Surgical treatment of spontaneous intracranial hypotension secondary to degenerative cervical spine pathology: a case report and literature review

Abstract

Objective and importance: A rare cause of intracranial hypotension is leakage of cerebrospinal fluid (CSF) through a dural breach from degenerative cervical spine pathology. To our knowledge there have been only four cases described in the English literature. Treatment is challenging and varies from case to case, with complete symptom resolution reported for only one patient. Herein we review the literature and describe our surgical management of a 46-year-old woman with symptomatic intracranial hypotension from the penetration of the cervical thecal sac.

Clinical presentation: The patient presented with a 3-month history of progressive orthostatic headaches. Magnetic resonance imaging demonstrated bilateral subdural hematomas and pachymeningeal gadolinium enhancement. An anterior epidural CSF collection commencing at a C4-5 calcified disc protrusion and osteophyte was evident on a computed tomography spinal myelogram.

Intervention: After three unsuccessful lumbar blood patches, we elected to attempt surgical removal of the causative pathology with exposure and primary closure of the dural defect by anterior cervical discectomy as described previously. After resection of the disc-osteophyte complex and dural exposure, immediate high volume egression of CSF mixed with blood at the surgical site. The dural defect was not visible but CSF egression promptly ceased. Cervical corpectomy for greater exposure and primary repair of the defect has been described, but we considered this unwarranted and felt the intraoperative blood collection formed a local blood patch. A collagen dural substitute membrane was inserted through the discectomy space for reinforcement.

Conclusion: Two months after this novel surgical blood patch procedure the patient was asymptomatic and follow-up imaging demonstrated complete resolution.

Fig. 1

a Preoperative axial T2 weighted MR image demonstrating bilateral subdural hematomas. b Preoperative coronal T2 weighted MR image demonstrating bilateral subdural hematomas. c Preoperative axial T1 post-gadolinium MR image demonstrating bilateral subdural hematomas with thickening and enhancement of the pachymeninges. d 2 month postoperative axial CT demonstrating resolution of the bilateral subdural hematomas

Fig. 2

Computed tomography spinal myelogram. a Midsagittal image demonstrating an anterior epidural CSF collection commencing at the site of a C4–5 calcified intervertebral disc protrusion (black arrow). b Coronal image of the cervical spine demonstrating the calcified intervertebral disc protrusion (black arrow). c Axial image of the C4–5 level exhibiting the calcified intervertebral disc protrusion (black arrow)