Background and Objective: Orthostatic headache is the key symptom of intracranial hypotension secondary to cerebral spinal fluid (CSF) leak. Spontaneous intracranial hypotension (SIH), i.e. intracranial hypotension in the absence of a known iatrogenic dural puncture, is an under recognized cause of orthostatic headache caused by intracranial hypotension. The most common cause of SIH is thought to be leakage of CSF from ruptured perineural cysts (i.e. Tarlov cysts). Conservative treatment, epidural blood patch (EBP) procedure and open surgical repair have been used to treat SIH.
Case Report: Here we report a case of patient with SIH who was initially treated with epidural blood patches with short term symptomatic relief when the CSF leakage site was not identified, but later developed recurrent headache with rapidly declining mental status and severe neurological symptoms. A dural tear related to a spondylotic osteophyte and life threatening brain herniation was identified with additional imaging studies. The patient eventually required urgent surgical repair with favorable clinical outcome.
Conclusion: This and other cases of SIH caused by spondylotic osteophyte-related durotomy suggest that SIH caused by spondylotic osteophyte has a different clinical course than other SIH cases. Such patients may only have transient response to epidural blood patch; their symptoms may acutely worsen due to larger durotomy by spondylotic osteophytes. Clinicians should be vigilant in monitoring neurological symptoms and consider spondylotic osteophyte as a potential etiology of spontaneous dural puncture. Once such etiology is identified, early surgical repair is indicated.