Spinal Alignment and Cerebrospinal Fluid Accumulation Patterns in Spontaneous Intracranial Hypotension

Abstract Spontaneous intracranial hypotension (SIH) is commonly caused by cerebrospinal fluid (CSF) leakage, resulting in epidural CSF accumulation. Although bony spurs and disc degeneration are traditionally implicated, SIH frequently affects younger individuals, suggesting that additional anatomical or biomechanical factors may contribute. We hypothesized that cervical spinal alignment, particularly reduced lordosis, may influence CSF retention patterns and contribute to SIH pathophysiology. A retrospective analysis was conducted on 30 SIH patients and 30 age- and sex-matched healthy controls. Cervical Cobb angles were measured from lateral MRI images, and CSF accumulation was evaluated for thickness, distribution (ventral vs. dorsal), and spinal level. Correlations were assessed between these variables. Group comparisons were performed using the Wilcoxon rank sum test. Pearson's correlation coefficient was used to evaluate associations between quantitative variables. A p-value of < 0.05 was considered statistically significant. SIH patients had significantly smaller Cobb angles than controls (p = 0.011), indicating reduced cervical lordosis or a straight neck alignment. A strong association was found between smaller Cobb angles and dorsal CSF accumulation (p < 0.001). Ventral retention was more common in the lower cervical spine, while dorsal retention predominated in the mid-thoracic region. No significant correlation was observed between Cobb angle and CSF thickness or patient age. Reduced cervical lordosis is associated with distinct CSF retention patterns in SIH, particularly dorsal accumulation. Despite the limited sample size due to the rarity of SIH, consistent and statistically significant trends were observed. These findings support the clinical relevance of assessing spinal alignment in SIH and suggest that anatomical factors may influence dural vulnerability. Further research should explore whether alignment-based interventions can mitigate dural stress and reduce CSF leakage risk.