Intracranial hypotension and abducens palsy following upper spinal manipulation

Intracranial hypotension with its characteristic orthostatic headache, a not infrequent complication of lumbar puncture, may also occur spontaneously. Evidence is accumulating that cervical manipulation can be a precipitating factor.1–6 When there are ophthalmic symptoms and signs, the patient may present to an ophthalmologist.7 Here we report an example of cervical manipulation-induced intracranial hypotension with ophthalmoplegia. A 46-year-old woman developed orthostatic headache and a unilateral abducens palsy within days of upper cervical manipulation by a chiropractor. Magnetic resonance imaging (MRI) showed meningeal enhancement after gadolinium administration, which was initially interpreted to represent an infiltrative process. However, lumbar puncture documented a low opening pressure and a high cerebrospinal fluid (CSF) protein content. The patient …