title: Treatment strategy for cerebral hypotension caused by spontaneous cerebrospinal fluid leaks.
abstract: OBJECTIVE
  Spontaneous spinal cerebrospinal fluid (CSF) leaks are rare (5 per 100,000 per year). Treatment generally consists of conservative therapy or interventional therapy with epidural blood patching. Surgical treatment is conducted rarely, usually in cases when conservative or interventional treatment has failed. The aim of our case series was to assess the clinical outcome after surgery.
  
  
  METHODS
  Our clinical database was reviewed for patients with spontaneous spinal CSF leaks who underwent surgical exploration between 2010 and 2013. Etiology, symptoms, preoperative imaging, type of required surgical method, intraoperative findings, and clinical outcome were reported.
  
  
  RESULTS
  We identified five patients with a mean age of 62 years with spontaneous spinal CSF leaks who were treated surgically. Two patients received surgery after failure of interventional treatment. The origin of the CSF leak could be identified intraoperatively in three cases. Surgical technique in all cases consisted of an interlaminar fenestration or hemilaminectomy and a complete foraminotomy to explore the thecal sack and the exiting nerve roots and identify the CSF leak. After surgery, the preoperative symptoms improved in all patients. In one case, there was a relapse after 4 weeks.
  
  
  CONCLUSIONS
  Preoperative identification of a CSF leak with MRI was positive in only one case. In all other cases, a post-myelography CT had to be performed. In all cases, the preoperative symptoms improved after surgery. Surgical treatment is an effective treatment of spontaneous cerebrospinal fluid leaks in cases of refractory symptoms after failed conservative or interventional treatment.
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany. insa.janssen@lrz.tum.de.
authors.forename: Insa
authors.identifier: http://orcid.org/0000-0002-4960-0467
authors.initials: I
authors.lastname: Janssen
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
authors.forename: Jens
authors.initials: J
authors.lastname: Gempt
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
authors.forename: Julia
authors.initials: J
authors.lastname: Gerhardt
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Meyer
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
authors.forename: Yu-Mi
authors.initials: YM
authors.lastname: Ryang
mesh_terms: D000328:Adult; D000368:Aged; D065634:Cerebrospinal Fluid Leak / Q000150:complications* / Q000601:surgery*; D016208:Databases, Factual; D005260:Female; D059526:Foraminotomy; D006261:Headache / Q000209:etiology; D006801:Humans; D019585:Intracranial Hypotension / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery*; D007431:Intraoperative Complications / Q000628:therapy; D007796:Laminectomy; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D012008:Recurrence; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: CSF leak; Epidural blood patching; Intracranial hypotension; Naked nerve roots; Orthostatic headache; Spinal meningeal cysts