{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T20:00:04Z","timestamp":1772827204407,"version":"3.50.1"},"reference-count":34,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,10,24]]},"abstract":"\n OBJECTIVE<\/jats:title>\n Spontaneous intracranial hypotension (SIH) with a ventral CSF leak (type 1) is believed to be caused by discogenic microspurs. Recently, this hypothesis was questioned, in which Hofmann\u2019s ligament, a fibrous connective tissue between the dura and posterior longitudinal ligament, was claimed to be the cause of a spinal dural tear. The primary objective of this study was to determine whether SIH type 1 lesions arise from a discogenic source or from fibrotic tissue.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n Patients with ventral CSF leaks treated at the authors\u2019 institution, in whom histopathological reports on microspurs were available, were included. All histopathological analyses were repeated and tissues classified into either a fibrotic (Hofmann\u2019s ligament) or discogenic group. Correlation analysis of microspur localization in the spine and their origin was conducted. Microspur length and Hounsfield units (HUs) on CT were compared between both groups.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n Twenty-seven patients (19 women, 8 men) with a median age of 57 (IQR 46\u201364) years were analyzed. Nine microspurs were identified originating from fibrous tissues (Hofmann\u2019s ligament) and 13 microspurs were of discogenic origin, while 5 microspurs could not be classified into either group. Nine microspurs were found at the cervicothoracic or thoracolumbar junction, while 18 were located within the midthoracic spine. The location of the microspurs did not correlate with the histopathological origin of the microspur (p = 0.29). The length of a microspur (p = 0.29) as well as its density measured in HUs (p = 0.90) did not show a statistically significant difference between the fibrous and discogenic groups.<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n These findings confirm that microspurs in patients with ventral CSF leaks originate from both the intervertebral disc and fibrous epidural ligament, suggestive of Hofmann\u2019s ligament.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2025.7.spine25497","type":"journal-article","created":{"date-parts":[[2025,11,17]],"date-time":"2025-11-17T20:52:58Z","timestamp":1763412778000},"page":"315-319","source":"Crossref","is-referenced-by-count":0,"title":["Unraveling the cause of microspurs in spontaneous intracranial hypotension type 1: discogenic origin or calcified Hofmann\u2019s ligament?"],"prefix":"10.3171","volume":"44","author":[{"given":"Danial","family":"Nasiri","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Theoni","family":"Maragkou","sequence":"additional","affiliation":[{"name":"Institute of Tissue Medicine and Pathology, University of Bern, Switzerland; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bastian","family":"Dislich","sequence":"additional","affiliation":[{"name":"Institute of Tissue Medicine and Pathology, University of Bern, Switzerland; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Levin","family":"H\u00e4ni","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Johannes","family":"Goldberg","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eike I.","family":"Piechowiak","sequence":"additional","affiliation":[{"name":"Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tomas","family":"Dobrocky","sequence":"additional","affiliation":[{"name":"Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"J\u00fcrgen","family":"Beck","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical Center\u2013University of Freiburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andreas","family":"Raabe","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ralph T.","family":"Sch\u00e4r","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern;"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"19","key":"b1","series-title":"JAMA","first-page":"2286","article-title":"Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension","volume":"295","author":"Schievink WI","year":"2006","unstructured":"Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295(19):2286\u20132296."},{"issue":"6","key":"b2","series-title":"J Headache Pain","first-page":"325","article-title":"Frequency of spontaneous intracranial hypotension in the emergency department","volume":"8","author":"Schievink WI","year":"2007","unstructured":"Schievink WI, Maya MM, Moser F, Tourje J, Torbati S. Frequency of spontaneous intracranial hypotension in the emergency department. J Headache Pain. 2007;8(6):325\u2013328."