Editors' note: Teaching NeuroImages: Cerebrospinal fluid leakage observed from skin after acupuncture

Abstract

In their article, Noh and colleagues reported the case of a young gentleman with longstanding lumbago and previous laminectomy with fusion of L4-S1 who developed a low-pressure headache following acupuncture. On examination, the patient had clear fluid extravasating from an acupuncture site in the lower back, suggestive of a transcutaneous CSF leak. A magnetic resonance myelogram confirmed CSF leakage, which was treated with duroplasty with improvement in the patient's headache. Although the patient's photo shows CSF leakage may be more cephalad and lateral to the location of the CSF collection on myelography—as Hu et al. appropriately identified—the authors reported that long needles (20 cm) were used at multiple lumbar sites and likely contributed to the exudate. The authors also reported having identified beta 2 transferrin from the sampled fluid, which has a >95% sensitivity and specificity for CSF. Although nonpharmacologic interventions such as acupuncture are recommended by many organizations to treat chronic nonmalignant pain, the authors caution the use of acupuncture around sites of previous spine surgery. In their article, Noh and colleagues reported the case of a young gentleman with longstanding lumbago and previous laminectomy with fusion of L4-S1 who developed a low-pressure headache following acupuncture. On examination, the patient had clear fluid extravasating from an acupuncture site in the lower back, suggestive of a transcutaneous CSF leak. A magnetic resonance myelogram confirmed CSF leakage, which was treated with duroplasty with improvement in the patient's headache. Although the patient's photo shows CSF leakage may be more cephalad and lateral to the location of the CSF collection on myelography—as Hu et al. appropriately identified—the authors reported that long needles (20 cm) were used at multiple lumbar sites and likely contributed to the exudate. The authors also reported having identified beta 2 transferrin from the sampled fluid, which has a >95% sensitivity and specificity for CSF. Although nonpharmacologic interventions such as acupuncture are recommended by many organizations to treat chronic nonmalignant pain, the authors caution the use of acupuncture around sites of previous spine surgery.