We report a case of intracranial hypotension and associated cranial nerve palsy following chiropractic manipulation of the neck. Intracranial hypotension usually presents with symptoms of orthostatic headache, nausea, and, occasionally, diplopia. Though the syndrome commonly results from meningeal disruption in lumbar puncture, noninvasive insults leading to dural tears may represent alternate etiologies. Our patient is a generally healthy 45-year-old woman who developed positional headache, malaise, and double vision within several days of chiropractic neck manipulation for a stiff neck. She was found to have abducens nerve palsy on neuro-ophthalmologic exam and low opening pressures on lumbar puncture, with elevation of the cerebrospinal fluid protein level. MRI showed meningeal enhancement after gadolinium administration, which is typically seen in cases of low intracranial pressure. The clinical presentation and laboratory findings indicated that the patient had intracranial hypotension, and the chronology suggested a likely association of the meningeal disruption with chiropractic neck adjustment. The natural history of intracranial hypotension is such that spontaneous resolution often occurs, and as expected, the patient experienced improvement of her symptoms without intervention. Recognition of the symptom complex may prevent the use of invasive measures for diagnosis. The entity of intracranial hypotension has relevance in the practice of neurology and ophthalmology, and the presentation of symptoms suggestive of the syndrome should prompt the consideration of alternate etiologies such as chiropractic complications.
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