Superficial Siderosis: A Case Report of Underdiagnosed Disorder.

Superficial siderosis (SS) is caused by subpial hemosiderin deposition due to chronic low-grade bleeding into the subarachnoid space. Dural tears are the most common etiology. Slowly progressive gait ataxia and hearing impairment are common clinical manifestations. Brain magnetic resonance imaging (MRI) shows linear superficial hypointensity on the T2 weighted images and gradient echo. The therapeutic approach is surgical repair of the bleeding source. The patient presented with progressive hearing loss and ataxia. Neurological examination revealed bilateral hearing loss, nystagmus, dysarthria, brisk deep tendon reflexes, and severe ataxia. Brain MRI showed linear superficial siderosis in the cerebrum, cerebellum, and brain stem. Spinal MRI showed ventral epidural cerebrospinal fluid (CSF) collection and disc-osteophyte complex. Six months after the surgical repair of the dural defect, the patient's neurological examination demonstrated improvement in ataxia and dysarthria. The patient was able to walk without any assistance. Surgical repair of the underlying bleeding source may be beneficial in preventing the progression and improving the symptoms of superficial siderosis SS. This case suggests that SS symptoms are potentially reversible by surgical treatment of the underlying spinal CSF leak after a long disease course.

Effectiveness of a Sellar Reconstruction Algorithm in Transsphenoidal Pituitary Surgery: Insights from 490 Cases.

BACKGROUND: Rhinorrhea is a common complication after endoscopic endonasal transsphenoidal pituitary surgery (EETPS). This study evaluates the effectiveness of our sellar reconstruction technique in preventing rhinorrhea. METHODS: From June 2020 to March 2024, a surgical team performed 490 EETPS procedures on 458 pituitary adenoma patients. Demographic data, surgery status, and radiological and histopathological classifications were retrospectively analyzed. 4 grades for sellar reconstruction were defined based on intraoperative cerebrospinal fluid (CSF) leakage and diaphragm sella defect size. Grade 0: no CSF leakage; cavity filled with absorbable material. Grade 1: small defect; covered with fat and fascia lata grafts. Grade 2: large defect; added lumbar drainage. Grade 3: extended approach; added nasoseptal flap. RESULTS: Of the 490 operations, 433 were primary and 57 recurrent. Patients were 50.2% male, mean age 49.01 years. Follow-up averaged 20.5 months. Postoperative rhinorrhea occurred in 8 cases (1.6%). In 404 surgeries (82.5%) without intraoperative CSF leakage, 3 cases (0.7%) developed postoperative rhinorrhea. CSF leakage was detected in 86 cases (17.5%), with postoperative rhinorrhea in 5 cases (5.8%). The risk of rhinorrhea was 8.3 times higher with intraoperative CSF leakage (P = 0.005). Rhinorrhea rates: 0.7% in Grade 0, 3% in Grade 1, 8.7% in Grade 2, and 0% in Grade 3 (P = 0.017). Meningitis occurred in 8 patients (1.7%) and pneumocephalus in 4 (0.9%), with one death (0.2%). The average hospital stay was 17.4 days with rhinorrhea and 5.2 without (P = 0.024). CONCLUSIONS: Intraoperative CSF leakage is highly correlated with rhinorrhea. Multilayered and graded closure strategies significantly reduce postoperative rhinorrhea rates in EETPS.

A Case of Superficial Siderosis with Elevated Anti-Ro/SSA Antibody.

Superficial siderosis (SS) of the central nervous system is a rare disorder that is caused by chronic or recurrent hemorrhage in the subarachnoid space via a dural defect at the spinal level. The most common clinical features of SS include slow-progressive sensorineural deafness, cerebellar symptoms, and pyramidal tract signs. Considering that SS can present with broad clinical manifestations, for precise diagnosis, this disease must be understood. Anti-Ro/SSA antibodies are commonly detected in patients with Sjögren's syndrome and are utilized as markers for autoimmune diseases. In this report, we present a unique pathological condition in which SS coincided with a positive anti-Ro/SSA antibody test result. During the diagnosis of gait disturbance, an elevation in anti-Ro/SSA antibody was detected, and steroid pulse therapy was initiated as the initial treatment for autoimmune diseases. Head magnetic resonance imaging (MRI) revealed extensive hypointensity as a dark band that surrounded the intracranial basal structures and cerebellar hemispheres. Spinal MRI indicated ventral longitudinal intraspinal fluid collection extending from C7 to T5 as well as a defect in the ventral T2-3 dura mater. Intraoperative visualization revealed that the intradural venous plexus was the source of bleeding that caused the SS. To our knowledge, this report is the first to discuss the presence of anti-Ro/SSA antibodies in patients with SS. The role of anti-Ro/SSA antibodies in the pathophysiology of SS remains unclear; therefore, to confirm a possible association, further research and accumulation of cases are required.

