- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
Daniel C. Lu
Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
DOI:10.4103/2152-7806.109456Copyright: © 2013 Kusnezov NA This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Kusnezov NA, Velani SA, Lu DC. Cerebrospinal fluid leak secondary to chiropractic manipulation. Surg Neurol Int 22-Mar-2013;4:
How to cite this URL: Kusnezov NA, Velani SA, Lu DC. Cerebrospinal fluid leak secondary to chiropractic manipulation. Surg Neurol Int 22-Mar-2013;4:. Available from: http://sni.wpengine.com/surgicalint_articles/cerebrospinal-fluid-leak-secondary-to-chiropractic-manipulation/
Background:There is a paucity of quality data on the incidence of adverse outcomes of chiropractic manipulation. Spontaneous intracranial hypotension (SIH) subsequent to cervical spinal manipulation has been documented. However, no imaging correlates have previously been presented demonstrating a clear causal relationship to manipulation with follow-up and correlating with clinical symptomatology.
Case Description:We present a case of subacute cervical cerebrospinal fluid (CSF) leak resulting from chiropractic manipulation of the cervical spine. The patient is a 29-year-old female who received manipulation one week prior to developing symptoms of severe orthostatic headache, nausea, and vomiting. Magnetic resonance imaging (MRI) revealed a new C5-C6 ventral CSF collection. Symptomatic onset corresponded with the recent cervical chiropractic adjustment. We present serial imaging correlating with her symptomatology and review the pertinent literature on complications of chiropractic manipulation.
Conclusion:Our case of ventral CSF leak with symptoms of intracranial hypotension demonstrated spontaneous symptomatic resolution without permanent neurological sequelae.
Keywords: Cerebrospinal fluid leak, chiropractic manipulation, intracranial hypotension
Chiropractics is a well-established facet of modern healthcare.[
This 29-year-old Asian female, who was otherwise in previously good health, presented with recurrent episodes of severe headache, nausea, and vomiting. She described the headache as “pulling” downward, triggered by standing, and resolving when supine. She reported having had axial tension and rotatory manipulation of her neck one week prior to the onset of her symptoms but denied immediate symptoms afterward. She experienced increasingly painful headaches over the 2 weeks following her chiropractic manipulation. She had no known prior history of trauma, dural structural pathology, or connective tissue disease.
Physical exam was normal with no neurological deficits. Previous cervical magnetic resonance imaging (MRI) with and without contrast had been unremarkable. Cervical MRI at presentation revealed only a CSF-isodense ventral extradural fluid collection in the lower cervical spine and upper thoracic spine without any mass effect on the thecal sac [
The patient was managed conservatively with bed rest for 2 weeks and made a complete spontaneous recovery. Follow-up cervical MRI at 6 months demonstrated decreased size of ventral extradural fluid collection [
Though widely accepted as benign, chiropractic manipulation can lead to many complications. Major complications are uncommon but can result in significant morbidity and mortality. Vascular events such as stroke, pseudoaneurysm formation, and epidural hematoma represent the most common major complications.[
Most cases of intracranial hypotension are thought to be caused by CSF leak resulting from traumatic dural tears.[
Intracranial hypotension most commonly presents with orthostatic headache that is relieved when supine. Other symptoms include nausea, vertigo, and auditory and visual disturbances. Symptoms are thought to be due to traction on neurovascular structures as a result of intracranial hypovolemia and reduced brain buoyancy in the orthostatic position.[
In the literature, there have been only five reports of SIH associated with CSF leaks that were thought to be secondary to chiropractic manipulation.[
To our knowledge, we present the first case of SIH secondary to cervical spinal manipulation with good serial imaging and clinical examination. We are thus able to demonstrate a good causal relationship to her preceding cervical spinal manipulation. Our patient experienced a characteristic orthostatic headache but an uncharacteristic onset and progression over the 2 weeks following her manipulation. Kurbanyan, et al. reported a case of abducens nerve palsy with spontaneous resolution.[
Long-term outcomes are poorly characterized due to the rarity of cases of SIH and the absence of follow-up with patients after the initial symptom resolution. However, an epidural blood patch can be considered for patients in whom headache resolution is not spontaneous.
