spinal leak can, in some patients, require several imaging modalities. Treatment similarly involves multiple options, including targeted epidural blood and/or fibrin patching as well as surgical closure. In this article, we review the current literature regarding this challenging condition and present an algorithm for management.
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Matsuhashi A, Takai K, Taniguchi M. Microsurgical anatomy and treatment of dural defects in spontaneous spinal cerebrospinal fluid leaks. J Neurosurg Spine 2021; 34:522-530. [PMID: 33186904 DOI: 10.3171/2020.6.spine20487] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spontaneous spinal CSF leaks are caused by abnormalities of the spinal dura mater. Although most cases are treated conservatively or with an epidural blood patch, some intractable cases require neurosurgical treatment. However, previous reports are limited to a small number of cases. Preoperative detection and localization of spinal dural defects are difficult, and surgical repair of these defects is technically challenging. The authors present the anatomical characteristics of dural defects and surgical techniques in treating spontaneous CSF leaks. METHODS Among the consecutive patients who were diagnosed with spontaneous CSF leaks at the authors' institution between 2010 and 2020, those who required neurosurgical treatment were included in the study. All patients' clinical information, radiological studies, surgical notes, and outcomes were reviewed retrospectively. Outcomes of two different procedures in repairing dural defects were compared. RESULTS Among 77 patients diagnosed with spontaneous CSF leaks, 21 patients (15 men; mean age 57 years) underwent neurosurgery. Dural defects were detected by FIESTA MRI in 7 patients, by CT myelography in 12, by digital subtraction myelography in 1, and by dynamic CT myelography in 1. The spinal levels of the defects were localized at the cervicothoracic junction in 16 patients (76%) and thoracolumbar junction in 4 (19%). Intraoperative findings revealed that the dural defects were small, circumscribed longitudinal slits located at the ventral aspect of the dura mater. The median dural defect size was 5 × 2 mm. The presence of dural defects at the thoracolumbar junction was associated with manifestation of an altered mental status, which was an unusual manifestation of CSF leaks (p = 0.003). Eight patients were treated via the posterior transdural approach with watertight primary sutures of the ventral defects, and 13 were treated with muscle or fat grafting. Regardless of the two different procedures, postoperative MRI showed either complete disappearance or significant reduction of the extradural CSF collection. No patient experienced postoperative neurological deficits. Clinical symptoms improved or stabilized in 20 patients with a median follow-up of 12 months. CONCLUSIONS Dural defects in spontaneous CSF leaks were small, circumscribed longitudinal slits located ventral to the spinal cord at either the cervicothoracic or thoracolumbar junction. Muscle/fat grafting may be an alternative treatment to watertight primary sutures of ventral dural defects with a good outcome.
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Kumar BV, Sekar S, Nandana J, Erat Sreedharan S. Spontaneous intracranial hypotension and lumbosacral spondylolisthesis-case report of a rare association. Clin Neurol Neurosurg 2021; 202:106511. [PMID: 33493877 DOI: 10.1016/j.clineuro.2021.106511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 11/24/2022]
Affiliation(s)
- B Vijay Kumar
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 11, India
| | - Sabarish Sekar
- Imaging Sciences and Interventional Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 11, India
| | - J Nandana
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 11, India
| | - Sapna Erat Sreedharan
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 11, India.
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Unnithan AS, Wang J, Krakowski JC. Neuraxial Anesthesia in a Patient With a History of Spontaneous Intracranial Hypotension: A Case Report. A A Pract 2019; 13:58-60. [PMID: 30893062 DOI: 10.1213/xaa.0000000000000990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
One commonly cited complication of neuraxial techniques is postdural puncture headache. Patients with spontaneous intracranial hypotension may present with a similar constellation of symptoms in the absence of any neuraxial instrumentation. The underlying physiology of spontaneous intracranial hypotension is similar to postdural puncture headache, but cerebrospinal fluid leaks may develop spontaneously at multiple levels of the neuraxis due to a variety of proposed mechanisms. We present a patient with a history of spontaneous intracranial hypotension who underwent a total knee arthroplasty under spinal anesthesia without complication and discuss the pathophysiology, proposed etiologies and treatments, and safety of neuraxial anesthesia in spontaneous intracranial hypotension.
