Clinical note
Development of Spontaneous Intracranial Hypotension Concurrent With Grade IV Mobilization of the Cervical and Thoracic Spine: A Case Report

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Abstract

Donovan JS, Kerber CW, Donovan WH, Marshall LF. Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report.

Spontaneous intracranial hypotension (SIH) has been clinically defined as the development of severe orthostatic headaches caused by an acute cerebrospinal fluid (CSF) leak. Typically, intracranial hypotension occurs as a complication of lumbar puncture, but recent reports have identified cases caused by minor trauma. We report a case of SIH secondary to a dural tear caused by a cervical and thoracic spine mobilization. A 32-year-old woman with SIH presented with severe positional headaches with associated hearing loss and C6-8 nerve root distribution weakness. CSF opening pressure was less than 5cmH2O and showed no abnormalities in white blood cell count. Cranial, cervical, and thoracic magnetic resonance imaging revealed epidural and subdural collections of CSF with associated meningeal enhancement. Repeated computed tomography myelograms localized the leak to multiple levels of the lower cervical and upper thoracic spine. A conservative management approach of bedrest and increased caffeine intake had no effect on the dural tear. The headache, hearing loss, and arm symptoms resolved completely after 2 epidural blood patches were performed. Practitioners performing manual therapy should be aware of this rare, yet potential complication of spinal mobilizations and manipulations.

Section snippets

Case Description

This study was approved by the Institutional Review Board of Chapman University. A 32-year-old woman presented with a 2-week history of severe occipital and posterior nuchal headaches, which were relieved by lying supine. The onset of her headaches was concurrent with a cervical and thoracic spine mobilization. With the patient prone, the physical therapist performed a grade IV mobilization to the thoracic and lower cervical spine with the ulnar borders of both hands, with audible cavitation.

Discussion

SIH is a rare disorder that is now being identified more frequently thanks to advanced imaging techniques. The most likely cause is a dural sleeve disruption, either spontaneous or post-trauma.9 SIH is now being reported by other clinicians as a result of spinal manipulation. Recent studies have described the onset of SIH after manipulations of the cervical and thoracic spine, but this is the first record of SIH caused by a grade IV mobilization.10 This report shows that SIH may be a potential

Conclusions

If patients complain of headache and/or hearing loss and radicular symptoms after manipulation or mobilization, they should be referred to a neurologist for a complete examination. SIH is a disabling, yet highly treatable condition of which practitioners performing manual therapy need to be aware.

Acknowledgment

We thank Bob Grossman, MD, for his consultation and expert insight into this report.

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Copyright © 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.