title: Diskogenic microspurs as a major cause of intractable spontaneous intracranial hypotension.
abstract: OBJECTIVE
  To visualize and treat spinal dural CSF leaks in all patients with intractable spontaneous intracranial hypotension (SIH) who underwent spinal microsurgical exploration.
  
  
  METHODS
  Patients presenting between February 2013 and July 2015 were included in this consecutive case series. The workup included spinal MRI without and with intrathecal contrast, dynamic myelography, postmyelography CT, and microsurgical exploration.
  
  
  RESULTS
  Of 69 consecutive patients, 15 had intractable symptoms. Systematic imaging revealed a suspicious single location of the leak in these 15 patients. Fourteen patients underwent microsurgical exploration; 1 patient refused surgery. Intraoperatively, including intradural exploration, we identified the cause of the CSF leaks as a longitudinal dural slit (6.1 ± 1.7 mm) on the ventral (10), lateral (3), or dorsal (1) aspect of the dura. In 10 patients (71%), a ventral, calcified microspur originating from the intervertebral disk perforated the dura like a knife. Three patients (22%) had a lateral dural tear with an associated spinal meningeal diverticulum, and in 1 patient (7%), a dorsal osteophyte was causal. The microspurs were removed and the dural slits sutured with immediate cessation of CSF leakage.
  
  
  CONCLUSIONS
  The nature of the CSF leak is a circumscribed longitudinal slit at the ventral, lateral, or dorsal dura mater. An extradural pathology, diskogenic microspurs, was the single cause for all ventral CSF leaks. These findings challenge the notion that CSF leaks in SIH are idiopathic or due to a weak dura. Microsurgery is the treatment of choice in cases with intractable SIH.
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland. juergen.beck@insel.ch.
authors: Jürgen
authors: J
authors: Beck
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Christian T
authors: CT
authors: Ulrich
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Christian
authors: C
authors: Fung
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Jens
authors: J
authors: Fichtner
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Kathleen
authors: K
authors: Seidel
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Michael
authors: M
authors: Fiechter
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Kety
authors: K
authors: Hsieh
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Michael
authors: M
authors: Murek
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: David
authors: D
authors: Bervini
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Niklaus
authors: N
authors: Meier
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Marie-Luise
authors: ML
authors: Mono
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Pasquale
authors: P
authors: Mordasini
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Ekkehard
authors: E
authors: Hewer
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Werner J
authors: WJ
authors: Z'Graggen
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Jan
authors: J
authors: Gralla
authors: From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
authors: Andreas
authors: A
authors: Raabe
mesh_terms: D000465:Algorithms; D065634:Cerebrospinal Fluid Leak / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D019585:Intracranial Hypotension / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery; D008279:Magnetic Resonance Imaging; D008297:Male; D008866:Microsurgery / Q000009:adverse effects; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects; D054850:Osteophyte / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery; D013122:Spinal Diseases / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome