Advertisement

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

      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.

      Key Words

      SPINAL MOBILIZATION TECHNIQUES are commonly used to attenuate muscle spasms, increase vertebral motion, ease restrictions, and improve overall alignment. Mobilizations are defined as oscillations of the vertebrae at varying speeds and amplitudes that can be resisted by the patient. Mobilizations can be further categorized from grade I to IV, based on the amount of resistance met in the tissue and the amplitude of the oscillation. It has been reported that nearly 72% of all patients with back pain and 37% of patients with neck pain receive some form of mobilization therapy.
      • Hurley L.
      • Yardley K.
      • Gross A.R.
      • Hendry L.
      • McLaughlin L.
      A survey to examine attitudes and patterns of practice of physiotherapists who perform cervical spine manipulation.
      The means used to teach mobilizations are largely qualitative, and no reliable quantification of the force produced by these procedures exists. These circumstances contribute to considerable variation among clinicians performing the same mobilization. A recent study confirms the high variability of force (200−727N) produced during posteroanterior mobilizations in the thoracic spine.
      • Sran M.
      • Khan K.M.
      • Zhu Q.
      • McKay H.A.
      • Oxland T.R.
      Failure characteristics of the thoracic spine with a posteroanterior load: investigating the safety of spinal mobilization.
      Therapists commonly underestimate the magnitude of the force they are applying as compared with the experimentally measured quantitative amounts.
      • Simmonds M.
      • Kumar S.
      • Lechelt E.
      Use of a spinal model to quantify the forces and motion that occur during therapists’ tests of spinal motion.
      It has also been noted that even if clinicians perform standardized thrust techniques, the wide variability between individual patients can contribute to different clinical results.
      • Harms M.
      • Bader D.L.
      Variability of forces applied by experienced therapists during spinal mobilization.
      Thoracic spine manipulations and mobilizations are considered to be the safest of all vertebral thrust techniques and are the most frequently performed, despite the lack of evidence for their specific clinical efficacy and potential complications. In fact, thoracic mobilizations and manipulations are now being used to address neck pain because of the belief that they relieve neck pain with a lower level of risk than cervical manual techniques. Several review articles have studied the complications typically associated with spinal mobilizations and manipulations, which are described as shearing of blood vessels and neurologic complications such as disk herniation, or spinal cord compression and inflammation.
      • Oppenheim J.S.
      • Spitzer D.E.
      • Segal D.H.
      Nonvascular complications following spinal manipulation.
      The incidence of such injuries is rare and ranges from 1 in every 40,000 manipulations to 1 in every 2,000,000 depending on the force generated during the mobilization.
      • Dabbs V.
      • Lauretti W.J.
      A risk assessment of cervical manipulation vs NSAIDs for the treatment of neck pain.
      Although there is a concerted effort to monitor disk and cord pathologies associated with spinal mobilizations, a lesser known malady, tearing of the dura, is starting to receive attention.
      Dural sleeve tears can lead to a spontaneous cerebrospinal fluid (CSF) leak and progress to spontaneous intracranial hypotension (SIH). SIH has been defined as a condition of low or negative CSF levels, which is recognized clinically by severe orthostatic headaches relieved by horizontal postural positioning.
      • Khurana R.
      Intracranial hypotension.
      First described by Schaltenbrand,
      • Schaltenbrand G.
      Normal and pathological physiology of cerebrospinal fluid circulation.
      possible additional symptoms may include nausea, vomiting, blurred vision, hearing loss, and cranial nerve VI palsy. It is most commonly noted in middle-aged women and an association has been noted between the development of the condition and a patient history of connective tissue disease.
      • Schievink W.
      Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension.
      The diagnosis is often confirmed using radiologic methodology including radionuclide cisternogram, computed tomography (CT) myelogram, and magnetic resonance imaging (MRI) of the head and neck. The purpose of this study was to describe the clinical and radiologic findings of a patient diagnosed with SIH caused by cervical and thoracic spine grade IV mobilization.

