Diagnosis and surgical therapy of spontaneous intracranial hypotension.

Spontaneous intracranial hypotension (SIH) is a serious medical condition caused by loss of cerebrospinal fluid at the level of the spine, which, when not treated, may cause substantial long-term disability and increase morbidity. The following video summarizes the necessary steps for successful diagnosis and treatment of SIH, starting with a brain and spine magnetic resonance imaging, followed by dynamic myelography. Because an epidural bloodpatch did not provide a lasting relief, the patient underwent surgery which demonstrated a ventral dural slit caused by an osteodiscogenic microspur. In the 1-month follow up, the patient was symptom free. This video is meant to raise awareness of SIH among clinicians in order to increase general sensitivity for this diagnosis.

Anterior Lumbar Interbody Fusion in Elderly Patients: Peri- and Postoperative Complications and Clinical Outcome.

BACKGROUND: Anterior lumbar interbody fusion (ALIF) is an effective surgical technique for treating various lumbar pathologies, but its use in elderly patients is controversial. Data concerning complications and effectiveness are sparse. We investigated peri- and postoperative complications, radiographic parameters, and clinical outcome in elderly patients. METHODS: Patients ≥65 years who underwent ALIF between January 2008 and August 2020 were included in the study. All surgeries were performed through a retroperitoneal approach. Clinical and surgical data as well as radiologic parameters were collected prospectively and analyzed retrospectively. RESULTS: A total of 39 patients were included; the mean age was 72.6 (±6.3) years (range: 65-90 years); and the mean American Society of Anesthesiologists (ASA) risk classification was 2.3 (±0.6). A laceration of the left common iliac vein was the only major complication recorded (2.6%). Minor complications occurred in 20.5% of patients. Fusion rate was 90.9%. Reoperation rate at the index level was 12.8 and 7.7% in adjacent segments. The multidimensional Core Outcome Measures Index (COMI) improved from 7.4 (±1.4) to 3.9 (±2.7) after 1 year and to 3.3 (±2.6) after 2 years. Oswestry disability index (ODI) improved from 41.2 (±13.7) to 20.9 (±14.9) after 1 year and to 21.5 (±18.8) after 2 years. Improvements of at least the minimal clinically important change score of 2.2 and 12.9 points in the ODI and COMI after 2 years were noted in 75 and 56.3% of the patients, respectively. CONCLUSION: With careful patient selection, ALIF is safe and effective in elderly patients.

Role of Conventional Dynamic Myelography for Detection of High-Flow Cerebrospinal Fluid Leaks : Optimizing the Technique.

BACKGROUND: Spinal imaging is essential to identify and localize cerebrospinal fluid (CSF) leaks in spontaneous intracranial hypotension (SIH) patients when targeted treatment is necessary. PURPOSE: Provide an in-depth presentation of the conventional dynamic myelography (CDM) technique for localizing spinal CSF leaks in SIH patients. MATERIAL AND METHODS: Consecutive SIH patients with a CSF leak confirmed on CDM and postmyelography computed tomography (CT) investigated at our institution between 2013 and 2019 were retrospectively analyzed. Intraoperative reports were reviewed to confirm the accuracy of CDM. RESULTS: In total, 62 patients (mean age 45 years) were included; 48 with a ventral dural tear, 12 with a meningeal diverticulum, and in 2 patients positive for spinal longitudinal extradural CSF collection the site remained unclear. The leak was identified during the first and the second CDM in 43 and 17 patients, respectively. The use of CDM correctly identified the site of the CSF leak in all but one patient undergoing surgical closure (45/46, 98%). The mean fluoroscopy time was 7.8 min (range 1.8-14.4 min) with a radiation dose for a single examination of 310 mGy (range 28-1237 mGy). CONCLUSION: The CDM procedure has a high accuracy for spinal CSF leak localization including dural tears and spinal nerve diverticula. It is the technique with the highest temporal resolution, is robust to breathing artifacts, allows great flexibility regarding patient positioning, compares favorably to other dynamic examinations with respect to the radiation dose and does not require general anesthesia. For CSF venous fistulas, however, other dynamic examinations, such as digital subtraction myelography, seem more appropriate.

Assessing Spinal Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension With a Scoring System Based on Brain Magnetic Resonance Imaging Findings.

Importance: Various signs may be observed on brain magnetic resonance imaging (MRI) in patients with spontaneous intracranial hypotension (SIH). However, the lack of a classification system integrating these findings limits decision making in clinical practice. Objective: To develop a probability score based on the most relevant brain MRI findings to assess the likelihood of an underlying spinal cerebrospinal fluid (CSF) leak in patients with SIH. Design, Setting, and Participants: This case-control study in consecutive patients investigated for SIH was conducted at a single hospital department from February 2013 to October 2017. Patients with missing brain MRI data were excluded. Three blinded readers retrospectively reviewed the brain MRI scans of patients with SIH and a spinal CSF leak, patients with orthostatic headache without a CSF leak, and healthy control participants, evaluating 9 quantitative and 7 qualitative signs. A predictive diagnostic score based on multivariable backward logistic regression analysis was then derived. Its performance was validated internally in a prospective cohort of patients who had clinical suspicion for SIH. Main Outcomes and Measures: Likelihood of a spinal CSF leak based on the proposed diagnostic score. Results: A total of 152 participants (101 female [66.4%]; mean [SD] age, 46.1 [14.3] years) were studied. These included 56 with SIH and a spinal CSF leak, 16 with orthostatic headache without a CSF leak, 60 control participants, and 20 patients in the validation cohort. Six imaging findings were included in the final scoring system. Three were weighted as major (2 points each): pachymeningeal enhancement, engorgement of venous sinus, and effacement of the suprasellar cistern of 4.0 mm or less. Three were considered minor (1 point each): subdural fluid collection, effacement of the prepontine cistern of 5.0 mm or less, and mamillopontine distance of 6.5 mm or less. Patients were classified into groups at low, intermediate, or high probability of having a spinal CSF leak, with total scores of 2 points or fewer, 3 to 4 points, and 5 points or more, respectively, on a scale of 9 points. The discriminatory ability of the proposed score could be demonstrated in the validation cohort. Conclusions and Relevance: This 3-tier predictive scoring system is based on the 6 most relevant brain MRI findings and allows assessment of the likelihood (low, intermediate, or high) of a positive spinal imaging result in patients with SIH. It may be useful in identifying patients with SIH who are leak positive and in whom further invasive myelographic examinations are warranted before considering targeted therapy.