Thecal sac ligation for the treatment of post-infectious intrathecal-prevertebral CSF fistula in a paraplegic patient

The occurrence of a symptomatic post-infectious intrathecal to prevertebral fistula is rare. We report the presentation and management of a 38-year-old chronically paraplegic male with longstanding thoracic osteomyelitis and epidural infection who developed a cerebrospinal fluid (CSF) fistula causing symptomatic intracranial hypotension (IH). During an interventional radiology (IR)-guided aspiration of what was thought to be residual abscess, pulsatile, clear fluid was observed. A subsequent CT myelogram showed air in the spinal canal and a CSF fistula between the thecal sac and the pre-vertebral space. Upon intraoperative exploration, a large ventral dural defect was identified with insufficient native dura for primary closure and the thecal sac was tied off cranial to the level of the fistula. Given the large ventral dural defect, the fistula was likely the result of longstanding infection in the epidural space rather than the IR guided aspiration. The aspiration likely transgressed an existing fistula and may have exacerbated the symptoms of IH by providing another route for CSF egress. The patient's postural headaches completely resolved post-operatively. Thecal sac ligation is a viable treatment option in select circumstances with symptomatic CSF fistula.