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Affiliation(s)
- Ajay S Unnithan
- From the Department of Anesthesiology, University of North Carolina Medical Center, Chapel Hill, North Carolina
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Intrathecal Saline Infusion as an Effective Temporizing Measure in the Management of Spontaneous Intracranial Hypotension. World Neurosurg 2019; 125:37-41. [DOI: 10.1016/j.wneu.2019.01.127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 11/22/2022]
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Beck J, Raabe A, Schievink WI, Fung C, Gralla J, Piechowiak E, Seidel K, Ulrich CT. Posterior Approach and Spinal Cord Release for 360° Repair of Dural Defects in Spontaneous Intracranial Hypotension. Neurosurgery 2018; 84:E345-E351. [DOI: 10.1093/neuros/nyy312] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 07/10/2018] [Indexed: 01/03/2023] Open
Affiliation(s)
- Jürgen Beck
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Christian Fung
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Jan Gralla
- Institute of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Eike Piechowiak
- Institute of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Christian T Ulrich
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Chai C, Li V, Bi X. Cervical disc herniation as a rare cause of intracranial hypotension: a case report. Neurol Sci 2018; 39:1475-1477. [PMID: 29502270 DOI: 10.1007/s10072-018-3290-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 02/13/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Changfeng Chai
- Department of Neurology, Shanghai Changhai Hospital, Shanghai, China
| | - Victor Li
- Djavad Mowafaghian Centre for Brain Health and Department of Medicine, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Xiaoying Bi
- Department of Neurology, Shanghai Changhai Hospital, Shanghai, China.
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13
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Merali Z, Witiw CD, Wang S, Phan N, Yang V. Spontaneous intracranial hypotension resulting in coma: Case report and review of the literature. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2018. [DOI: 10.1016/j.inat.2017.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Davidson B, Nassiri F, Mansouri A, Badhiwala JH, Witiw CD, Shamji MF, Peng PW, Farb RI, Bernstein M. Spontaneous Intracranial Hypotension: A Review and Introduction of an Algorithm For Management. World Neurosurg 2017; 101:343-349. [DOI: 10.1016/j.wneu.2017.01.123] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/29/2017] [Accepted: 01/30/2017] [Indexed: 11/29/2022]
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Intracranial hypotension secondary to spinal pathology: Diagnosis and treatment. Clin Neurol Neurosurg 2016; 143:95-8. [DOI: 10.1016/j.clineuro.2016.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/09/2016] [Accepted: 02/10/2016] [Indexed: 11/19/2022]
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Dash D, Jalali A, Harsh V, Omeis I. Transpedicular surgical approach for the management of thoracic osteophyte-induced intracranial hypotension refractory to non-operative modalities: case report and review of literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25 Suppl 1:209-15. [PMID: 26831535 DOI: 10.1007/s00586-016-4408-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/11/2016] [Accepted: 01/15/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE In this article, we aim to describe the presentation and management of a case of spontaneous intracranial hypotension caused by a dural tear from a ventral thoracic osteophyte at the T12 level that was refractory to non-surgical treatment modalities. A review of the literature has been performed. Also a proposal of diagnostic and treatment algorithm is presented. Intracranial hypotension and CSF leak as a result of dural tear is a common phenomenon. However, the detection of the source of CSF leak from a thoracic spinal osteophyte has rarely been reported. METHODS Diagnostic workup including MRI and CT Myelogram as well as application of epidural blood patches and surgical technique of hemilaminectomy and osteophytectomy by transpedicular approach have been described. Literature review was conducted using relevant search terms in PubMed. RESULTS The patient's spontaneous intracranial hypotension symptoms resolved and this persisted on follow up visits. Review our experience as well as similar cases in the literature pointed us towards a diagnostic and treatment algorithm. CONCLUSIONS Spontaneous resolution is the norm for intracranial hypotension of most etiologies and management of all such cases begins with fluid resuscitation coupled with bed rest. On failure of conservative therapy, autologous epidural blood patches into the spinal epidural space should be tried, which often produce an immediate relief of symptoms. Osteophyte-induced dural tear and consequent intracranial hypotension may require surgical intervention if the symptoms are refractory to conservative treatment. Under all circumstances a careful step-wise approach for diagnosis and treatment of spontaneous intracranial hypotension needs to be followed, as we have proposed in our article.
