The Cerebrospinal Fluid Leak Medical Treatment Center mainly deals with three cases: spontaneous intracranial hypotension syndrome (SIH), iatrogenic, and traumatic cerebrospinal fluid (CSF) leaks. The first, SIH, develops without any apparent cause. However it is characterized by orthostatic headaches (headaches occurring when the patient stands), and is easily diagnosed with an MRI brain scan. The second, iatrogenic CSF leak, is accompanied with post-dural puncture headache, occurring after patients undergo procedures such as spinal anesthesia or lumbar puncture for spinal fluid sampling. Yearly, we treat approximately 10 to 20 of these two cases combined, which are mostly referred by other medical facilities. The primary treatment is bed rest, which ordinarily results in spontaneous healing. However, if there is not enough improvement in one to two weeks, we would consider epidural blood patch (EBP) treatment.

The third case, traumatic CSF leak, is the most common, with 70 to 80 new patients accepted every year, about half of whom are referred from other hospitals. The majority are caused traffic injuries which initially appear minor, such as whiplash. However, there are a variety of other causations such as sport injuries, tumbles and falls. In this case, headaches when the patient stands are fairly rare, instead, we suspect cerebrospinal fluid leak by the presence of symptoms shown in Chart 1. The current procedure for the treatment is shown in Chart 2. Firstly, we try to locate leaks outside of dura mater by MRI scan inspection of the whole spinal cord (fat suppression T2-weighted image). A general diagnosis can be made by MRI scan examination. If a CSF leak is suspected, patients will be hospitalized for examination, followed by EBP treatment. If the leak is not found, we will commence pain clinic treatment, such as neck trigger point injection or intervertebral joint block injection. About 60% of CSF leaks can be cured with a single EBP treatment, and if needed, further treatment will be added. Patients with traffic injuries will often require pain clinic treatment after the leak has stopped. In some cases, it is difficult to determine if a CSF leak exists, or if a leak has completely stopped. As approximately 10% of patients cannot be cured, we strive to continuously to improve our diagnostic and treatment skills.

Considering the Possibility of Cerebrospinal Fluid Leaks in Patients

If we rely on orthostatic headaches as the sole criteria, we will miss CSF leaks in many patients. Of course it is true that many patients of this condition complain of orthostatic headaches, which worsen over time. When carefully interviewed, in many cases patients experience no problems when they wake up, but suffer from a headache that worsens as the day passes, together with the patient’s physical activity. In patients with traffic injuries, CSF leaks are often accompanied by conditions such as whiplash-associated disorders (WAD), thoracic outlet syndrome, and symptoms will persist despite bed rest. Thus, the patient is often unaware of the orthostatic nature of this condition. Other symptoms, such as nausea, general malaise, tinnitus and dizziness, can help identify a CSF leak. Even for apparently minor trauma, we must also be cautious when patients complain of persistent neck ache, headache, or similar symptoms, which interfere with day to day life or work.

Cerebrospinal Fluid Leak Medical Treatment Center Manager
Dr. Eiji Moriya