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High-Flow Spinal CSF Leaks Precisely Localized by Dynamic Myelography: Association with Body Mass Index? 2012

General Spine

Richard, E, Rosebrock, MD
Felix, E, Diehn, MD, Non ASSR Member
Jonathan, M, Morris, MD, Non ASSR Member
Patrick, H, Luetmer, MD, Non ASSR Member
Kent, R, Thielen, MD, Non ASSR Member

Paper/Mentor

Purpose

In patients with high-flow spinal CSF leaks, who typically present with clinical symptoms and imaging features characteristic of spontaneous intracranial hypotension, precise anatomic localization of the leak site can be achieved by evolving and emerging dynamic myelographic techniques. Spiculated spinal osteophytes and/or calcified discs piercing the dura are being increasingly recognized as a causative etiology, but the literature on this subject is largely limited to case reports and small series. We have anecdotally observed that patients with high-flow spinal CSF leaks are relatively thin, which has not been reported to our knowledge. Our goal was to retrospectively review the frequency of spiculated osteophytes/calcified discs in our recent single-institution experience of evaluating patients with high-flow CSF leaks with dynamic myelographic techniques, and to explore the potential association of low Body Mass Index (BMI) with such leaks.

Methods & Materials

Following IRB approval, we retrospectively identified 15 patients found to have precisely localized high-flow spinal CSF leaks on dynamic myelography between November 2008 and December 2010 at our institution. The presence or absence of a spiculated osteophyte/calcified disc at the site of leak was noted. The Body Mass Index (BMI) on the date closest to (and no more than 30 days from) this myelographic procedure was collected for each patient. The BMI for each patient was compared to data for BMI from the National Health and Nutrition Examination Survey (from Centers for Disease Control), matched to sex and age-range. The exact sign test was used to analyze for statistical significance.

Results

There were 9 males (60%) and the mean age was 54 years (range, 37-72). In 13 of 15 (87%) of these patients, the diagnosis was made by ultra-fast dynamic CT myelography, with standard dynamic CT myelography performed in one patient and dynamic fluoroscopic myelography in another. In 11 of 15 patients (73%), a spiculated osteophyte/calcified disc was identified at the site of leak. Twelve of 15 patients (80%) had a BMI which was below the expected national average, matched for age-range and sex, while 3 of 15 patients (20%) had values above the national average. This difference was statistically significant (p = 0.035).

Conclusion

In this series of patients, a high-flow CSF leak was likely to be caused by a spiculated osteophyte/calcified disc. The patients with high-flow CSF leaks were statistically likely to have a BMI below the national average when matched for gender and age-range. Whether this is a causative risk factor or incidental association requires further study. We suspect that the lower BMI may correlate with decreased ventral epidural fat and/or higher activity levels, either of which could predispose these patients to dural injury.

References/Financial Disclosures

1. Thielen KR, Sillery J, Morris JM, Luetmer PH. Ultrafast Dynamic CT Myelography for the Precise Identification of High-Flow Cerebrospinal Fluid Leaks Caused by Spiculated Osteophytes of the Spine. Annual Meeting of the American Society of Neuroradiology. June 6, 2011. Seattle, WA. 2. Winter SCA, Martens NF, Anslow P, Teddy PJ. Spontaneous intracranial hypotension due to thoracic disc herniation. J Neurosurg (Spine 3) 2002;96:343-5. 3. Eross EJ, Dodick DW, Nelson KD, Bosch P, Lyons M. Orthostatic headache syndrome with CSF leak secondary to bony pathology of the cervical spine. Cephalalgia 2002;22:439-43. 4. Binder DK, Sarkissian V, Dillon WP, Weinstein PR. Spontaneous intracranial hypotension associated with transdural thoracic osteophyte reversed by primary dural repair. J Neurosurg: Spine 2005;2:614-8. 5. Witiw CD, Fallah A, Muller PJ, Ginsberg HJ. Surgical treatment of spontaneous intracranial hypotension secondary to degenerative cervical spine pathology: a case report and literature review. Eur Spine J, Aug 2011. 6. Hasiloglu ZI, Abuzayed B, Imal AE, Cagil E, Albayram S. Spontaneous intracranial hypotension due to intradural thoracic osteophyte with superimposed disc herniation: report of two cases. Eur Spine J, May 2011. 7. Rapport RL, Hillier D, Scearce T, Ferguson C. Spontaneous intracranial hypotension from intradural thoracic disc herniation. Case report. J Neurosurg 2003;98:282-4. 8. Yokota H, Yokoyama K, Noguchi H, Uchiyama Y, Iwasaki S, Sakaki T. Thoracic osteophyte causing spontaneous intracranial hypotension. Cephalalgia 2008;4:396-8. 9. Vishteh AG, Schievink WI, Baskin JJ, Sonntag VK. Cervical bone spur presenting with spontaneous intracranial hypotension. Case report. J Neurosurg 1998;89:483-4.

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