Intracranial hypotension typically presents with orthostatic headache caused by cerebrospinal fluid (CSF) hypovolemia, most commonly resulting from spontaneous or iatrogenic CSF leaks. Traumatic rupture of an occult congenital sacral meningocele following a minor injury is exceptionally rare and may be diagnostically challenging. We report the case of a 40-year-old woman in Korea who developed sudden severe orthostatic headache immediately after a minor coccygeal contusion. Magnetic resonance myelography demonstrated a 5.8-cm dural ectasia/meningocele at the S3 level with a focal CSF fistula extending into the presacral space, accompanied by a tethered cord and an intradural lipoma. Given the anticipated risks associated with definitive surgical repair, a targeted trans-sacrococcygeal epidural blood patch was administered, resulting in substantial symptomatic improvement. This case highlights that while most post-traumatic CSF leaks occur at the cervical or thoracic level, occult spinal dysraphism should be considered a rare predisposing factor in post-traumatic orthostatic headache, particularly when trauma involves the sacrococcygeal region or when standard imaging findings are unrevealing. This finding also suggests that targeted caudal epidural blood patches may serve as a reasonable and less invasive treatment option when surgical intervention carries a high risk.
Myung et al. (2026) studied this question.