Funding for this research was made possible by the Yang Family Foundation.
1. Beck J, Raabe A, Seifert V, Dettmann E. Intracranial hypotension after chiropractic manipulation of the cervical spine. J Neurol Neurosurg Psychiatry. 2003. 74: 821-2
2. Chen WL, Chern CH, Wu YL, Lee CH. Vertebral artery dissection and cerebellar infarction following chiropractic manipulation. Emerg Med J. 2006. 23: E1-2
3. Chung SJ, Kim JS, Lee MC. Syndrome of cerebral spinal fluid hypovolemia: Clinical and imaging features and outcome. Neurology. 2000. 55: 1321-7
4. Couch JR. Sponaneous intracranial hypotension: The syndrome and its complications. Curr Treat Options Neurol. 2008. 10: 3-11
5. DeVocht JW. History and overview of theories and methods of chiropractic: A counterpoint. Clin Orthop Relat Res. 2006. 444: 243-9
6. Domenicucci M, Ramieri A, Salvati M, Brogna C, Raco A. Cervicothoracic epidural hematoma after chiropractic spinal manipulation therapy: Case report and review of the literature. J Neurosurg Spine. 2007. 7: 571-4
7. Egizii G, Dupeyron A, Vautravers P. Spinal manipulation: Survey of French medical physicians who graduated with the national diploma of osteopathy from Strasbourg University. Ann Readapt Med Phys. 2005. 48: 623-31
8. Enrst E. Adverse effects of spinal manipulation: A systematic review. J R Soc Med. 2007. 100: 330-8
9. Ernst E.editors. Chiropractic manipulation for non-spinal pain: A systematic review. N Z Med J. 2003. 116: U539-
10. Kurbanyan K, Lessell S. Intracranial hypotension and abducens palsy following upper spinal manipulation. Br J Ophthalmol. 2008. 92: 153-5
11. Malone DG, Baldwin NG, Tomecek FJ, Boxell CM, Gaede SE, Covington CG. Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice. Neurosurg Focus. 2002. 13: ecp1-
12. Mathews MK, Frohman L, Lee HJ, Segott RC, Savino PJ. Spinal fluid leak after chiropractic manipulation of the cervical spine. Arch Ophthalmol. 2006. 124: 283-
13. Meeker WC, Halderman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Ann Intern Med. 2002. 136: 216-27
14. Mokri B. Headaches caused by decreased intracranial pressure: Diagnosis and management. Curr Opin Neurol. 2003. 16: 319-26
15. Oppenheim JS, Spitzer DE, Segal DH. Nonvascular complications following spinal manipulation. Spine J. 2005. 5: 660-6
16. Powell FC, Hanigan WC, Olivero WC. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery. 1993. 33: 73-8
17. Rinsky LA, Reynolds GG, Jameson RM, Hamilton RD. A cervical spinal cord injury following chiropractic manipulation. Paraplegia. 1976. 13: 223-7
18. Rivett DA, Milburn P. A prospective study of complications of cervical spine manipulation. J Man Manip Ther. 1996. 4: 166-70
19. Rothwell DM, Bony SJ, Williams JI. Chiropractic manipulation and stroke: A population-based case-control study. Stroke. 2001. 32: 1054-60
20. Schievink WI, Louy C. Precipitating factors of spontaneous spinal CSF leaks and intracranial hypotension. Neurology. 2007. 69: 700-2
21. Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW. Spinal manipulation therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003. 60: 1424-8
22. Strauss S, Stemper B, Leis S, Platsch G, Tomandl B, Heckmann JG. Intracranial hypotension following chiropraxis. Eur Neurol. 2005. 53: 47-50
23. Suh SI, Koh SB, Choi EJ, Kim BJ, Park MK, Park KW. Intracranial hypotension induced by cervical spine chiropractic manipulation. Spine (Phila Pa 1976). 2005. 30: E340-2