},{"issue":"7","key":"b3","series-title":"Headache J Head Face Pain","first-page":"1034","article-title":"Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks","volume":"53","author":"Mokri B","year":"2013","unstructured":"Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache J Head Face Pain. 2013;53(7):1034\u20131053."},{"issue":"10","key":"b4","series-title":"J Neurol","first-page":"5466","article-title":"The impact of spontaneous intracranial hypotension on social life and health-related quality of life","volume":"269","author":"Jesse CM","year":"2022","unstructured":"Jesse CM, H\u00e4ni L, Fung C, The impact of spontaneous intracranial hypotension on social life and health-related quality of life. J Neurol. 2022;269(10):5466\u20135473."},{"issue":"2","key":"b5","series-title":"Neurol Clin Pract","first-page":"e200272","article-title":"Impact of spinal CSF leaks on quality of life and mental health and long-term reversal by surgical closure","volume":"14","author":"Volz F","year":"2024","unstructured":"Volz F, Wolf K, Fung C, Impact of spinal CSF leaks on quality of life and mental health and long-term reversal by surgical closure. Neurol Clin Pract. 2024;14(2):e200272."},{"issue":"7","key":"b6","series-title":"Neurology","first-page":"673","article-title":"A classification system of spontaneous spinal CSF leaks","volume":"87","author":"Schievink WI","year":"2016","unstructured":"Schievink WI, Maya MM, Jean-Pierre S, Nu\u00f1o M, Prasad RS, Moser FG. A classification system of spontaneous spinal CSF leaks. Neurology. 2016;87(7):673\u2013679."},{"issue":"12","key":"b7","series-title":"Neurology","first-page":"1220","article-title":"Diskogenic microspurs as a major cause of intractable spontaneous intracranial hypotension","volume":"87","author":"Beck J","year":"2016","unstructured":"Beck J, Ulrich CT, Fung C, Diskogenic microspurs as a major cause of intractable spontaneous intracranial hypotension. Neurology. 2016;87(12):1220\u20131226."},{"issue":"1","key":"b8","series-title":"J Neurosurg Spine","first-page":"43","article-title":"Calcified Hofmann\u2019s ligaments as the cause of spinal cerebrospinal fluid leaks associated with spinal ventral dural tears","volume":"42","author":"Takai K","year":"2025","unstructured":"Takai K, Endo T, Komori T. Calcified Hofmann\u2019s ligaments as the cause of spinal cerebrospinal fluid leaks associated with spinal ventral dural tears. J Neurosurg Spine. 2025;42(1):43\u201348."},{"issue":"7","key":"b9","series-title":"Am J Neuroradiol","first-page":"1486","article-title":"Prevalence and characteristics of microspurs in patients with spontaneous intracranial hypotension compared to the general population","volume":"46","author":"Nasiri D","year":"2025","unstructured":"Nasiri D, H\u00e4ni L, Goldberg J, Prevalence and characteristics of microspurs in patients with spontaneous intracranial hypotension compared to the general population. Am J Neuroradiol. 2025;46(7):1486\u20131492."},{"issue":"8","key":"b10","series-title":"Spine (Phila Pa 1976).","first-page":"1030","article-title":"Relationship of the dura, Hofmann\u2019s ligaments, Batson\u2019s plexus, and a fibrovascular membrane lying on the posterior surface of the vertebral bodies and attaching to the deep layer of the posterior longitudinal ligament: an anatomical, radiologic, and clinical study","volume":"18","author":"Wiltse LL","year":"1993","unstructured":"Wiltse LL, Fonseca AS, Amster J, Dimartino P, Ravessoud FA. Relationship of the dura, Hofmann\u2019s ligaments, Batson\u2019s plexus, and a fibrovascular membrane lying on the posterior surface of the vertebral bodies and attaching to the deep layer of the posterior longitudinal ligament: an anatomical, radiologic, and clinical study. Spine (Phila Pa 1976).1993;18(8):1030\u20131043."},{"issue":"6","key":"b11","series-title":"Spine (Phila Pa 1976).","first-page":"623","article-title":"The anterior dural (Hofmann) ligaments","volume":"29","author":"Wadhwani S","year":"2004","unstructured":"Wadhwani S, Loughenbury P, Soames R. The anterior dural (Hofmann) ligaments. Spine (Phila Pa 1976).2004;29(6):623\u2013627."},{"issue":"3","key":"b12","series-title":"JAMA Neurol","first-page":"329","article-title":"Clinical presentation, investigation findings, and treatment outcomes of spontaneous intracranial hypotension syndrome: a systematic review and meta-analysis","volume":"78","author":"D\u2019Antona L","year":"2021","unstructured":"D\u2019Antona L, Jaime Merchan MA, Vassiliou A, Clinical presentation, investigation findings, and treatment outcomes of spontaneous intracranial hypotension syndrome: a systematic review and meta-analysis. JAMA Neurol. 