Cerebrospinal Fluid Hypotension following Fall in a Ten Year Old Child: Case Report

Background: Sacral fractures are uncommon injuries resulting from high-energy trauma. They are frequently underdiagnosed and mistreated, and so are their complications. Our goal is to report a case of Cerebrospinal Fluid (CSF) hypotension, under unusual circumstances, and highlight the importance of a careful clinical history and examination.

Methods: The authors analyzed the atypical presentation, and diagnostic challenges, of a CSF fistula in a ten-year-old boy following a sacral fracture adjacent to a meningocele.

Results: A previously well ten-year-old boy presented with hip pain, after falling on the previous day, clashing the sacral region against the ground. Later, he reported hip and lower limb pain, while trying to move, that led him to seek medical attention. On examination, he was again able to mobilize both lower limbs. He reported no leg pain nor irradiation, no lack of sphincter control or any sensitive deficits. The neurological examination was normal and there were no cutaneous stigmata of occult spinal dysraphism. However, when asked to stand up, he began biparietal headache, nausea and several vomiting episodes, which improved when laying down and worsened with head elevation.

CT scan showed a sacral fracture of S3 and a meningocele, previously unknown. MRI scan of the head and spine revealed collections of CSF between the posterior arches of C1 and C2, between C7-D1, D1-D11 and along the anterior sacral surface. It confirmed a cystic intracanal lesion between S2-S4: a meningocele with probable spinal dysraphism associated and a recent fracture of S3 with potential laceration of the meningocele and opening of a CSF fistula.

Our diagnosis was CSF hypotension, secondary to the fistula opening. The child was in bedrest for two weeks, under watchful waiting in neurosurgical care. Subsequent control MRI showed significant CSF absorption with meningocele refilling and the child started to ambulate gradually.

Conclusion: The final diagnosis was challenging. The child presented with symptoms of CSF hypotension with no evident cause. The discovery of the meningocele led us to hypothesize a possible opening of a fistula, which is a rare diagnosis, later confirmed by MRI.