Detection of Dural Defect Localization Using 4-Dimensional Dynamic Computed Tomography Myelography for Patients with Superficial Siderosis.

BACKGROUND: There are cases of superficial siderosis (SS) with spinal ventral fluid-filled collection in the spinal canal. In our previous study, the balanced steady-state free precession sequence magnetic resonance imaging is useful in identifying the location of dural defects. However, because of its narrow scan area and long scan time, it cannot easily detect the defect location in some patients with small dural defect. In this study, we applied 4-dimensional (4D) dynamic computed tomography (CT) imaging, including time-axis imaging, to myelography using the latest CT imaging equipment, which can perform short-time continuous imaging, to identify the dural defect site. METHODS: Twenty SS patients with ventral fluid-filled collection in the spinal canal (9 males, 11 females; mean age 61.6 years) underwent 4D dynamic CT myelography. A 192-row helical CT (SOMATOM Force, SIEMENS, Munich, Germany) with high-speed scanning capability was used to obtain 9-11 scans per minute at low dose while passing contrast medium into the subarachnoid space. Then, contrast leakage sites were identified. RESULTS: The contrast leakage sites could be identified in all 20 cases: C7/Th1, 2 cases; Th1/2, 5 cases; Th2/3, 9 cases; Th3/4, 1 case; Th5/6, 1 case; Th7/8, 1 case; and Th8/9, 1 case. Eighteen cases underwent surgical operation, and actual dural defects were confirmed at the contrast leakage sites. The mean ± standard deviation of leakage time from contrast agent injection was 19.0 ± 9.2 s. CONCLUSIONS: The 4D dynamic CT myelography can be used to reliably identify the location of spinal fluid leakage. In SS cases, dural defects could be visualized in an average of 19 seconds.

Extradural spinal cyst in a pediatric patient: A case report.

Background: Spinal extradural arachnoid cysts comprise <1% of all spinal lesions and are rare findings in pediatric patients. The pathogenesis of spinal extradural arachnoid cysts is not well known but is thought to most commonly be due to congenital dural defects. Other origins include trauma, inflammation, or infection, such as arachnoiditis. Spinal magnetic resonance imaging is the gold standard for diagnosis, showing a fluid-filled space dorsal to the spinal cord with signal intensity akin to cerebrospinal fluid (CSF) and often the site of dural defect with CSF leak. While most spinal extradural arachnoid cysts are asymptomatic, large cysts can compress the spinal cord or nerve roots, leading to myelopathy, radiculopathy, or focal pain symptoms. In such cases, surgical management is indicated. Case Description: Here, we present a case of a 15-year-old female who presented with lower back pain radiating to her bilateral posterior thighs and knees, with imaging indicating a thoracolumbar spinal extradural arachnoid cyst. After failed conservative treatment, surgical intervention in the form of laminectomy, fenestration of the arachnoid cyst, and repair of the dural defect was required, resolving the patient's symptoms with no recurrence of the cyst. Conclusion: Complete resolution of pain in our patient following surgical management of spinal arachnoid cyst suggests that treatment of the arachnoid cyst can be achieved through minimal exposure to the site of the CSF leak to fenestrate the cyst and repair the leak.

Spinal intradural pseudocyst formation in central nervous system superficial siderosis.

The figure shows tissue samples taken from three previous cases, revealing the cause of hemosiderin deposition in the central nervous system because of superficial siderosis.

Trans-Nasal Endoscopic Repair of CSF Rhinorrhea: An Institutional Experience.

