Refractory headaches due to multilevel thoracic cerebrospinal fluid leaks

Background: Spontaneous cerebrospinal fluid leak is a well-documented cause of postural headache. We report a medically refractory headache due to multilevel thoracic cerebrospinal fluid leaks. Case report: A 44-year-old male with an acute onset of postural headache failed to respond to bed rest, hydration, and analgesics. Magnetic resonance imaging demonstrated a large cerebrospinal fluid leak centered at the right T4 and left T11 to 12 levels, with bony pathology evident at the lower thoracic level. Lumbar (L4 to 5) and computed tomography guided T4 to 5 level epidural blood patches provided minimal pain relief. Percutaneous epidural fibrin glue injection at T4 followed by a repeat computed tomography guided epidural blood patch led to significant but incomplete symptom relief. Subsequent imaging demonstrated persistent fluid at the T11 to 12 level. Fibrin glue and epidural blood patches at this level reduced but did not eliminate the leak and residual symptoms. Extensive corrective surgery was offered but declined by the patient. Conclusion: Treatment of multifocal cerebrospinal fluid leaks can be challenging, particularly when at least part of the underlying etiology is fixed structural bony pathology.