Lumbar puncture-related cerebrospinal fluid leakage on magnetic resonance myelography: is it a clinically significant finding?

Abstract

Background: Post-dural puncture headache (PDPH) due to excessive cerebrospinal fluid (CSF) leakage is a well-known complication of lumbar puncture. Although various factors, especially the type of spinal needle, have been demonstrated to be associated with PDPH, the clinical implications of CSF leakage detected on magnetic resonance myelography (MRM) images remain unclear. The objective of this case-control study was to evaluate the association between radiologically visualized CSF leakage and PDPH.

Methods: Clinical data including patients' age and gender, types of spinal needle, duration of bed rest, interval between lumbar puncture procedures and MRM studies, and incidence of PDPH were compared between patients who were radiologically-positive and -negative for CSF leakage.

Results: Of the 22 patients with definite CSF leakage on MRM images, most were asymptomatic (86%, 19/22). The remaining three patients, who were suffering from PDPH, only complained of headaches and were treated conservatively. In a review of patients' clinical data, there were no significant differences in any parameter including the incidence of PDPH between the 22 patients who were radiologically-positive for CSF leakage and the 31 radiologically-negative patients.

Conclusion: The significance of radiologically visualized CSF leakage should not be overestimated, as most such incidents are not associated with PDPH and do not require any treatment.

Figure 1

Representative magnetic resonance myelography (MRM) images of postpuncture cerebrospinal fluid (CSF) leakage. 2D MRM images were performed about 28 and 6 hours after the lumbar punctures in a 44-year-old male with chronic inflammatory demyelinating polyneuropathy (patient A) and a 42-year-old female with multiple sclerosis (patient B), respectively. Bilateral fluid collection around the nerve roots and paraspinal area (a, d) were depicted on 2D MRM images (arrows). Additionally, sagittal fat-suppressed T2-weighted (b) and axial T2-weighted (c) images of patient A revealed abnormal epidural and paraspinal fluid collections (arrowheads). In spite of such leakage, patient A was asymptomatic. However, patient B complained of an orthostatic headache that had persisted for six days. Arrowheads indicate fluid accumulation that was unrelated to CSF leakage (e.g., the bladder and ovarian cysts).