We're one of few multidisciplinary teams trained to find and repair spinal cerebrospinal fluid (CSF) leaks.
Cerebrospinal fluid (CSF) surrounds the brain and spinal cord, providing a cushion to protect these organs from injury. A spinal CSF leak occurs when a hole or tear develops in the outermost membrane containing the CSF fluid (dura mater). This causes pressure around the brain and spinal cord to drop (spontaneous intracranial hypotension, or SIH), which can lead to a sudden and severe headache that typically occurs when upright
With advances in imaging, this diagnosis is now more common than previously recognized. At MedStar Health, we're one of few teams in the country with expertise in diagnosing and treating this condition—and the only one in the Washington, D.C., region. Using a multidisciplinary approach, our specialists in neuroradiology, neurology, headache medicine, and neurosurgery work together to identify and fix spinal CSF leaks. This ensures our patients receive the proper diagnosis and appropriate treatment, with the best chance of a full recovery from debilitating headaches and neurologic symptoms.
CSF Leaks Symptoms
The most common spinal CSF leak symptom is a headache that:
- Begins abruptly
- Is felt at the back of the head
- Worsens when in an upright posture
- Improves immediately when lying down
This is different from other headaches that may develop gradually or persist regardless of position change. That's why it's important to see a headache specialist who can determine the cause of your pain.
Although a positional headache is a common symptom, not everyone with this condition will have head pain. Other symptoms may include:
- Nausea and vomiting
- Ear ringing (tinnitus)
- Neck pain
- Dizziness
- Sensitivity to light
- Vision changes
Causes and risk factors
Although uncommon, spinal CSF leaks can be caused by:
- Trauma or injury, even minor trauma like lifting a heavy object
- Twisting or turning movements of the spine
- Spinal procedures such as spinal tap (lumbar puncture) or epidural injections
- Bone spurs along the spine
- Spinal surgery
However, this condition may not always be linked to a specific event or clear cause. Many times spontaneous spinal CSF leaks occur seemingly out of nowhere. As a result, the hole or tear can be challenging to locate, making it harder to treat. Treatment may require several attempts, even under the care of the most experienced team.
Anyone can develop a spinal CSF leak, although they most commonly occur in adults between 20 to 60. We continue investigating risk factors for this condition. Patients who have a connective tissue disorder may be more susceptible to a dural tear.
Evaluation and diagnosis
Because many spinal CSF leaks occur spontaneously and providers may be unfamiliar with the condition, it's often misdiagnosed, or diagnosis is delayed. An accurate and timely diagnosis requires skilled providers who are familiar with the signs and symptoms of spinal CSF leaks. A critical element in accurate diagnosis is the use of complex imaging under the guidance of a specialized neuroradiologist with advanced training and experience in identifying this condition.
At your first consultation by a member of our interdisciplinary team, we'll perform a detailed evaluation that begins with a conversation about your medical history and symptoms. Many physical signs can indicate a leak, which is important because imaging findings don't always reveal a clear-cut diagnosis.
There are several imaging tests we may use to confirm a diagnosis, including:
- MRI of the brain and spine: This non-invasive imaging test may show findings of leaking fluid such as engorged veins, brain sagging, fluid collections, or other abnormalities associated with the condition. However, the absence of these signs doesn't mean that a patient does not have a leak. Sometimes additional imaging is necessary to confirm a diagnosis or pinpoint the leak origin.
- Myelography: A computed tomography (CT) myelogram involves injecting contrast dye using a tiny needle and imaging the spine to identify the leak site. We may gather additional information about the condition using more complex types of myelography, such as a:
- Dynamic CT myelogram
- Decubitus CT myelogram
- Digital subtraction myelogram
- MR myelogram
- Lumbar puncture: Also known as a spinal tap, this diagnostic procedure can measure pressure but is not required for diagnosis. It's also not uncommon for a patient with this condition to have normal pressure, so normal findings don't rule out a diagnosis.
CSF Leaks Treatment
Treatment is essential because low pressure in the brain can lead to worsening neurologic symptoms. Fortunately, spontaneous CSF leaks are highly treatable with the care of experienced specialists. Your treatment options will vary based on the severity of your symptoms, ranging from conservative approaches to surgical repair.
Blood patch injections
An interventional neuroradiologist can often patch the leak using a patient's own blood alone or in combination with a fibrin glue sealant. The outpatient procedure is performed under CT guidance using minimally invasive techniques, such as a small needle. This can be performed as a targeted blood patch when we know the exact location of the tear and is highly effective. It can also be performed as an empiric blood patch in an attempt to seal a large amount of the dura where a potential hole may be. The medical procedure is 30 percent effective even when the location is unknown. As a result, it may take several treatments to completely seal the leak and alleviate symptoms. Knowing this ahead of time can help patients to manage their expectations.
Recovery will vary by person, but we advise patients to rest and avoid strenuous lifting or twisting for several weeks. If treatment does not completely relieve patients of symptoms, we will meet to discuss the next steps, which may include surgical options.
