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Updated: Mar 15, 2026
Microvascular Decompression: Salient Surgical Principles and Technical Nuances
Published on: July 5, 2011
Diskogenic microspurs as a major cause of intractable spontaneous intracranial hypotension
Jürgen Beck1, Christian T Ulrich2, Christian Fung2
1From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland. juergen.beck@insel.ch.
Objective:
To visualize and treat spinal dural CSF leaks in all patients with intractable spontaneous intracranial hypotension (SIH) who underwent spinal microsurgical exploration.
Methods:
Patients presenting between February 2013 and July 2015 were included in this consecutive case series. The workup included spinal MRI without and with intrathecal contrast, dynamic myelography, postmyelography CT, and microsurgical exploration.
Results:
Of 69 consecutive patients, 15 had intractable symptoms. Systematic imaging revealed a suspicious single location of the leak in these 15 patients. Fourteen patients underwent microsurgical exploration; 1 patient refused surgery. Intraoperatively, including intradural exploration, we identified the cause of the CSF leaks as a longitudinal dural slit (6.1 ± 1.7 mm) on the ventral (10), lateral (3), or dorsal (1) aspect of the dura. In 10 patients (71%), a ventral, calcified microspur originating from the intervertebral disk perforated the dura like a knife. Three patients (22%) had a lateral dural tear with an associated spinal meningeal diverticulum, and in 1 patient (7%), a dorsal osteophyte was causal. The microspurs were removed and the dural slits sutured with immediate cessation of CSF leakage.
Conclusion:
The nature of the CSF leak is a circumscribed longitudinal slit at the ventral, lateral, or dorsal dura mater. An extradural pathology, diskogenic microspurs, was the single cause for all ventral CSF leaks. These findings challenge the notion that CSF leaks in SIH are idiopathic or due to a weak dura. Microsurgery is the treatment of choice in cases with intractable SIH.
Insights
Spinal microsurgery effectively treats intractable spontaneous intracranial hypotension (SIH) by repairing longitudinal dural slits, often caused by diskogenic microspurs, challenging the idea of idiopathic leaks.
Area of Science:
- Neurosurgery
- Radiology
- Spinal Surgery
Background:
- Spontaneous intracranial hypotension (SIH) presents with intractable symptoms.
- Identifying the precise source of cerebrospinal fluid (CSF) leaks is crucial for effective treatment.
- Previous understanding often attributed SIH to idiopathic causes or dural weakness.
Purpose of the Study:
- To visualize and treat spinal dural CSF leaks in patients with intractable SIH.
- To characterize the nature and origin of CSF leaks requiring surgical intervention.
Main Methods:
- A consecutive case series of patients with intractable SIH undergoing spinal microsurgical exploration.
- Diagnostic workup included spinal MRI with and without intrathecal contrast, dynamic myelography, and postmyelography CT.
- Intraoperative findings from microsurgical exploration were meticulously recorded.
Main Results:
- Fifteen of 69 patients had intractable SIH and a single suspicious leak location identified on imaging.
- Microsurgery revealed longitudinal dural slits in all 14 surgically treated patients.
- Ventral diskogenic microspurs were the cause in 71% of cases, with lateral tears and dorsal osteophytes identified in others.
Conclusions:
- CSF leaks in SIH are characterized by circumscribed longitudinal dural slits.
- Extradural pathologies, particularly diskogenic microspurs, are a primary cause of ventral CSF leaks.
- Microsurgery is the definitive treatment for intractable SIH caused by identifiable spinal CSF leaks.