Introduction: Cerebrospinal Fluid (CSF) rhinorrhea results from breakdown in the integrity of structures separating the subarachnoid space and nasal cavity, namely subarachnoid space and dura mater, the bony skull base and periostea alongside the upper aerodigestive tract mucosa. Endoscopic repair is considered the treatment of choice for CSF rhinorrhea. Our aim of study was to analyze the etiopathogenesis and outcomes of treatment. Material and Methods: A retrospective study review of patients treated with endoscopic repair of CSF rhinorrhea at tertiary care hospital in ENT Department Benazir Bhutto hospital Rawalpindi from august 2013 to September 2017 identified 25 patients. Majority of them were male. The defects were closed in three layers using fat, fascia lata and nasal mucosa along with fibrin sealant in majority of patients. Pre operatively subarachnoid drain was placed in all patients. Patients were followed up to 3 months. Results: Forty-four patients underwent endoscopic repair of CSF rhinorrhea. The age group ranged from 16 to 55 years. Of the total of 44 patients 26 (59%) were males and 18(41%) females. The mean age of the patients in our study was 32.8 ± 9.7. Post trauma CSF leak was seen up to 52.3% of the patients. The most common site of leakage was identified Cribriform plate area. Our success rate of endoscopic repair was 88.6%. The most commonly observed complication was meningitis that was observed in 2 (4.5%) of the patients that too were managed conservatively. Conclusion: Accurate localization of site of leakage appears to be essential for successful endoscopic repair of CSF rhinorrhea. In our study cribriform plate area was commonly observed area of CSF leak. In our study, the success rate was 88.6% and low complication rate 4.5%.

Trans-Defect Underlay Watertight Duraplasty for Traumatic Anterior Skull Base Dural Defect: Technical Report.

BACKGROUND: Watertight duraplasty is essential for surgical management of traumatic anterior skull base (ASB) dural defect but challenging in the deep and narrow operative corridor. Here, the authors report a trans-defect underlay watertight duraplasty (TDUWD) technique for traumatic ASB dural defect. METHODS: TDUWD was performed by inserting a free pericranium graft under the dural defect. The diameter of the pericranium graft was larger than the dural defect. The pericranium graft was sutured to the dural defect watertightly in an "inside-to-outside" direction, with the needle not penetrating the inner layer of pericranium graft. The pedicled pericranium flap was used as a second layer of reconstruction. The characteristics, complications, and outcomes of patients who received TDUWD are reported. RESULTS: A total of 29 patients received TDUWD. Immediate postoperative cessation of cerebrospinal fluid (CSF) leak occurred in 28 patients. One patient recovered after lumber drainage. No patient needed a second operation or reported delayed recurrence of CSF leak. No complication related to the surgical technique was observed. CONCLUSIONS: Use of TDUWD for traumatic ASB dural defect results in an immediate, 1-stage, and definitive correction of CSF leak and seems to be simple, safe, and reliable for large and deeply located dural defects.

Bibrachial amyotrophy as a rare manifestation of intraspinal fluid collection: a case report and systematic review.

INTRODUCTION: Intraspinal cerebrospinal fluid (CSF) collection has been reported as a rare cause of lower motor neuron (LMN) disorder. We report a case of bibrachial diplegia associated with intraspinal CSF collection and perform a systematic literature review. PATIENT AND METHODS: A 52-year-old man developed a bibrachial amyotrophy over 6 years, confirmed by the presence of cervical subacute neurogenic changes at electromyography (EMG). Brain magnetic resonance imaging (MRI) revealed cerebral siderosis, while spine MRI showed a ventral longitudinal intraspinal fluid collection (VLISFC) from C2 to L2. No CSF leakage was localized at myelography; a conservative treatment was chosen. We searched for all published cases until 30th April 2023 and extrapolated data of 44 patients reported in 27 publications. RESULTS: We observed a male predominance, a younger disease onset compared to amyotrophic lateral sclerosis, and a quite long disease duration, highlighting a slow disease progression. LMN signs were more frequently bilateral, mostly involving C5-C6 myotomes. Around 61% of patients presented additional symptoms, but only three referred to a history of headache. Accordingly, CSF opening pressure was mostly normal. Spinal MRI revealed the presence of VLISFC and in some cases myelomalacia. EMG patterns displayed both chronic and subacute neurogenic change in the cervical region. The disease course mainly depended on the treatment choice, which was mostly represented by a surgical approach when a specific dural defect was detected by imaging. CONCLUSION: Bibrachial diplegia due to VLISFC can be a treatable cause of focal amyotrophy and presents some clinical and radiological "red flags" which cannot be missed by a clinical neurologist.

The "Gift Wrap" Technique - A Method that Simplifies the Placement of Fascia Lata in the Reconstruction of the Skull Base Following Endoscopic Endonasal Surgery: A Technical Note.

