Postural Headache: An Unusual Complication After Brachial Plexus Injury and Cerebrospinal Fluid Leak

Abstract

To the Editor: Cervical nerve root traction and avulsion may occur after traumatic brachial plexus injury, and cerebrospinal fluid (CSF) leakage can develop as a result of dural rupture (1). We report a case of postural headache caused by cervical CSF loss after brachial plexus injury. An 18-yr-old male injured in a traffic accident 10 days earlier was admitted to our emergency department with fractures of the right proximal humerus and distal third of the clavicle and brachial plexus injury. During the presurgical consultation with the anesthesiologist, the patient described the spontaneous onset of a severe postural headache of 48 h duration that was accompanied by progressively worsening nausea and vomiting. The results of a neurologic examination and computed tomographic studies of the brain were within normal limits. During surgical exploration, avulsion of the brachial plexus nerve root and CSF leakage were identified (Fig. 1). During telephone follow-up at the patient’s home 2 wk after surgery, the patient reported that his headache had resolved.Figure 1.: Avulsion of the brachial plexus nerve root and cerebrospinal fluid leakage.In our patient, fractures of the right proximal humerus and distal third of the clavicle and traction on the brachial plexus nerve root resulting from trauma caused a dural rupture. During surgery, the dural leak stopped as a result of cessation of the traction of the cervical nerve root and connective tissue approximation over the wound. Two weeks later, the patient’s postural headache resolved. Although he experienced clinical symptoms of a postural headache, we could not confirm that diagnosis preoperatively. Examination with computed tomographic scanning revealed no subarachnoid or intracranial hemorrhage, nor did it indicate intracranial hypotension. If we had suspected a CSF leak, we could have confirmed it using myelography, radionuclide cisternography, or magnetic resonance imaging. Ayda Turkoz, MD H. Evren Eker, MD Lale Titiz, MD Gulnaz Arslan, MD Department of Anesthesiology Baskent University Faculty of Medicine Ankara, Turkey [email protected]