Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac

Object: The purpose of this study was to describe significant CT myelography findings for determination of the leak site and outcome of targeted epidural blood patch (EBP) in patients with spontaneous CSF leaks.

Methods: During 2005-2013, spontaneous CSF leaks were diagnosed for 12 patients with orthostatic headaches. The patients received targeted EBP on the basis of CT myelography assessments.

Results: Computed tomography myelograms revealed ventral extradural collection of contrast medium distributed over multiple spinal levels (average 16 levels). Intraforaminal contrast medium extravasations were observed at multiple spinal levels (average 8.2 levels). For 8 (67%) of 12 patients, spinal lesions were noted around the thecal sac and included calcified discs with osteophytes, an ossified posterior longitudinal ligament, and an ossified yellow ligament; lesions were mostly located ventral to the thecal sac and were in close contact with the dura mater. The levels of these spinal lesions were considered potential leak sites and were targeted for EBP. For the remaining 4 patients who did not have definite spinal lesions around the thecal sac, leak site determination was based primarily on the contrast gradient hypothesis. The authors hypothesized that the concentration of extradural contrast medium would be the greatest and the same as that of intradural contrast medium at the leak site but that it would decrease with increased distance from the leak site according to the contrast gradient. Epidural blood patch was placed at the level of spinal lesions and/or of the greatest and same concentration of contrast medium between the intradural and extradural spaces. For 10 of the 12 patients, the orthostatic headaches decreased significantly within a week of EBP and disappeared within a month. For the remaining 2 patients, headaches persisted and medical treatment was required for several months. For 3 patients, thick chronic subdural hematomas caused severe headaches and/or disturbed consciousness because of the mass effect of the hematomas, which were removed by bur hole drainage surgery. For 1 patient, bur hole drainage before EBP on the day of admission to hospital resulted in subdural tension pneumocephalus. The patient's headache immediately disappeared after EBP, and the hematoma did not recur. The other 2 patients underwent EBP followed by bur hole drainage, which resulted in improvements and disappearance of the hematomas. Over the follow-up period (mean 39 months), no CSF leaks or chronic subdural hematomas had recurred in any patient after EBP; by the final follow-up visit, all patients had returned to their jobs.

Conclusions: The most significant finding of this study was that spinal ventral calcified or ossified lesions, which may be associated with a dural tear, were present in approximately 70% of patients. Targeted EBP to these lesions resulted in good outcomes.