Spinal CSF Leak FAQ
Spinal CSF Leak FAQ
What is a cerebrospinal fluid leak?
A cerebrospinal fluid (CSF) leak happens when cerebrospinal fluid (secreted by the brain) leaks through the coverings of the nervous system. This fluid can cause headaches and other symptoms. CSF leaks can happen after an epidural or a lumbar puncture (spinal tap), with the fluid draining into the subcutaneous tissue and, in turn, not visible to the patient. CSF leaks can also occur spontaneously for unknown reasons, or because of trauma to the spine.
The brain normally floats in this fluid, which helps to cushion the brain from injury. A CSF leak is when a tear or a hole in the dura allows the fluid to leak out. When this occurs, it reduces the CSF fluid volume and the pressure drops. This can cause a condition known as intracranial hypotension. When this intracranial hypotension occurs, the brain can sag, causing a headache that worsens when the body is in an upright position (as gravity allows fluid to continue to drain).
What can cause CSF leak?
CSF leak can be either from trauma, medical procedure, or spontaneous, including:
- Trauma: fall, accident
- Medical procedures: spine surgery, lumbar puncture/spinal tap, epidural steroid injections
- Spontaneous is usually unknown cause, however can be from:
- Following exertion (ie: swinging a golf club, (excess) weight lifting)
- Can be also rarely be associated with some genetic conditions, like connective tissue disorders
What are the symptoms of CSF leak?
The classic symptom is severe headache when upright (sitting, standing), which is then relieved or significantly decreased by lying completely flat.
Other symptoms can include: nausea, vomiting, double vision, possible muffled hearing, and occasionally neck pain.
How is a CSF leak diagnosed?
Diagnosis can frequently be based on the postural dependency of the headache. A diagnosis of intracranial hypotension is not usually a first consideration.
On a MRI brain with contrast, there will typically be thickened and enhancing meninges (ie pachymeningeal enhancement).
Determining the site of a CSF leak in the spinal canal can be challenging. Some of the methods include:
- Dynamic myelogram with fluoroscopy and CT scan
- Radioisotope cisternography
- Digital subtraction myelography
In some cases, the site of the leak cannot be identified.
What are ways to treat CSF leak?
For most patients, symptoms go away without any treatment. If a patient believes they may be suffering from a CSF headache, the following measures are usually suggested: bed rest, increased hydration, and (increased) caffeine intake. The bed rest can be for a short duration (few days, weekend) or last as long as a few weeks.
If these conservative measures don't resolve the headache, then the most common treatment is epidural blood patching. This can even be done even if the specific location of the leak is unknown. This procedure is done by performing a fluoroscopic placement of one or more needles into the epidural space and then some of the patient's blood is then injected into the spinal canal outside the dura. The blood clots over the hole, acting as a plug in order to stop the leak. This can be performed several times if required.
Sometimes a lumbar drain is placed to divert the flow of the CSF. This decreases the pressure at the leak site and often allows it to heal.
Other options (if the epidural blood patch fails) are: epidural injections of fibrin glue at site of leak or surgery at the precise location of the leak. A surgical intervention would use sutures, clips, synthetic sealants, or artificial materials to close the tear.