2021;78(3):329\u2013337."},{"issue":"10","key":"b13","series-title":"J Neurol Neurosurg Psychiatry","first-page":"835","article-title":"Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension","volume":"94","author":"Cheema S","year":"2023","unstructured":"Cheema S, Anderson J, Angus-Leppan H, Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension. J Neurol Neurosurg Psychiatry. 2023;94(10):835\u2013843."},{"issue":"3","key":"b14","series-title":"J Neurosurg Spine","first-page":"432","article-title":"Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac: clinical article","volume":"21","author":"Yoshida H","year":"2014","unstructured":"Yoshida H, Takai K, Taniguchi M. Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac: clinical article. J Neurosurg Spine. 2014;21(3):432\u2013441."},{"key":"b15","series-title":"Surg Neurol Int","first-page":"33","article-title":"Anatomy of the posterolateral spinal epidural ligaments","volume":"12","author":"Santos JLM","year":"2021","unstructured":"Santos JLM, Kalhorn SP. Anatomy of the posterolateral spinal epidural ligaments. Surg Neurol Int. 2021;12:33."},{"issue":"3","key":"b16","series-title":"J Neurosurg Spine","first-page":"522","article-title":"Microsurgical anatomy and treatment of dural defects in spontaneous spinal cerebrospinal fluid leaks","volume":"34","author":"Matsuhashi A","year":"2021","unstructured":"Matsuhashi A, Takai K, Taniguchi M. Microsurgical anatomy and treatment of dural defects in spontaneous spinal cerebrospinal fluid leaks. J Neurosurg Spine. 2021;34(3):522\u2013530."},{"issue":"9","key":"b17","series-title":"Cureus","first-page":"e779","article-title":"The epidural ligaments (of Hofmann): a comprehensive review of the literature","volume":"8","author":"Tardieu GG","year":"2016","unstructured":"Tardieu GG, Fisahn C, Loukas M, The epidural ligaments (of Hofmann): a comprehensive review of the literature. Cureus. 2016;8(9):e779."},{"issue":"19","key":"b1","series-title":"JAMA","first-page":"2286","article-title":"Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension","volume":"295","author":"Schievink WI","year":"2006","unstructured":"Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295(19):2286\u20132296."},{"issue":"6","key":"b2","series-title":"J Headache Pain","first-page":"325","article-title":"Frequency of spontaneous intracranial hypotension in the emergency department","volume":"8","author":"Schievink WI","year":"2007","unstructured":"Schievink WI, Maya MM, Moser F, Tourje J, Torbati S. Frequency of spontaneous intracranial hypotension in the emergency department. J Headache Pain. 2007;8(6):325\u2013328."},{"issue":"7","key":"b3","series-title":"Headache J Head Face Pain","first-page":"1034","article-title":"Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks","volume":"53","author":"Mokri B","year":"2013","unstructured":"Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache J Head Face Pain. 2013;53(7):1034\u20131053."},{"issue":"10","key":"b4","series-title":"J Neurol","first-page":"5466","article-title":"The impact of spontaneous intracranial hypotension on social life and health-related quality of life","volume":"269","author":"Jesse CM","year":"2022","unstructured":"Jesse CM, H\u00e4ni L, Fung C, The impact of spontaneous intracranial hypotension on social life and health-related quality of life. J Neurol. 2022;269(10):5466\u20135473."},{"issue":"2","key":"b5","series-title":"Neurol Clin Pract","first-page":"e200272","article-title":"Impact of spinal CSF leaks on quality of life and mental health and long-term reversal by surgical closure","volume":"14","author":"Volz F","year":"2024","unstructured":"Volz F, Wolf K, Fung C, Impact of spinal CSF leaks on quality of life and mental health and long-term reversal by surgical closure. Neurol Clin Pract. 2024;14(2):e200272."},{"issue":"7","key":"b6","series-title":"Neurology","first-page":"673","article-title":"A classification system of spontaneous spinal CSF leaks","volume":"87","author":"Schievink WI","year":"2016","unstructured":"Schievink WI, Maya MM, Jean-Pierre S, Nu\u00f1o M, Prasad RS, Moser FG. A classification system of spontaneous spinal CSF leaks. Neurology. 2016;87(7):673\u2013679."},{"issue":"12","key":"b7","series-title":"Neurology","first-page":"1220","article-title":"Diskogenic microspurs as a major cause of intractable spontaneous intracranial hypotension","volume":"87","author":"Beck J","year":"2016","unstructured":"Beck J, Ulrich CT, Fung C, Diskogenic microspurs as a major cause of intractable spontaneous intracranial hypotension. Neurology. 2016;87(12):1220\u20131226."