Case Report
Intracranial hypotension without postural headache after minimally invasive lumbar endoscopic surgery: A case report
Volume 29,Issue 2,Pages 57-64
Yi-Chun Chen1 , Feng-Sheng Lin1.2 , Lin-Hsue Yang3

1 Department of Anesthesiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan

2Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan

3Department of Neurosurgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan




We report a patient presenting with chronic pain after artifical disk place performed five years ago for herniation of the lumbar vertebral disk. He had recently undergone endoscopic minimally invasive transforaminal adhesiolysis for progressive radiculopathy. There were no symptoms, including headache, of postoperative complications until discharge except a complaint of general malaise.

He presented with diplopia without classic postural headache to the emergency
department on the ninth postoperative day after the transforaminal percutaneous
endoscopic lumbar surgery. Emergent brain magnetic resonance imaging (MRI)
revealed features of low intracranial cerebral pressure. Complete spine MRI revealed a left ventral dural defect and cerebrospinal fluid leakage over the lumbar region. He recovered after revision neurosurgery performed to repair the dural tear over the ventral sac using the Biodesign dural graft and fibrin glue. It is interesting to note that the patient dod not present with typical pain, only non-specific fatigue, which cannot be diagnosed to a specific etiology during hospitalization and return visits. The dural tear manifested as intracranial hypotension and diplopia on the ninth day after the surgery. Hence, pain physicians should be aware of the potential risk and treatment of dural tears during lumbar transforaminal endoscopic surgery.


Key Words

minimally invasive, lumbar endoscopic, surgery, dural tear, headache, diplopia

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J. Xu, Y. Li, B. Wang, G. Lv, L. Li, Y. Dai, B. Jiang, Z.Zheng

Minimum 2-Year Efficacy of Percutaneous Endoscopic Lumbar Discectomy versus Microendoscopic Discectomy: A Meta- Analysis.

World Neurosurg, (2020) 138, 19–26.



K. Sairyo, T. Chikawa, A.

Nagamachi, State-of- the-art transforaminal percutaneous endoscopic lumbar surgery under local anesthesia: discectomy, foraminoplasty, and ventral facetectomy.

J Orthop Sci, (2018) 23:2, 229–236.



B. Wu, G. Zhan, X. Tian, L. Fan, C. Jiang, B.Deepti, H. Cao, J. Li, Q. Lian, X. Huang, F. Xu

Comparison of transforaminal percutaneous endoscopic lumbar discectomy with and without foraminoplasty for lumbar disc herniation: A 2-year follow-up.

Pain Res Manag, (2019), 6924941.



B. Zhu, Y. Jiang, L. Shang, M. Yan, H-J. Ma, D-J. Ren, X-G. Liu

Complications of percutaneous endoscopic lumbar discectomy: experiences and literature review.

J Spine, (2017) 6:6, 402.



S. K. Kalevski, N. A. Peev, D. G. Haritonov

Incidental dural tears in lumbar decompressive surgery: Incidence, causes, treatment, results.

Asian J Neurosurg, (2010) 5:1, 54–59.



Y. Ahn, H. Y. Lee, S-H. Lee, J. H. Lee

Dural tears in percutaneous endoscopic lumbar discectomy

Eur Spine J, (2011) 20:1, 58-64.



C. Zhou, G. Zhang, R. R. Panchal, X. Ren, H. Xiang, M. Xuexiao, X. Chen, G. Tongtong, W. Hong, A. D. Dixson

Unique complications of percutaneous endoscopic lumbar discectomy and percutaneous endoscopic interlaminar discectomy.

Pain Physician, (2018) 21:2, E105-E112.



M. Azarmina, H. Azarmina.

The six syndromes of the sixth cranial nerve.

J Ophthalmic Vis Res, (2013) 8:2, 160-171.



W. M. Durand, J. M. DePasse, E. O. Kuris, J. W. Yang, A. H. Daniels

Late-presenting dural tear: Incidence, risk factors, and associated complications.

Spine J, (2018) 18:11, 2043-2050.



S. Takenaka, T. Makino, Y. Sakai, M. Kashii, M. Iwasaki, H. Yoshikawa, T. Kaito

Prognostic impact of intra- and postoperative management of dural tear on postoperative complications in primary degenerative lumbar diseases.

Bone Joint J, (2019) 101:B9, 1115-1121.



W. I. Schievink

Misdiagnosis of spontaneous intracranial hypotension.

Arch Neurol, (2003) 60:12, 1713–1718.



W. I. Schievink, M. M. Maya, F. Moser, J. Tourje, S. Torbati

Frequency of spontaneous intracranial hypotension in the emergency department.

J Headache Pain, (2007) 8:6, 325–328.



W. Kim, S. K. Kim, S. S. Kang, H. J. Park, S. Han, S. C. Lee

Pooled analysis of unsuccessful percutaneous biportal endoscopic surgery outcomes from a multi-institutional retrospective cohort of 797 cases.

Acta Neurochir (Wien), (2020) 162:2, 279-287.



E. Kogias, J. H. Klingler, P. F. Jimenez, I. Vasilikos, R. Sircar, C. Scholz, U. Hubbe

Incidental durotomy in open versus tubular revision microdiscectomy: A retrospective controlled study on incidence, management, and outcome.

Clin Spine Surg, (2017) 30:10, E1333-E1337.