Objective:

To report a case of a 64-year-old male presenting with somnolence and headaches, diagnosed ultimately with intracranial hypotension due to nerve sheath dural tear after chiropractic manipulation. Adding to few case reports which narrate such incidence.  

Background:

A 64-year-old male with PMH of chronic left DVT treated with Coumadin, DM2, OSA and HTN underwent a chiropractic neck manipulation and presented a week later with history of morning somnolence, headaches, nausea, and intermittent bilateral gluteal numbness radiating to the posterior thigh. His headaches were worsened on bending forward. He denied experiencing fever, chills, or systemic illness. CPAP trial did not alleviate his morning somnolence. Initial evaluation including labs and EEG were negative. CT scan of the head revealed bilateral subacute subdural hematomas with possible early signs of brain herniation. he denied experiencing fever, chills, or diarrhea. At the time, the patient was anticoagulated on Coumadin, with an INR of 3. It was reversed with vitamin K and prothrombin complex concentrate. 

Design/Methods:

NA

Results:

MRI of the brain demonstrated diffuse pachymeningeal thickening and enhancement, with effacement of the basilar cisterns and sagging of the brainstem, consistent with intracranial hypotension. The previously identified bilateral subdural hematomas were stable in size. CT Cervical Spine showed multilevel spondylytic changes with osteophytic spurs and CT-Myelography further indicated abnormal contrast distribution, extending into several nerve root sleeves, particularly at C4-C5, C5-C6, and bilaterally at C6-C7, suggestive of a nerve sheath dural tear. 

Conclusions:

This case highlights the possibility of nerve sheath tears occurring secondary to chiropractic maneuvers especially in patients with multilevel spondylotic changes with osteophytic spurs, warranting inclusion in the differential diagnosis for somnolence and headache following such interventions. The application of an epidural blood patch resulted in significant alleviation of symptoms especially somnolence, underscoring its therapeutic utility in cases of intracranial hypotension associated with nerve sheath dural tears.