BACKGROUND: With the advancement of endoscopic endonasal surgery in the treatment of anterior skull base (ASB) pathologies, extended, watertight reconstructions are needed to prevent cerebrospinal fluid (CSF) leakage. This often involves the use of multilayers closure, with free fascia lata (FL) graft frequently used as an in- and/or outlay. However, positioning the FL properly can be challenging and time-consuming, particularly on wider defects. In this technical note, we present an easier and faster way to position FL using a silicone sheet. METHODS: FL graft is harvested using a standard technique. The required dimensions are evaluated depending on the extent of the dural defect taking in consideration that FL graft should exceed the edges of the dural defect especially laterally. It is then wrapped around a semi rigid pattern (Silastic sheet) and secured with several monofilament 5/0 sutures. The "package" is transferred through the endonasal corridor to the defect. The sutures are divided and taken out; the fascia is unfolded, and its edges are inserted into the subdural space without any twisting or folding of the flap. Finally, the silicone sheet is withdrawn from the nasal cavity, leaving the FL well-stretched in perfect position. RESULTS: We illustrate this technique in the management of a large anterior skull base chondrosarcoma, which necessitated significant bone and dural resection. CONCLUSIONS: The "Gift wrap" technique offers an alternative approach for positioning the FL, which is less time-consuming compared to the traditional technique. Moreover, it enables improved placement of the FL, enhancing its efficacy.

Spinal Arachnoid Cyst Analysis of Surgical Experience in a Single Tertiary Care Centre and Review of Literature.

OBJECTIVE: To study patients with spinal arachnoid cysts, who underwent cyst excision with dural defect repair or marsupialization, and their outcomes. METHODS: The retrospective analysis involved reviewing the records of 38 patients who underwent surgical treatment for spinal arachnoid cysts in the Department of Neurosurgery at Christian Medical College, Vellore, between August 2004 and December 2022. The study examined the demographics, clinical presentation, imaging, surgical intervention, and outcomes of these patients. RESULTS: The majority of patients in the study were male (29/38, with 76.3%) and the thoracic region was the most common location for the cyst (17, with 44.7%). Weakness was the primary complaint and 94.7% of patients had myelopathy. The bladder was affected in 13 patients (34.2%). Of the 38 patients, 26 (71%) had cysts in extradural locations, while the rest were intradural. In total, 45.5% of intradural cysts were located in the ventral region. Seventeen (65.4%) had dural defects along the root sleeve and 29 (76.3%) underwent complete excision. All extradural cysts underwent complete excision and repair of the dural defect. Thirty patients (78.9%) experienced improved outcomes with reduced spasticity and improved weakness. One patient developed new-onset weakness postoperatively due to epidural hematoma. The mean follow-up period was 41 months and one patient experienced a recurrence. CONCLUSIONS: Spinal arachnoid cyst is a rare benign spinal condition that is typically treated with surgery in symptomatic patients. Surgical intervention may involve either the excision of the cyst or marsupialization.

Clinical management of dural defects: A review.

Dural defects are common in spinal and cranial neurosurgery. A series of complications, such as cerebrospinal fluid leakage, occur after rupture of the dura. Therefore, treatment strategies are necessary to reduce or avoid complications. This review comprehensively summarizes the common causes, risk factors, clinical complications, and repair methods of dural defects. The latest research progress on dural repair methods and materials is summarized, including direct sutures, grafts, biomaterials, non-biomaterial materials, and composites formed by different materials. The characteristics and efficacy of these dural substitutes are reviewed, and these materials and methods are systematically evaluated. Finally, the best methods for dural repair and the challenges and future prospects of new dural repair materials are discussed.

How I do it: epidural transposition of the temporoparietal fascia flap for anterior skull base reconstruction.

BACKGROUND: Multilayer closures and the use of vascularized flaps have been showed to be very effective in the reconstruction of the anterior skull base (ASB) after extended endonasal approaches resulting in large bone and dural defects. In the case of unavailability of a local flap, regional ones like the temporoparietal fascia flap (TPFF), used until now via a transpterygoïd route (Bolzoni Villaret et al. in Eur Arch Otorhinolaryngol 270(4):1473-1479, 2023; Fortes et al. in Laryngoscope 117(6):970-976, 2017; Veyrat et al. in Acta Neurochir (Wien) 158(12):2291-2294, 2016), can be an effective alternative. METHOD: We describe a step-by-step technique of TPFF transposition via an epidural supraorbital corridor for the reconstruction of a large midline ASB defect. CONCLUSION: TPFF is a promising alternative for the reconstruction of the ASB defects.

