Surgical Treatment of Spontaneous Spinal Cerebrospinal Fluid Leaks

Cormac O. Maher, M.D., Fredric B. Meyer, M.D., Bahram Mokri, M.D., Departments of Neurosurgery and Neurology, Mayo Clinic, Rochester, Minnesota

Neurosurg Focus. 2000;9(1) 

In This Article


In patients with a characteristic history, the diagnosis may be confirmed by obtaining head MR images or lumbar puncture. In most patients low or unmeasurable CSF pressures are observed; however, in a significant minority normal opening pressures will be demonstrated on serial lumbar punctures.[9,12] Increased levels of CSF protein concentration and a lymphocytic pleocytosis are common.[12] On MR imaging examination of the head, although diffuse pachymeningeal enhancement is a very frequent finding, its absence does not exclude the diagnosis of CSF leakage.[4,13,18,28] In some cases, pachymeningeal enhancement may resolve despite a continued symptomatic CSF leak.[11] "Sagging" of the brain, sometimes with enough descent of the cerebellar tonsils to appear as an acquired Chiari I malformation, and subdural fluid collections, usually thin and bilateral, are observed in many patients.[1,16,18,19] In most cases, these MR imaging findings are resolved following a successful repair of the CSF leak. Leptomeningeal enhancement is not a feature of this condition, and, if present, alternative diagnoses should be considered.

The location of the CSF leak should be demonstrated by radioisotope cisternography, myelography, CT myelogram, or MR imaging examination of the spine in all patients for whom surgical repair of the CSF leak is considered (Fig. 1).[5,30] Indium-111 radioisotope cisternography is helpful but CT myelography is the most sensitive diagnostic modality for establishing the presence of a CSF leak.[15] If an initial myelogram demonstrates normal findings, repeating the study several weeks later may be useful.[10] Magnetic resonance imaging examination of the spine may be used preoperatively to identify structural abnormalities in patients with known leaks (Fig. 2). Furthermore, spine MR imaging or radioisotope cisternography may help identify the approximate level of the leak, which can then be better defined by CT myelography in which multiple thin sections are obtained at the suspected level (Fig. 3). Diverticula are not uncommon and, when present, should not automatically be identified as the source of the CSF leak.

Figure 1. Standard myelogram (anteroposterior view) obtained in a patient with a spontaneous spinal CSF leak.

Figure 2. Magnetic resonance cisternography. Sagittal (left) and parasagittal (right) views revealing an abnormal signal consistent with a CSF leak in the region of T-10 on the right.

Figure 3. Computerized tomography myelography demonstrating a large meningeal diverticulum on the right. Extraarachnoid contrast surrounds the thecal sac.

Some cases of spontaneous spinal CSF leak will resolve without any treatment. Therefore, surgery is rarely indicated for symptoms that have been present for a short duration. In general, an epidural blood patch procedure should be attempted at least once.[22] Epidural blood patches are usually effective when directed at the appropriate level; however, symptoms will frequently recur after a few days. If the symptoms do recur, it is reasonable to offer patients one or more epidural blood patch procedures prior to considering surgical repair. Some patients have been treated with epidural saline infusion[7,21,29] or epidural injection of fibrin glue.[3,6] The results of these treatments are unpredictable and often not long lasting. Experience with fibrin glue is limited in this setting.


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