Intracranial Hypotension Following Spinal Manipulation: A Case Report and Scoping Review of the Literature

PURPOSE: Spinal manipulative therapies, including chiropractic and osteopathic maneuvers, are widely practiced for musculoskeletal complaints. However, rare but serious complications such as cerebrospinal fluid (CSF) leak with subsequent intracranial hypotension (IH) have been described. The pathophysiological mechanism is presumed to involve mechanical stress on the spinal dura during high-velocity movements, leading to dural tears, particularly in the cervicothoracic region. METHODS: We conducted a scoping review in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR) guidelines, through a comprehensive search of PubMed and Scopus. We complemented the review with an illustrative case from our institution. RESULTS: We identified 21 eligible studies, including 21 patients with IH following spinal manipulation. Most patients were women (81%), aged 29-54 years, and the majority underwent cervical maneuvers. Symptom onset was typically within the first week, and all presented with orthostatic headache, often accompanied by nausea, neck pain, tinnitus, or visual disturbances. Neuroimaging consistently revealed features of IH, with pachymeningeal enhancement and subdural collections as the most frequent findings; spinal imaging frequently demonstrated extradural CSF collections. Management was conservative in about one-third of cases, but most required epidural blood patching, which was effective in the majority. Surgical repair was necessary in rare, refractory cases, particularly in the presence of structural spinal abnormalities. Overall prognosis was favorable, with 95% of patients achieving full recovery. Our illustrative case highlights the potential for severe complications such as subdural hematomas and recurrence if the underlying leak is not addressed. CONCLUSION: Clinicians should recognize the possibility of CSF leaks after spinal manipulation, especially in patients with new-onset orthostatic headache.