Safety and effectiveness of spinal dural defect repair in the management of superficial siderosis: A systematic review and patient-level analysis.

OBJECTIVE: Superficial siderosis (SS) is a disabling neurodegenerative condition that may be caused by spinal dural defects. Surgical repair is increasingly performed, however clinical outcomes remain unclear. METHODS: A systematic search of PubMed, MEDLINE, and EMBASE was conducted (inception to February 2020). Studies reporting cases of (i) superficial siderosis, (ii) spinal dural defect, (iii) and surgical closure of the defect were included. Demographic characteristics, clinical presentation, operative technique and clinical outcome were extracted for patient-level analysis. RESULTS: A total of 26 publications were included, which reported 38 patients with a median age of 58 years, and a male predominance (78.9 %). Ataxia (85.7 %) and hearing loss (80.0 %) were the most common presenting symptoms. The causative dural defect was most commonly ventral in location (91.7 %) and most commonly identified by CT myelography (48.6 %). Operative technique was highly variable and included primary suture, fibrin glue, dural substitute, or tissue (fat or muscle) graft. Clinical improvement was reported in 21 %, with stabilisation of symptoms in the majority (66 %) and clinical deterioration in 13.2 %. Surgical complications were observed in 7.9 %. CONCLUSION: In patients with superficial siderosis and spinal dural defect, operative closure leads to improvement or stabilisation of symptoms in the vast majority (87%) of patients.

Outcome of epidural blood patch for imaging-negative spontaneous intracranial hypotension.

BACKGROUND: Spontaneous intracranial hypotension is diagnosed by an abnormal finding in brain MRI, spinal imaging, or lumbar puncture. However, the sensitivity of each test is low. We investigated whether patients with suspected spontaneous intracranial hypotension and negative imaging findings would respond to epidural blood patch. METHODS: We prospectively recruited patients with new-onset orthostatic headache admitted at the Samsung Medical Center from January 2017 to July 2021. In patients without abnormal imaging findings and no history of prior epidural blood patch, treatment outcome-defined as both 50% response in maximal headache intensity and improvement of orthostatic component-was collected at discharge and three months after epidural blood patch. RESULTS: We included 21 treatment-naïve patients with orthostatic headache and negative brain and spinal imaging results who received epidural blood patch. After epidural blood patch (mean 1.3 times, range 1-3), 14 (66.7%) and 19 (90.5%) patients achieved both 50% response and improvement of orthostatic component at discharge and three months post-treatment, respectively. Additionally, complete remission was reported in 11 (52.4%) patients at three-month follow-up, while most of the remaining patients had only mild headaches. Among nine (42.9%) patients who underwent lumbar puncture, none had an abnormally low opening pressure (median 13.8 cm H2O, range 9.2-21.5). CONCLUSION: Given the high responder rates of epidural blood patch in our study, empirical epidural blood patch should be considered to treat new-onset orthostatic headache, even when brain and spinal imaging are negative. The necessity of lumbar puncture is questionable considering the high response rate of epidural blood patch and low rate of "low pressure."

Spinal extradural arachnoid cysts: A novel formation mechanism and dural defect location technology.

Purpose: The formation mechanism of spinal extradural arachnoid cysts (SEACs) remains unclear. There are several hypotheses for the formation of SEACs, but none of them can fully explain its pathological findings and surgical procedures. In this study, we retrospectively analyzed the cases of SEACs, aiming to clarify the formation mechanism of SEACs. In addition, we summarize a concise method for locating dural defects preoperatively and formulate a putative explanation of this method. Methods: The clinical data of 14 patients with SEACs underwent surgery in our hospital from January 2017 to December 2021 were retrospectively analyzed. Results: Fourteen patients were identified during the study period. The cysts all spanned the T12/L1 segment, and dural defects were also located at the T12/L1 level (2 cases not recorded) as well as the middle or the upper-middle level of the cysts. Nine cases were treated with total cyst excision, 2 cases were treated with dural defect closure only, and 3 cases were treated with total cyst excision and dural defect closure. Histopathological examination demonstrated that the cyst wall contained both the arachnoid epithelial and compact fibrous connective tissue. The symptoms were relieved in all patients, and no recurrence was observed. Conclusions: According to intraoperative and pathological findings, the dural outer layer cyst (DOLC) is a more reasonable hypothesis about SEACs formation. When CT myelography or cinematic MRI cannot determine the location of the dural defect preoperatively, it can be located according to the middle level of the SEACs with high accuracy.

