Spontaneous CSF Collection in the Cervical Spine may Cause Neurological Deficit and Intra-cranial Hypotension
A 68 year old right hand dominant, Caucasian man was referred to the neurology service with a 2 year history of arm weakness. The patient had noticed increasing difficulty lifting items of high shelves, carrying luggage or shopping. There was no associated pain or loss of sensation in the arms. Dexterity was unaffected. His walking, lower limbs and bladder/bowel control were unaffected. He had no other neurological symptoms except mild postural headache. There was no history of previous spinal surgery or intervention. He was taking no regular medications. At examination, cranial nerves were intact, wasting was seen at the deltoids with weakness in myotomes C5 and C6, MRC grade 3/5. Biceps jerk was reduced bilaterally. Reflexes were diminished in the lower limbs but sensation, power and gait were normal.\nThe patient underwent investigations for myositis and peripheral neuropathy with blood tests including electrolytes, renal function, full blood count, calcium, liver enzymes, erythrocyte sedimentation rate, vitamin B12, fasting glucose, serum electrophoresis and auto-antibodies. All of these were normal. MRI of the brain, shown in Fig. () demonstrated enhancement of the meninges intracranially. Also seen on other slices were bilateral subdural CSF collections and sagging of the posterior fossa structures. A lumbar puncture demonstrated no abnormalities on cell count, cytology or microbiology and the opening pressure was in the normal range. Electromyography and nerve conduction studies showed bilateral severe C5 and C6 radiculopathies. MRI whole spine was subsequently ordered and Fig. () demonstrated a cervical cord fluid collection anteriorly at C2-C5 with signal isointense to CSF on T1, T2 and T2 FLAIR sequences, associated with signal change and atrophy of the cord at those levels. There was no enhancement with gadolinium administration. CT myelogram confirmed the collection to be CSF with pressure on the C5 and C6 roots, but no leaking point was identified. Blood patch was therefore not undertaken. The patient's neurological deficit remained stable and he did not want any further intervention, undergoing physical therapy only. Subsequent MRI scan at 6 months has shown no change in the size of the fluid collection and no change in the intracranial appearances.