Surgery
If less invasive treatments don't work, several different surgical options for repairing a spinal CSF leak are available. Surgery can be complex because of the spine anatomy and high variety of potential leak locations. Therefore, surgical treatment is personalized to each patient based on the specific location and type of the leak and may include:
- Direct repair, which involves removal of bone spurs and stitching holes/tears closed
- Indirect repair, which uses grafts and glue materials to reconstruct and strengthen the weak or blistered areas of the dura
- Ligation, which involves repairing abnormal connections between the dura and its surrounding veins
Our center specializes in minimally invasive, image-guided, and robotic spinal surgery, and it is possible that surgical repair can be performed using less invasive techniques. Hospital stay length and recovery will vary patient-by-patient. It is possible to experience higher than normal pressure following the repair, but medication may help to manage any pain and discomfort.
Why choose us
We're one of few teams in the country trained and experienced in diagnosing and treating this condition.
We work closely with other health systems and non-profit organizations to raise awareness and advance research for spinal CSF leaks. According to the Spinal CSF Leak Foundation, there are only 15 states in the country with medical professionals trained and equipped to care for patients with this condition, and we're the only healthcare facility in Washington, D.C., recognized in their online directory. In addition, our specialists have over a decade of combined experience in evaluating and treating patients who struggled to find relief elsewhere. As a result, patients travel from all over to see us, and we're honored to care for an average of 150 to 200 patients with this condition every year.
We provide the entire continuum of care under one roof.
Unlike other centers, our care team involves experts with sub-specialized training in different areas, all in one location. Whether you have a spinal CSF leak or other headache disorder, we work diligently to identify and address the root cause of your pain so you can get back to a life without limitations. Diagnosis and treatment involves the expertise of the following specialists who work together to personalize your care:
- Neuroradiologists
- Interventional radiologists
- Headache specialists
- Neurosurgical spine surgeons
- Neuro-ophthalmologists
Because we all work together in the same setting, it's easy and convenient to get well-coordinated, comprehensive care. From the latest imaging techniques and expert imaging interpretation to minimally invasive treatments and sophisticated surgeries, we offer the full range of options that will lead to your best outcome.
We won't give up until you experience relief.
Spontaneous leaks can be challenging to treat, potentially requiring several procedures over time. The most effective treatment begins with having the correct diagnosis, and we take the time upfront to accurately determine the cause of your headache or neurologic symptoms. This may involve several different imaging studies or various treatments, and we're dedicated to seeing it through until your leak symptoms are relieved.
Our providers
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Co-Directors
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Vinay R. Deshmukh, MD
Spine Surgery & Neurosurgery
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Anousheh Sayah, MD
Diagnostic Radiology, Neuroradiology & Interventional Neuroradiology
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Carrie Oakley Dougherty, MD
Neurology
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Katherine T Hamilton, MD
Neurology & Headache Medicine
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Benjamin Joseph Osborne, MD
Neuro-Ophthalmology & Neurology
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Amanda Grace Tinsley, MD
Neurology
Our locations
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MedStar Health: Center for Spinal CSF Leaks at MedStar Georgetown University Hospital
3800 Reservoir Road, NW Suite CG 201 Washington, DC 20007
Frequently asked questions
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How are spinal and cranial CSF leaks different?
Cerebrospinal fluid leaks can also occur in the brain (cranial CSF leak), but these result in different symptoms than a leak in the spinal dura. Cranial CSF leaks can cause watery drainage from the nose or ear, hearing loss, or meningitis, but they don't typically present with positional headaches. In addition, cranial leaks generally do not cause brain sag or spinal collections of spinal fluid like spinal CSF leaks do. A cranial leak may also be spontaneous or occur after a head injury or skull base surgery.
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What can patients expect during the first appointment?
If you already have imaging that suggests you may have a spinal leak, you will meet with a member of our team (either a neurosurgeon, neuroradiologist, or neurologist) who will review your medical history, symptoms, and prior imaging or tests. During that consultation, we'll determine if you need any additional testing to confirm a diagnosis and devise a treatment plan.
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Are spinal leaks preventable?
No, these leaks happen unpredictably, so you can't prevent it from happening. However, if you have a chronic headache that interferes with your day-to-day living, talk to your doctor. You may benefit from a referral to a MedStar Health headache specialist who can help determine the type of headache and how to manage it.
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What if the pressure rises after a leak is treated?
In some cases, patients who have undergone repair of a spinal CSF leak can experience rebound headaches (usually behind the eyes in the front of the head) due to high pressure. This can cause nausea, headache, or vomiting but is often temporary and manageable with medication. Your care team will stay in close contact to monitor any side effects or complications and ensure a successful recovery.
Referring providers
When should I refer a patient to MedStar Health for this condition?
If you suspect a spinal cerebrospinal fluid leak because of a patient's symptoms or imaging results, you should refer them to the experts at MedStar Georgetown University Hospital. Our comprehensive and collaborative approach ensures that your patients receive individualized, timely care using the latest diagnostic tools and treatment approaches that lead to the best results.
Contact us
To refer a patient, please call 202-444-8993.