The Association of Spinal Meningeal Diverticula Number and Size with the Detection of CSF-Venous Fistulas: Evidence from a Contemporary Myelography Cohort.

BACKGROUND AND PURPOSE: Meningeal diverticula are commonly seen on spine imaging, but their relationship to CSF leak remains debated. A prior study found no association with spontaneous intracranial hypotension (SIH), but this predated recognition of CSF-venous fistulas (CVFs). We reexamined this question, hypothesizing that greater diverticula burden is associated with a higher rate of CVF on myelography. Secondary aims included exploring associations with age, sex, and connective tissue disease (CTD).

MATERIALS AND METHODS: Spine MRIs of 42 consecutive patients who underwent dynamic myelography for suspected CVF (April 2024 to January 2025) were reviewed; those without 3D T2 fat-suppressed MRI were excluded. Diverticular size and number were quantified, and CVF presence on myelography was recorded. Associations were examined using parametric and nonparametric tests, trend analyses, and age- and sex-adjusted logistic regression models.

RESULTS: Patients with definite CVF had significantly larger (mean 9.8 versus 5.0 mm; P = .003) and more diverticula (mean 20.6 versus 9.8, P = .009). Nonparametric trend testing further confirmed stepwise increases in both diverticular number (Spearman ρ = 0.44; P = .005) and size (ρ = 0.37; P = .02). Patients with definite CVF were significantly older than controls (mean 62.6 versus 48.3 years; P = .001). After adjusted analyses including age and sex, there were attenuated associations with diverticular size (OR 1.20; 95% CI, 1.00-1.43; P = .05) and number (OR 1.06; 95% CI, 0.99-1.13; P = .09), no longer reaching statistical significance; age remained an independent predictor in both models.

CONCLUSIONS: Both the number and size of diverticula were associated with the presence of CVF, challenging assumptions that diverticula are incidental in SIH and suggesting that diverticular burden may offer supportive information when evaluating patients for suspected CVF, while recognizing that age exerts a strong influence on both diverticular burden and CVF status.