Intracranial hypotension secondary to a spontaneous cervical nerve root leak repaired using a chimeric rotational paraspinal flap: a multidisciplinary surgical approach. Illustrative case.

BACKGROUND: Spontaneous intracranial hypotension (SIH) caused by a CSF leak due to a subtle dural defect often leads to debilitating orthostatic headaches and subdural fluid collection. Various surgical techniques have been described for iatrogenic leaks but not for spontaneous cervical nerve root leaks.

OBSERVATIONS: A 35-year-old female presented with progressive neck pain, severe orthostatic headaches, and bilateral subdural fluid collection. Imaging revealed a type 1b ventral dural tear at the right C8 nerve root. A posterior cervical approach exposing the nerve roots located the subtle leak site. A team consisting of neurosurgeons and a head and neck reconstructive surgeon harvested and positioned a paraspinal musculature flap, fashioned into two leaflets, to envelop the nerve roots ventrally and dorsally. Fibrin sealant and muscle plugs reinforced the closure. Postoperatively, the patient experienced rapid resolution of orthostatic headaches. At 6 months, she reported only mild, intermittent neck tightness without headache recurrence or evidence of CSF leakage.

LESSONS: A multidisciplinary surgical approach utilizing a chimeric rotational paraspinal flap to repair a spontaneous cervical CSF leak at the right C8 nerve root provided robust, vascularized coverage with resolution of SIH signs and symptoms. This flap-based technique offers a durable solution for challenging CSF leaks. https://thejns.org/doi/10.3171/CASE25698.