707 - Clinical Diagnosis of a Cerebrospinal Fluid Leak: A Rare Complication of Sacrectomy

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

PB

Pranav Bollavaram, MD

Resident Physician
The Ohio State University
Columbus, Ohio, United States

Co-Author(s)

Sheital Bavishi, DO

Associate Professor Clinical, Residency Program Director, Medical Director Brain Injury Program
The Ohio State University
Columbus, Ohio, United States

Presenting Author(s)

AG

Adam Given, MD

Resident Physician
Ohio State University
Columbus, Ohio, United States

Case Diagnosis: Spontaneous intracranial hypotension secondary to cerebrospinal fluid leak following partial sacrectomy and lumbosacral laminectomy

Case Description: This case describes a 58-year-old woman with medical history notable for metastatic breast adenocarcinoma and radiation-induced right iliac sarcoma, who underwent right-sided external hemipelvectomy and partial sacrectomy with L5-S3 laminectomy and S1 nerve root sacrifice. Following surgery, she was admitted to an inpatient rehabilitation (IPR) hospital. While undergoing rehabilitation, she demonstrated limited therapy participation due to pain and headaches. She demonstrated clinical signs of spontaneous intracranial hypotension (SIH) presumably related to cerebrospinal fluid (CSF) leak; MRI imaging confirmed CSF leak as the cause of her symptomology. She was re-admitted to acute care and underwent primary dural repair, which led to resolution of her headaches and positional symptoms. She returned to IPR thereafter and made accelerated functional gains.

Discussions: This case highlights the importance of broad differential diagnosis in the evaluation of acute headache in the rehabilitation setting. Given the complex medical and surgical history for this patient, many factors could have contributed to her headaches. A review of available literature suggests that CSF leak is not a common occurrence following sacrectomy. However, the positionality of this patient’s headaches associated with nausea and vomiting, and lack of relief with conservative measures raised clinical suspicion for SIH. In pursuit of this clinical suspicion, she was ultimately found to have an uncommon post-operative complication of sacrectomy in the form of CSF leak.

Conclusions: Though this patient’s surgery was very extensive and unique to her case, it is noteworthy to include CSF leak and SIH on the differential for patients who have sacral orthopedic or neurological surgery. Broad differential diagnosis coupled with thorough history, physical examination, and discussion with consulting teams ensures all possibilities are considered and addressed precisely.