Idiopathic spinal cord herniation at the cervicothoracic junction level presenting with unilateral sensory symptoms.

Idiopathic spinal cord herniation (ISCH) most commonly occurs through a ventral dural defect at the midthoracic levels with a predilection to affect middle-aged females. It can have various presentations, the most common of which are Brown-Séquard syndrome and spastic paraparesis. Due to its rarity in clinical practice, the diagnosis of ISCH can be challenging to physicians unfamiliar with this entity. We report an exceedingly rare case of ISCH at the C7-T1 intervertebral disc level in a 44-year-old male presenting with eight months of isolated unilateral sensory symptoms. The diagnosis was made based on the findings on the patient's magnetic resonance imaging of the spinal cord, including the presence of an extradural cerebrospinal fluid collection. Surgical reduction of the herniated segment and patching of the dural defect resulted in a remarkable clinical improvement beginning in the immediate postoperative period. Follow-up MRIs showed no sign of reherniation, and the patient remained asymptomatic after one year of follow-up. Early diagnosis and surgical intervention led to an excellent early outcome in this case. However, long-term follow-up is necessary to monitor for reherniation and relapse of the symptoms in ISCH patients.

Closure of a dural defect as a cause of superficial siderosis: does early dural repair lead to a better outcome? Illustrative case.

BACKGROUND: Superficial hemosiderosis (SS) of the central nervous system is a rare condition that is caused by chronic, repeated hemorrhage into the subarachnoid space. The subsequent deposition of hemosiderin in the brain and spinal cord causes neurological deterioration. In this report, the authors describe a repair procedure for SS associated with a dural defect in the thoracic spine. OBSERVATIONS: A 75-year-old man presented with tinnitus symptoms that began about 1 year prior. Subsequently, his hearing loss progressed, and he gradually became unsteady on walking. Magnetic resonance imaging (MRI) of the head showed diffuse hemosiderin deposition on the surface of the cerebellum. Thoracic MRI showed ventral cerebrospinal fluid leakage of T2-7, and computed tomography myelography showed leakage of contrast medium that appeared to be a dural defect. Dural closure was successful, and MRI showed decreased fluid collection ventral to the dura. The patient's symptoms of wobbliness on walking and tinnitus improved dramatically from the postoperative period. LESSONS: Dural abnormalities of the spine must always be considered as one of the causes of SS. Early dural closure is an effective means of preventing the progression of symptoms.

How to locate the dural defect in a spinal extradural meningeal cyst: a literature review.

Spinal extradural meningeal cysts (SEMCs) are rare lesions of the spinal canal. Although closure of the dural defect can achieve satisfactory therapeutic effects, locating the fistula is difficult. This review summarizes the methods for locating the fistula of SEMCs and the distribution and features of fistula sites.This was a non-systematic literature review of studies on SEMCs. We searched PubMed for English-language articles to summarize the methods of locating the defect. The search words were "epidural arachnoid cyst," "dural cyst," "epidural cyst," and "epidural meningeal cyst." For the defect location component of the study, case reports, studies with a sample size less than four, controversial ventral dural dissection(s), and undocumented fistula location reports were excluded.Our review showed that radiography and computed tomography (CT) may show changes in the bony structure of the spine, with the largest segment of change indicating the fistula site. Occasionally, magnetic resonance imaging (MRI) can show a cerebrospinal fluid (CSF) flow void at the fistula site. The middle segment of the cyst on sagittal MRI, the largest cyst area, and cyst laterality in the axial view indicate the fistula location. Myelography can show the fistula location in the area of the enhanced cyst and subarachnoid stenosis. Digital subtraction or delayed CT can be used to observe the location of the initial cyst filling. Cine MRI and time-spatial labeling inversion pulse techniques can be used to observe CSF flow. Steady-state image construction interference sequence MRI has a high spatial resolution. Neuroendoscopy, MRI myelography, and ultrasound fistula detection can be performed intraoperatively. Moreover, the fistula was located most often in the T12-L1 segment.Identifying the fistula location is difficult and requires a combination of multiple examinations and experience for comprehensive judgment.