The Relief of Unilateral Painful Thoracic Radiculopathy without Headache from Remote Spontaneous Spinal Cerebrospinal Fluid Leak.

Byung-Chul Son,Sang-Woo Ha,Jin-Gyu Choi,Si-Hoon Lee

doi:10.1155/2016/4798465

Abstract

Spontaneous intracranial hypotension (SIH) caused by spontaneous spinal cerebrospinal fluid (CSF) leaks produces orthostatic headaches. Although upper arm pain or paresthesia is reportedly associated with SIH from spontaneous spinal CSF leak in the presence of orthostatic headache, low thoracic radicular pain due to spontaneous spinal CSF leak unassociated with postural headache is extremely rare. We report a 67-year-old female who presented with chronic, positional radicular right T11 pain. Computed tomography myelography showed a spontaneous lumbar spinal CSF leak at L2-3 and repeated lumbar epidural blood patches significantly alleviated chronic, positional, and lower thoracic radiculopathic pain. The authors speculate that a chronic spontaneous spinal CSF leak not severe enough to cause typical orthostatic headache or epidural CSF collection may cause local symptoms such as irritation of a remote nerve root. There might be considerable variabilities in the clinical features of SIH which can present a diagnostic challenge.

Highlights

Most spinal cerebrospinal fluid (CSF) leaks are iatrogenic, occurring after lumbar puncture, epidural injection, or spinal surgery
Spontaneous intracranial hypotension (SIH) is a postural headache syndrome unrelated to dural puncture and it is an uncommon but increasingly recognized clinical syndrome associated with reduced CSF pressure or CSF volume caused by spontaneous CSF leaks [1,2,3,4,5]
The occurrence of cervical unilateral radiculopathic pain caused by spontaneous spinal CSF leak has been reported in association with a typical orthostatic headache

Summary

Introduction

Most spinal cerebrospinal fluid (CSF) leaks are iatrogenic, occurring after lumbar puncture, epidural injection, or spinal surgery. An orthostatic headache is the prototypical manifestation, but other headache patterns occur as well, and associated symptoms are common [5] When onset of such headache is spontaneous, the diagnostic challenge is created even though SIH has been recognized for more than 6 decades and the diagnosis has been greatly aided by magnetic resonance imaging (MRI) [4]. Paresthesia in the upper extremity [4] have been reportedly associated with SIH, an isolated presentation of unilateral low thoracic radiculopathic pain from spontaneous CSF leak without typical positional headache has not been reported. We report a case of spontaneous lumbar CSF leak presenting as a chronic, intractable, positional, unilateral lower thoracic radiculopathic pain, not associated with the typical symptom of orthostatic headache

Case Presentation

Findings

Discussion

Conclusion