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Affiliation(s)
- Debadutta Dash
- University Hospitals, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Ali Jalali
- Department of Neurosurgery, Baylor College of Medicine, 6501 Fannin St, Suite NC 100, Houston, TX, 77030, USA
| | - Viraat Harsh
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, JH, 834009, India
| | - Ibrahim Omeis
- Department of Neurosurgery, Baylor College of Medicine, 6501 Fannin St, Suite NC 100, Houston, TX, 77030, USA.
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Wilson D, Steel T, Sutton I. Surgical treatment of cervical disc protrusion causing intracranial hypotension following chiropractic manipulation. J Clin Neurosci 2015; 22:1523-5. [DOI: 10.1016/j.jocn.2015.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 03/03/2015] [Indexed: 11/26/2022]
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18
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Spontaneous intracranial hypotension resulting from a thoracic osteophyte. J Clin Neurosci 2015; 22:1054-6. [DOI: 10.1016/j.jocn.2014.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 11/30/2014] [Accepted: 12/07/2014] [Indexed: 11/22/2022]
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Pricola Fehnel K, Borges LF. Posterior thoracic laminoplasty with dorsal, intradural identification of ventral defect and transdural discectomy for a spontaneous cerebrospinal fluid leak: case report. J Neurosurg Spine 2015; 22:478-82. [DOI: 10.3171/2014.10.spine14439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spontaneous intracranial hypotension (SIH) has been increasingly reported in the literature concomitant with the improved sensitivity of imaging modalities. Although typically associated with meningeal weakening, a handful of cases of SIH secondary to thoracic disc osteophytes have been reported. Five of 7 reported cases were treated with epidural blood patch (EBP) alone while 2 required surgical management. There is no standard operative approach; both anterior and posterolateral approaches can be cumbersome and associated with morbidity, particularly in young, healthy patients. The authors report a case of SIH in which a ventral dural tear secondary to a calcified thoracic disc was repaired via posterior thoracic laminoplasty with dorsal durotomy and intradural exposure of the ventral defect with transdural discectomy followed by primary closure.
A 34-year-old man presented with low-pressure headaches following axial load injury from a ski accident 5 years earlier. The patient's symptoms were refractory to a trial of conservative treatment and EBP, and he developed bilateral upper-extremity paresthesias. MRI of the spine demonstrated an extrathecal collection spanning the thoracic spine, and dynamic CT myelography identified contrast extravasation adjacent to a calcified paramedian disc at T9–10. The patient underwent posterior laminoplasty with neuromonitoring. A ventral dural defect was visualized via a dorsal durotomy, the penetrating disc osteophyte was removed transdurally, and the ventral and dorsal dura maters were closed primarily. Both somatosensory and motor evoked potentials were unchanged during surgery. The patient has remained asymptomatic more than 10 months postoperatively and he has resumed work as a surgeon.
Cases of SIH secondary to a calcified thoracic disc are rare with little precedent as to optimal surgical intervention. This case illustrates the potential usefulness of posterior laminectomy in nonmyelopathic patients in whom there is no evidence of canal compromise and for whom neuromonitoring is available. Additionally, surgeon experience and patient preference may guide surgical planning.
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Affiliation(s)
- Katie Pricola Fehnel
- 1Department of Neurosurgery, Massachusetts General Hospital; and
- 2Vascular Biology Program and Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
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Le AQ, Walcott BP, Redjal N, Coumans JV. Cervical osteophyte resulting in compression of the jugular foramen: Case report. J Neurosurg Spine 2014; 21:565-7. [PMID: 25014503 DOI: 10.3171/2014.6.spine13908] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Jugular foramen syndrome is a condition characterized by unilateral paresis of cranial nerves IX, X, and XI in the setting of extrinsic compression. Here, the authors describe the case of a giant cervical osteophyte resulting in compression of the jugular foramen. A 74-year-old man who presented with progressive dysphagia and dysarthria was found to have right-sided tongue deviation, left palatal droop, and hypophonia. His dysphagia had progressed to the point that he had lost 25 kg over a 4-month period, necessitating a gastrostomy to maintain adequate nutrition. He underwent extensive workup for his dysphagia with several normal radiographic studies. Ultimately, CT scanning and postcontrast MRI revealed a posterior osteophyte arising from the C1-2 joint space and projecting into the right jugular foramen. This resulted in a jugular foramen syndrome in addition to delayed filling of the patient's right internal jugular vein distal to the osteophyte. Although rare, a posterior cervical osteophyte should be considered in cases of jugular foramen syndrome.
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Affiliation(s)
- Andrew Q Le
- Department of Neurosurgery, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
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