Cerebrospinal fluid leakage and headache after lumbar puncture: a prospective non-invasive imaging study

Abstract

The spatial distribution and clinical correlation of cerebrospinal fluid leakage after lumbar puncture have not been determined. Adult in-patients receiving diagnostic lumbar punctures were recruited prospectively. Whole-spine heavily T2-weighted magnetic resonance myelography was carried out to characterize post-lumbar puncture spinal cerebrospinal fluid leakages. Maximum rostral migration was defined as the distance between the most rostral spinal segment with cerebrospinal fluid leakage and the level of lumbar puncture. Eighty patients (51 female/29 male, mean age 49.4 ± 13.3 years) completed the study, including 23 (28.8%) with post-dural puncture headache. Overall, 63.6% of periradicular leaks and 46.9% of epidural collections were within three vertebral segments of the level of lumbar puncture (T12-S1). Post-dural puncture headache was associated with more extensive and more rostral distributions of periradicular leaks (length 3.0 ± 2.5 versus 0.9 ± 1.9 segments, P = 0.001; maximum rostral migration 4.3 ± 4.7 versus 0.8 ± 1.7 segments, P = 0.002) and epidural collections (length 5.3 ± 6.1 versus 1.0 ± 2.1 segments, P = 0.003; maximum rostral migration 4.7 ± 6.7 versus 0.9 ± 2.4 segments, P = 0.015). In conclusion, post-dural puncture headache was associated with more extensive and more rostral distributions of periradicular leaks and epidural collections. Further, visualization of periradicular leaks was not restricted to the level of dural defect, although two-thirds remained within the neighbouring segments.

Keywords: cerebrospinal fluid leakage; magnetic resonance myelography; post-dural puncture headache; spontaneous intracranial hypotension.

Using whole-spine MR myelography in patients receiving diagnostic lumbar punctures, Wang et al. show that post-dural puncture headache is associated with more extensive and more rostral CSF leakages. Compared to other types of CSF leakage, periradicular leaks have a better spatial correlation with the dural defect introduced by lumbar puncture.

Figure 1

Spinal CSF leakage in patients with post-dural puncture headache on heavily T₂-weighted magnetic resonance myelography. Right periradicular leaks (filled arrows) and epidural collections (open arrow) at L2 (A) and L5 retrospinal collections (arrowhead; B) in a 43-year-old female patient. Right T5 periradicular leak (filled arrow; C) and left T10 periradicular leak (filled arrow; D) with epidural collections (open arrows) in a 40-year-old male patient (C and D).

Figure 2

Distribution of spinal CSF leakages. In general, periradicular leaks were most commonly seen around the upper lumbar region (A), epidural collections were mainly distributed between middle thoracic to upper lumbar regions (B), and retrospinal collections were primarily seen in the lower lumbar region (C). When analysed separately, patients with post-dural puncture headache (D and E) had more rostral distributions of periradicular leaks (D and F) and epidural collections (E and G) than those without (F and G).