},{"issue":"1","key":"b8","series-title":"J Neurosurg Spine","first-page":"43","article-title":"Calcified Hofmann\u2019s ligaments as the cause of spinal cerebrospinal fluid leaks associated with spinal ventral dural tears","volume":"42","author":"Takai K","year":"2025","unstructured":"Takai K, Endo T, Komori T. Calcified Hofmann\u2019s ligaments as the cause of spinal cerebrospinal fluid leaks associated with spinal ventral dural tears. J Neurosurg Spine. 2025;42(1):43\u201348."},{"issue":"7","key":"b9","series-title":"Am J Neuroradiol","first-page":"1486","article-title":"Prevalence and characteristics of microspurs in patients with spontaneous intracranial hypotension compared to the general population","volume":"46","author":"Nasiri D","year":"2025","unstructured":"Nasiri D, H\u00e4ni L, Goldberg J, Prevalence and characteristics of microspurs in patients with spontaneous intracranial hypotension compared to the general population. Am J Neuroradiol. 2025;46(7):1486\u20131492."},{"issue":"8","key":"b10","series-title":"Spine (Phila Pa 1976).","first-page":"1030","article-title":"Relationship of the dura, Hofmann\u2019s ligaments, Batson\u2019s plexus, and a fibrovascular membrane lying on the posterior surface of the vertebral bodies and attaching to the deep layer of the posterior longitudinal ligament: an anatomical, radiologic, and clinical study","volume":"18","author":"Wiltse LL","year":"1993","unstructured":"Wiltse LL, Fonseca AS, Amster J, Dimartino P, Ravessoud FA. Relationship of the dura, Hofmann\u2019s ligaments, Batson\u2019s plexus, and a fibrovascular membrane lying on the posterior surface of the vertebral bodies and attaching to the deep layer of the posterior longitudinal ligament: an anatomical, radiologic, and clinical study. Spine (Phila Pa 1976).1993;18(8):1030\u20131043."},{"issue":"6","key":"b11","series-title":"Spine (Phila Pa 1976).","first-page":"623","article-title":"The anterior dural (Hofmann) ligaments","volume":"29","author":"Wadhwani S","year":"2004","unstructured":"Wadhwani S, Loughenbury P, Soames R. The anterior dural (Hofmann) ligaments. Spine (Phila Pa 1976).2004;29(6):623\u2013627."},{"issue":"3","key":"b12","series-title":"JAMA Neurol","first-page":"329","article-title":"Clinical presentation, investigation findings, and treatment outcomes of spontaneous intracranial hypotension syndrome: a systematic review and meta-analysis","volume":"78","author":"D\u2019Antona L","year":"2021","unstructured":"D\u2019Antona L, Jaime Merchan MA, Vassiliou A, Clinical presentation, investigation findings, and treatment outcomes of spontaneous intracranial hypotension syndrome: a systematic review and meta-analysis. JAMA Neurol. 2021;78(3):329\u2013337."},{"issue":"10","key":"b13","series-title":"J Neurol Neurosurg Psychiatry","first-page":"835","article-title":"Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension","volume":"94","author":"Cheema S","year":"2023","unstructured":"Cheema S, Anderson J, Angus-Leppan H, Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension. J Neurol Neurosurg Psychiatry. 2023;94(10):835\u2013843."},{"issue":"3","key":"b14","series-title":"J Neurosurg Spine","first-page":"432","article-title":"Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac: clinical article","volume":"21","author":"Yoshida H","year":"2014","unstructured":"Yoshida H, Takai K, Taniguchi M. Leakage detection on CT myelography for targeted epidural blood patch in spontaneous cerebrospinal fluid leaks: calcified or ossified spinal lesions ventral to the thecal sac: clinical article. J Neurosurg Spine. 2014;21(3):432\u2013441."},{"key":"b15","series-title":"Surg Neurol Int","first-page":"33","article-title":"Anatomy of the posterolateral spinal epidural ligaments","volume":"12","author":"Santos JLM","year":"2021","unstructured":"Santos JLM, Kalhorn SP. Anatomy of the posterolateral spinal epidural ligaments. Surg Neurol Int. 2021;12:33."},{"issue":"3","key":"b16","series-title":"J Neurosurg Spine","first-page":"522","article-title":"Microsurgical anatomy and treatment of dural defects in spontaneous spinal cerebrospinal fluid leaks","volume":"34","author":"Matsuhashi A","year":"2021","unstructured":"Matsuhashi A, Takai K, Taniguchi M. Microsurgical anatomy and treatment of dural defects in spontaneous spinal cerebrospinal fluid leaks. J Neurosurg Spine. 2021;34(3):522\u2013530."},{"issue":"9","key":"b17","series-title":"Cureus","first-page":"e779","article-title":"The epidural ligaments (of Hofmann): a comprehensive review of the literature","volume":"8","author":"Tardieu GG","year":"2016","unstructured":"Tardieu GG, Fisahn C, Loukas M, The epidural ligaments (of Hofmann): a comprehensive review of the literature. 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