Sacral Dural Tears as a Cause of Spontaneous Intracranial Hypotension

Abstract

Purpose Dural tears at the level of the cervical, thoracic, and lumbar spine cause spontaneous intracranial hypotension (SIH) in patients with a spinal longitudinal extradural CSF collection (SLEC); however, sacral dural tears have rarely been reported so far. This study focuses on sacral dural tears as a cause of SIH. Methods Retrospective data from SIH patients with confirmed sacral dural tears studied between October 2020 and November 2022 were analyzed with respect to demographic, clinical and imaging features. Digital subtraction myelography (DSM) and lumbar epidural blood patch (EBP) were modified by placing the patient in reversed Trendelenburg position. Results Of the SIH patients, 9 (all women; mean age, 38.5 years; mean body mass index, BMI, 22.9) out of 149 had a sacral dural leak (6%) that occurred spontaneously in 7/9, while 2/9 were likely associated with minor trauma. None had a sacral fracture. The mean SIH score was 6.8. All patients showed SLEC on heavily T2-weighted MR myelography (T2-MRM), 4/9 exclusively sacral and 5/9 with partial or complete involvement of the remaining spine. 4/9 had none, but 5/9 had meningeal sacral cysts, 2/5 had large cysts/ectasia. Confirmation of the sacral origin of the leak was provided in 4/9 by T2-MRM, in 2/9 by DSM and 3/9 by CT myelography (CTM) whereas 0/9 revealed the exact site of leak within the sacrum. Conclusion Sacral dural tears should be considered as a possible cause for SIH. It is concluded to implement T2-MRM covering the entire sacrum in the standard MRI protocol and propose EBP in the reverse Trendelenburg position as a therapeutic approach.

Non-invasive biomarkers for spontaneous intracranial hypotension (SIH) through phase-contrast MRI

“…Bern score was additionally stratified into low (≤ 2 points), intermediate (3-4 points), and high probability (5-9 points) [23]. The type of the CSF leak [20][21][22] was diagnosed on subsequent dynamic myelogram (digital subtraction myelogram and/or dynamic CT-myelogram).…”

Spontaneous intracranial hypotension – a spinal disease

“…In addition to these three types, there are indications of a fourth group in the sacral region (approx. 6 % of cases), with this being almost exclusively seen in women [24]. Further information about sacral leaks and etiology is not yet available.…”

“…20 s per examination block) and are helpful for visualizing epidural fluid or prominent meningeal diverticula (▶ Fig. 2A, B) [24].…”

Don’t delay, but don’t despair: symptom duration, comorbidity and outcome after closure of spinal cerebrospinal fluid leaks

“…The primary cause of SIH are spontaneous spinal cerebrospinal fluid (CSF) leaks, which can be classified into different types [ 7 – 10 ]: Type 1 leaks (ventral leaks) are dural tears often associated with discogenic microspurs, usually at the disc level ventral to the spinal cord; Type 2 leaks (lateral leaks) are lateral dural tears in the area of a spinal nerve root; Type 3 leaks are CSF-venous fistulas. Recently, sacral dural tears have been identified as another cause of SIH [ 10 ].…”

“…The primary cause of SIH are spontaneous spinal cerebrospinal fluid (CSF) leaks, which can be classified into different types [ 7 – 10 ]: Type 1 leaks (ventral leaks) are dural tears often associated with discogenic microspurs, usually at the disc level ventral to the spinal cord; Type 2 leaks (lateral leaks) are lateral dural tears in the area of a spinal nerve root; Type 3 leaks are CSF-venous fistulas. Recently, sacral dural tears have been identified as another cause of SIH [ 10 ]. After failure of conservative measures, sometimes including one or several epidural blood or fibrin glue patches, microsurgical closure is a viable option for all types of spinal CSF leaks [ 2 ], resulting in significant improvement of impact of headaches [ 9 , 11 – 13 ] and quality of life [ 14 ] (Volz et al, Neurology: Clinical Practice, accepted 01/2024, CPJ-2023-000465).…”