title: Transpedicular surgical approach for the management of thoracic osteophyte-induced intracranial hypotension refractory to non-operative modalities: case report and review of literature.
abstract: In this article, we aim to describe the presentation and management of a case of spontaneous intracranial hypotension caused by a dural tear from a ventral thoracic osteophyte at the T12 level that was refractory to non-surgical treatment modalities. A review of the literature has been performed. Also a proposal of diagnostic and treatment algorithm is presented. Intracranial hypotension and CSF leak as a result of dural tear is a common phenomenon. However, the detection of the source of CSF leak from a thoracic spinal osteophyte has rarely been reported.
  
  
  
  Diagnostic workup including MRI and CT Myelogram as well as application of epidural blood patches and surgical technique of hemilaminectomy and osteophytectomy by transpedicular approach have been described. Literature review was conducted using relevant search terms in PubMed.
  
  
  
  The patient's spontaneous intracranial hypotension symptoms resolved and this persisted on follow up visits. Review our experience as well as similar cases in the literature pointed us towards a diagnostic and treatment algorithm.
  
  
  
  Spontaneous resolution is the norm for intracranial hypotension of most etiologies and management of all such cases begins with fluid resuscitation coupled with bed rest. On failure of conservative therapy, autologous epidural blood patches into the spinal epidural space should be tried, which often produce an immediate relief of symptoms. Osteophyte-induced dural tear and consequent intracranial hypotension may require surgical intervention if the symptoms are refractory to conservative treatment. Under all circumstances a careful step-wise approach for diagnosis and treatment of spontaneous intracranial hypotension needs to be followed, as we have proposed in our article.
authors.affiliation: University Hospitals, Case Western Reserve University, Cleveland, OH, 44106, USA.
authors.forename: Debadutta
authors.initials: D
authors.lastname: Dash
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, 6501 Fannin St, Suite NC 100, Houston, TX, 77030, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Jalali
authors.affiliation: Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, JH, 834009, India.
authors.forename: Viraat
authors.initials: V
authors.lastname: Harsh
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, 6501 Fannin St, Suite NC 100, Houston, TX, 77030, USA. omeis@bcm.edu.
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Omeis
mesh_terms: D000328:Adult; D017217:Blood Patch, Epidural; D004388:Dura Mater / Q000293:injuries; D005260:Female; D006801:Humans; D019585:Intracranial Hypotension / Q000000981:diagnostic imaging / Q000209:etiology*; D008279:Magnetic Resonance Imaging; D013128:Spinal Osteophytosis / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D014057:Tomography, X-Ray Computed
keywords: Cerebrospinal fluid leak; Spontaneous intracranial hypotension; Thoracic osteophyte; Transpedicular approach
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