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


      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

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • 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