Spinal Fluid Leak After Chiropractic Manipulation of the Cervical Spine

Forceful flexion and distension of the cervical spine is a well-established mechanism for causing dural tears and ICH.1 But even small insults, like Valsalva maneuvers, may lead to CSF leakage, usually in conjunction with a focal weakness of the thecal sac.2 There are only a few reports of dural tears with CSF leakage and ICH after chiropractic manipulation, none of which recount any neurologic symptoms besides headache. In our patient's case, headache that worsened after each manipulation and the appearance of cranial nerve VI palsy shortly thereafter strongly suggest a cause-effect relationship between spinal manipulation and the radiologically proven CSF leak. In fact, the estimated complication rate of chiropractic treatment ranges from 1.3 in 100 000 to 1 in 2 million manipulations3 with the most frequent serious complication being cerebral or cerebellar stroke caused by dissection or occlusion of the vertebral or internal carotid artery.4 Fortunately, unlike stroke, neurologic deficits caused by ICH usually resolve, albeit slowly, once normal intracranial pressure has been reestablished.