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Background:     This image report with technical notes is the first to illustrate and describe the technique used to treat spinal cerebrospinal fluid (CSF) leaks with the “snowman” muscle pledget. A 49-year-old male presented with orthostatic headaches as well as the left abducens nerve palsy. Patient’s workup including findings of diffuse meningeal enhancement on magnetic resonance imaging, lumbar puncture opening pressure of 4 cm H2O, and CT myelogram demonstrating evidence of ventral spinal thoracic CSF leak.    Case Description:   Procedure took place in a hybrid biplane operating room so that simultaneous digital subtraction myelogram may also be performed for intraoperative localization. Dural defect was identified intraoperatively and repaired with thoracic laminectomy and “snowman” muscle pledget technique. Postoperatively, the patient did well with resolution of his symptoms.    Conclusion:   The authors have proposed a grading scale to aid in the work up and management of intracranial hypotension. The use of a hybrid biplane operating room and “snowman” muscle pledget technique is a safe and effective technique to treat spontaneous spinal CSF leaks resulting from dural defects.

Intraoperative localization and “snowman” muscle pledget repair for ventral dural defect in a case of spontaneous intracranial hypotension