Lumbar microspur-related ventral cerebrospinal fluid leak localized by digital subtraction myelography: A case report
Daito Nakamura1,2, Jun Tsugawa1,2, Ritsurou Inoue3
1Department of Neurology, Fukuoka University Chikushi Hospital, Fukuoka, Japan.
Spontaneous intracranial hypotension (SIH) is commonly caused by spinal cerebrospinal fluid (CSF) leakage. Microspur-related ventral dural tears are an increasingly recognized etiology of SIH; however, lumbar lesions remain extremely rare. A 41-year-old woman presented with severe orthostatic headache and nausea. Whole-spine magnetic resonance imaging demonstrated spinal longitudinal extradural CSF collection (SLEC), suggesting spinal CSF leakage. Computed tomography myelography identified a small calcified lesion at the L1/2 level consistent with a discogenic microspur compressing the ventral dural sac. Digital subtraction myelography (DSM) demonstrated active contrast extravasation into the epidural space at the corresponding level, consistent with a ventral dural tear caused by the microspur. Targeted epidural blood patch treatment at the L1/2 level resulted in rapid symptom resolution without recurrence during 18 months of follow-up. This case demonstrates that lumbar microspurs can cause SLEC-positive SIH through ventral dural injury. DSM was useful for dynamic localization of the active CSF leak and facilitated targeted treatment. To the best of our knowledge, this is the first reported case of lumbar microspur-induced SIH confirmed by DSM.
Spontaneous intracranial hypotension (SIH) is commonly caused by spinal cerebrospinal fluid (CSF) leakage. Microspur-related ventral dural tears are an increasingly recognized etiology of SIH; however, lumbar lesions remain extremely rare. A 41-year-old woman presented with severe orthostatic headache and nausea. Whole-spine magnetic resonance imaging demonstrated spinal longitudinal extradural CSF collection (SLEC), suggesting spinal CSF leakage. Computed tomography myelography identified a small calcified lesion at the L1/2 level consistent with a discogenic microspur compressing the ventral dural sac. Digital subtraction myelography (DSM) demonstrated active contrast extravasation into the epidural space at the corresponding level, consistent with a ventral dural tear caused by the microspur. Targeted epidural blood patch treatment at the L1/2 level resulted in rapid symptom resolution without recurrence during 18 months of follow-up. This case demonstrates that lumbar microspurs can cause SLEC-positive SIH through ventral dural injury. DSM was useful for dynamic localization of the active CSF leak and facilitated targeted treatment. To the best of our knowledge, this is the first reported case of lumbar microspur-induced SIH confirmed by DSM.
