Response to “Postural Headaches Due to Cerebrospinal Fluid Leakage Through Subarachnoid‐Pleural Fistula: A Case Report”

In response to the letter from Tuchin, herewith we provide a detailed clinical course for the patient. The patient received chiropractic treatment every 2 weeks for 2 years, and she had another extraordinary vigorous chiropractic manipulation of the neck 2 days before the development of progressive postural headache. Preceding the presentation of postural headache, she had neither any strenuous exercise nor head, neck, or chest trauma. She was not used to taking pain killers such as NSAIDs or COX-II inhibitors. She had no connective tissue disease and she did not receive any other physical or manual therapies or undertake any new exercise regime. We have to emphasize that the lumbar dural puncture for the patient was performed 4 days AFTER the development of her postural headache developed and 2 days AFTER her brain/spinal MR. Therefore, her very low CSF pressure was absolutely not caused by the lumbar puncture procedure. Since this is a case report, we just wanted to present a rare case with subarachnoid-pleural fistula (SPF) and severe postural headache after receiving chiropractic manipulation of the neck, as a reference for medical and paramedical personnel to diagnose and treat this kind of patient, and it was categorically never our intent to make a critical comment about chiropractic or massage. Because of its scarcity, it is reasonable that this kind of case is not included in any causality criteria. We suggest sincerely that if the author of the letter is interested in the topic, it is a good idea to design a study to recruit patients with spontaneous intracranial hypotension or vertebral artery dissection under different types, frequency, duration, and so on of neck treatment, such as massage, manual therapies, or chiropractic manipulations. Such a study would be valuable and beneficial for a better understanding of neck treatment by involving medical or paramedical staff.