title: Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report.
abstract: Spontaneous intracranial hypotension (SIH) has been clinically defined as the development of severe orthostatic headaches caused by an acute cerebrospinal fluid (CSF) leak. Typically, intracranial hypotension occurs as a complication of lumbar puncture, but recent reports have identified cases caused by minor trauma. We report a case of SIH secondary to a dural tear caused by a cervical and thoracic spine mobilization. A 32-year-old woman with SIH presented with severe positional headaches with associated hearing loss and C6-8 nerve root distribution weakness. CSF opening pressure was less than 5cmH(2)O and showed no abnormalities in white blood cell count. Cranial, cervical, and thoracic magnetic resonance imaging revealed epidural and subdural collections of CSF with associated meningeal enhancement. Repeated computed tomography myelograms localized the leak to multiple levels of the lower cervical and upper thoracic spine. A conservative management approach of bedrest and increased caffeine intake had no effect on the dural tear. The headache, hearing loss, and arm symptoms resolved completely after 2 epidural blood patches were performed. Practitioners performing manual therapy should be aware of this rare, yet potential complication of spinal mobilizations and manipulations.
authors.affiliation: Department of Physical Therapy, Chapman University, Orange, CA, USA.
authors.forename: J Skye
authors.initials: JS
authors.lastname: Donovan
authors.forename: Charles W
authors.initials: CW
authors.lastname: Kerber
authors.forename: William H
authors.initials: WH
authors.lastname: Donovan
authors.forename: Lawrence F
authors.initials: LF
authors.lastname: Marshall
mesh_terms: D000328:Adult; D015119:Aminocaproic Acid / Q000008:administration & dosage; D000933:Antifibrinolytic Agents / Q000008:administration & dosage; D017217:Blood Patch, Epidural; D002574:Cervical Vertebrae / Q000473:pathology; D003131:Combined Modality Therapy; D004388:Dura Mater / Q000293:injuries* / Q000473:pathology; D005119:Extravasation of Diagnostic and Therapeutic Materials / Q000209:etiology; D005260:Female; D006801:Humans; D019585:Intracranial Hypotension / Q000209:etiology* / Q000628:therapy; D008279:Magnetic Resonance Imaging; D020393:Manipulation, Spinal / Q000009:adverse effects*; D009192:Myelography; D009460:Neurologic Examination; D026741:Physical Therapy Modalities / Q000009:adverse effects*; D013353:Subdural Effusion / Q000209:etiology* / Q000628:therapy; D013904:Thoracic Vertebrae / Q000473:pathology; D014057:Tomography, X-Ray Computed
chemical_list: D000933:Antifibrinolytic Agents; D015119:Aminocaproic Acid