      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. Immediately after the procedure, the patient felt lightheaded and developed a severe headache several hours later. She was originally diagnosed with viral meningitis by an emergency department physician and was given an injection of ketorolac tromethamine (Toradol) with metoclopramide hydrochloride (Reglan) and intravenous hydration which only minimally alleviated the pain. She continued to have severe headaches, nausea, and photophobia in the upright position. With prolonged standing (>1h), she developed neck stiffness and radicular symptoms in her left C8 dermatome with associated supination and finger flexion and extension weakness and significant hearing loss in her left ear. All of these symptoms were relieved when she was in the supine position. Cranial CT was unremarkable and showed only sinusitis. MRI studies of the head showed meningeal thickening and enhancement. A radionuclide cisternogram was performed and lumbar puncture opening pressure was found to be less than 5cmH2O; however, the results indicated that there was no evident CSF leak. CSF analysis was normal. Thoracic and cervical spine gadolinium-enhanced MRI revealed abnormal epidural and subdural collections of CSF, spinal epidural venous engorgement, and diffuse spinal dural enhancement. A CT myelogram showed a large leak that spanned from C8-T5 primarily on the left (fig 1).
      Figure thumbnail gr1
      Fig 1T2-weighted CT myelogram, mid-sagittal plane. Note the presence of contrast material in the epidural space spanning several vertebrae.

      Intervention

      Conservative management with hydration, bedrest, and ingestion of caffeine had no effect on the pain. Taking the location into consideration, the patient underwent 2 epidural blood patches (5mL), administered 1 week apart, targeted at C7 and T5. The patient was also advised to take aminocaproic acid (Amicar) to aid with the clotting process. The patient’s headache resolved within 2 weeks.
      The patient’s headache, arm symptoms, and hearing loss resolved within 2 weeks. The patient reports that she is free from headaches and other associated symptoms 1 year after the procedure.

      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.
      • Schievink W.
      Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension.
      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.
      • Suh S.
      • Koh S.B.
      • Choi E.J.
      • et al.
      Intracranial hypotension induced by cervical spine chiropractic manipulation.
      This report shows that SIH may be a potential complication of manual therapy treatments.

      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.

      References

        • Hurley L.
        • Yardley K.
        • Gross A.R.
        • Hendry L.
        • McLaughlin L.
        A survey to examine attitudes and patterns of practice of physiotherapists who perform cervical spine manipulation.
        Man Ther. 2002; 7: 10-18
        • Sran M.
        • Khan K.M.
        • Zhu Q.
        • McKay H.A.
        • Oxland T.R.
        Failure characteristics of the thoracic spine with a posteroanterior load: investigating the safety of spinal mobilization.
        Spine. 2004; 29: 2382-2388
        • Simmonds M.
        • Kumar S.
        • Lechelt E.
        Use of a spinal model to quantify the forces and motion that occur during therapists’ tests of spinal motion.
        Phys Ther. 1995; 75: 212-222
        • Harms M.
        • Bader D.L.
        Variability of forces applied by experienced therapists during spinal mobilization.
        Clin Biomech (Bristol, Avon). 1997; 12: 393-399
        • Oppenheim J.S.
        • Spitzer D.E.
        • Segal D.H.
        Nonvascular complications following spinal manipulation.
        Spine J. 2005; 5: 660-667
        • Dabbs V.
        • Lauretti W.J.
        A risk assessment of cervical manipulation vs NSAIDs for the treatment of neck pain.
        J Manipulative Physiol Ther. 1995; 18: 530-536
        • Khurana R.
        Intracranial hypotension.
        Semin Neurol. 1996; 16: 5-10
        • Schaltenbrand G.
        Normal and pathological physiology of cerebrospinal fluid circulation.
        Lancet. 1953; 1: 805-808
        • Schievink W.
        Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension.
        JAMA. 2006; 295: 2286-2296
        • Suh S.
        • Koh S.B.
        • Choi E.J.
        • et al.
        Intracranial hypotension induced by cervical spine chiropractic manipulation.
        Spine. 2005; 30: E340-E342