[krm123]

#25502

Hello Dr Corenman,

I am a 32 year old male who has had sciatic like symptoms on leg/buttock and twitching muscles all over develop last year in August 2016. In late November 2016 i developed positional orthostatic headaches, dizziness , nausea, pulsatile tinnitus which resolved after 1 week of bed rest (Local General Practitioner wrongly suspected sinus issues) . Meanwhile 12 days after the headache/dizzyness symptoms cleared i had an MRI that was pre-planned by a neurosurgeon to investigate nerve pain in leg/buttock and it came back unremarkable and Neurosurgeon could see no explanation for sciatica pain and could not explain all over twitching. The MRI report discussed some minor disc bulges and degeneration but not herniations. I did not mention my episode of headaches/dizzyness to the neurosurgeon as i though it was unconnected and it had since cleared up.

The positional headaches and dizzyness devloped once again in early Feb 2017, but this time i saw a neurologist who suspected intracranial hypotension due to spontaneous CSF leak. I had another MRI with contrast in March 2017 as symptoms were ongoing.

Location of CSF leak could not be found but signs of CSF leak were present such as meningeal enhancement and extra dural CSF was seen mostly dorsal at cervical/thoracic area. A blind epidural blood patch was performed.

4 months have passed since the blood patch and i do feel somewhat better as time has gone on with less positional headaches and no dizziness but pulsatile tinnitus still remaining but improved from onset. I also still have the sciatic like symptoms in buttock/leg and muscle twitching all over and DRs are unsure if it is related to the CSF leak since it came on 3-4 month before leak symptoms.

I have been reviewing my two MRIs, and i note that my spinal cord seems much wider/thicker with less spinal canal space on my newer MRI from March 2017 compared with the December 2016 MRI. Both scans were done on closed MRI scanners but in different locations. Can this be explained by the use of different MRI machines or is there something more sinister at play? The MRI doesn’t appear to show any lesions on T2, but to my untrained eye, i definitely see a difference in the cord and space around it. Could this explain all the symptoms and show they are indeed connected? Is there something else i should be looking for?

MRI comparison across cervical area here -> MRI Comparison

Also, as i mentioned i still get pulsatile tinnitus, some minor headaches, but definitely improved overall. My Neurosurgeon suggested a radionuclide cisternogram to see if i have slow leak or he could also possibly try another blind blood patch. I am unsure if i should wait it out longer since i feel alot better, or should i continue treatment. I have heard CSF leak symptoms can take along time to fully resolve. I am hypermobile (Possibly have EDS), and have read that connective tissue disorders can lead to a weak dura and getting a contrast injection into the dura may not be a good idea in this subset of people, as it can cause another leak.

[Donald Corenman, MD, DC]

#25515

Meningeal enhancement and spontaneous dural leaks are very rare. You could have had an arachnoid/dural cyst that somehow leaked and is causing your symptoms. I suspect there is more to this than that simple explanation. Even though there are two different MRI machines which could explain some differences, you can use the canal to cord ratio to compare the two images. Regardless of magnification differences, the diameter of the cord compared to the diameter of the canal should be the same on each set of images. If there is a difference, that data is reliable to acknowledge the difference.

Any contrast injection into the dura can cause a leak as you have to penetrate the dura with a needle to place the contrast in the CSF. You might have thin dura but normally with thin dura, you should develop Tarlov cysts (cystic root sleeve dilatations) in the lower back (which will be noted on the lumbar MRI). No cysts would indicate relatively normal strength dura.

You should get a number of consultations from various neurologists who have experience in unusual clinical presentations. This is an unusual disorder and long experience in this field would be helpful as I’ms sure someone will be able to recognize this disorder and discuss treatment. It might take some time to find the individual who knows this disorder.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[krm123]

#25526

Thanks for your excellent and detailed response, it is very much appreciated.

I feel like my life is a giant jigsaw puzzle right now and I’m trying to pull the pieces together. However I don’t know if all the pieces are part of the same puzzle, or if I’m dealing with two separate puzzles.

With regards to a difference in the spinal cord diameter on the two images, is there particular disease/illness that can causes this? I’ve done a bit of research and while I have read about cord swelling, it seems less uniform when it occurs in those cases and more particular areas of swelling along the cord. My images look quite uniform, which makes me wonder if it is just MRI machine differences on the settings, slice setting etc.

I have a few questions which may/or may not be relevant to my recent issues. I feel they are all connected, as I have been a healthy individual up until the nerve pain started last year. Then the leak was only a few months later.
– My 1st neurosurgeon didn’t think I can get a leak as I had no trauma (Which turned out to not be true).
– my neurologist thinks the nerve pain/leak could be connected by nerve compression of cranial nerves due to brain sag.
– my new neurosurgeon (Who is probably the closest we have to a CSF leak specialist in Australia) thinks it is a coincidence and separate issues.

My neck since leaking seems to catch when I move my head up/down or to side. Sometimes it will catch multiple times in a row. My neck has been chronically tight and sore since my leak began, so unsure if the catching is due to tight muscles, or some kind of instability back there but it sure feels like a bone catching. I had no previous history of neck issues pre-leak. I know neck pain is a classic CSF leak symptom.

If I push on my spinous process around C5/C6 at beck of neck I feel a bone move in and pop. Unsure if this is actually a bone moving or if it is a tendon/muscle, but when I push the end point of the process it feel like the spinous process moving in.

When originally investigating the nerve pain in leg/buttock, My 1st neurosurgeon sent me for diagnostic SI joint injections on both sides as he was unsure what could be causing nerve pain, then asked me to take a pain diary post injections. After the injection it went numb for maybe 1 day due to the anaesthetic injection done right before the steroid injection. Once the anaesthetic wore off the next day it was business as usual and the steroid injection didn’t seem to do much and the pain in sciatic nerve came back the next day. My gut feeling is that SI joint is not involved but Neurosurgeon told me to try physio. I’ve just started physio couple of weeks ago and the physio thinks my SI joint is not as mobile on left side, and has given me exercises. I have read that nerves in that area can be affected or irritated by SI joints, but I don’t have any pain from the SI joint. My nerve pain seems to be in the buttock middle/outside around area of the piriformis. I have read piriformis tightness can cause nerve issues. My Physio does not believe in piriformis syndrome though.

Another thing to note is that my greater trochanter noticeably sticks out more on my left when standing up, which is my side of nerve pain and sensitivity on buttocks. If I sit on a chair, and put my feet flat, then use a spirit box level across my knees, It is not balanced and I can see my left leg appears longer from the knee downwards, if I lift my right leg at the heel while sitting the spirit level balances. If I stand up and lift my right leg at heels a little, my left greater trochanter seems to move inwards and become more balanced with the right greater trochanter. I know leg length discrepancies are quite common in the general population but wonder if this could be related to nerve pain, muscle imbalances. People have noted in the past that I have a slightly twisty walk, my hips kind of swing/twist quite a lot with each step. My fleet are also very flat, and I started to wear shop bought orthotic inserts last year due to pronation as I had bad wear pattern on my shoes at the edges. After wearing the orthotics, the wear pattern seemed to improve. I wonder if custom made orthotics could address both the flat feet, and leg length discrepancy and pull the greater trochanter back in on left? I have also read hip abductor exercise can help with these issues.

Back to the leak/neck issues I have read one paper where a few individuals had funicular pain from the neck that presented as sciatic like symptoms in leg/buttock. At the moment I’m struggling to understand what is causing my issues and if there are connections between leak , twitching muscles and nerve pain in leg.

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