Spinal Cerebrospinal Fluid (CSF) Leaks

Causes and risk factors

Although uncommon, spinal CSF leaks can be caused by:

• Trauma or injury, even minor trauma like lifting a heavy object
• Twisting or turning movements of the spine
• Spinal procedures such as spinal tap (lumbar puncture) or epidural injections
• Bone spurs along the spine
• Spinal surgery

However, this condition may not always be linked to a specific event or clear cause. Many times spontaneous spinal CSF leaks occur seemingly out of nowhere. As a result, the hole or tear can be challenging to locate, making it harder to treat. Treatment may require several attempts, even under the care of the most experienced team.

Anyone can develop a spinal CSF leak, although they most commonly occur in adults between 20 to 60. We continue investigating risk factors for this condition. Patients who have a connective tissue disorder may be more susceptible to a dural tear.

Evaluation and diagnosis

Because many spinal CSF leaks occur spontaneously and providers may be unfamiliar with the condition, it's often misdiagnosed, or diagnosis is delayed. An accurate and timely diagnosis requires skilled providers who are familiar with the signs and symptoms of spinal CSF leaks. A critical element in accurate diagnosis is the use of complex imaging under the guidance of a specialized neuroradiologist with advanced training and experience in identifying this condition.

At your first consultation by a member of our interdisciplinary team, we'll perform a detailed evaluation that begins with a conversation about your medical history and symptoms. Many physical signs can indicate a leak, which is important because imaging findings don't always reveal a clear-cut diagnosis.

There are several imaging tests we may use to confirm a diagnosis, including:

• MRI of the brain and spine: This non-invasive imaging test may show findings of leaking fluid such as engorged veins, brain sagging, fluid collections, or other abnormalities associated with the condition. However, the absence of these signs doesn't mean that a patient does not have a leak. Sometimes additional imaging is necessary to confirm a diagnosis or pinpoint the leak origin.
• Myelography: A computed tomography (CT) myelogram involves injecting contrast dye using a tiny needle and imaging the spine to identify the leak site. We may gather additional information about the condition using more complex types of myelography, such as a:
  • Dynamic CT myelogram
  • Decubitus CT myelogram
  • Digital subtraction myelogram
  • MR myelogram
• Lumbar puncture: Also known as a spinal tap, this diagnostic procedure can measure pressure but is not required for diagnosis. It's also not uncommon for a patient with this condition to have normal pressure, so normal findings don't rule out a diagnosis.

Treatment

Treatment is essential because low pressure in the brain can lead to worsening neurologic symptoms. Fortunately, spontaneous CSF leaks are highly treatable with the care of experienced specialists. Your treatment options will vary based on the severity of your symptoms, ranging from conservative approaches to surgical repair.

Blood patch injections

An interventional neuroradiologist can often patch the leak using a patient's own blood alone or in combination with a fibrin glue sealant. The outpatient procedure is performed under CT guidance using minimally invasive techniques, such as a small needle. This can be performed as a targeted blood patch when we know the exact location of the tear and is highly effective. It can also be performed as an empiric blood patch in an attempt to seal a large amount of the dura where a potential hole may be. The medical procedure is 30 percent effective even when the location is unknown. As a result, it may take several treatments to completely seal the leak and alleviate symptoms. Knowing this ahead of time can help patients to manage their expectations.

Recovery will vary by person, but we advise patients to rest and avoid strenuous lifting or twisting for several weeks. If treatment does not completely relieve patients of symptoms, we will meet to discuss the next steps, which may include surgical options.

Surgery

If less invasive treatments don't work, several different surgical options for repairing a spinal CSF leak are available. Surgery can be complex because of the spine anatomy and high variety of potential leak locations. Therefore, surgical treatment is personalized to each patient based on the specific location and type of the leak and may include:

• Direct repair, which involves removal of bone spurs and stitching holes/tears closed
• Indirect repair, which uses grafts and glue materials to reconstruct and strengthen the weak or blistered areas of the dura
• Ligation, which involves repairing abnormal connections between the dura and its surrounding veins

Our center specializes in minimally invasive, image-guided, and robotic spinal surgery, and it is possible that surgical repair can be performed using less invasive techniques. Hospital stay length and recovery will vary patient-by-patient. It is possible to experience higher than normal pressure following the repair, but medication may help to manage any pain and discomfort.