Wikipedia:Peer review/Spontaneous cerebrospinal fluid leak/archive1

Spontaneous cerebrospinal fluid leak

This peer review discussion has been closed.
I've listed this article for peer review because… I have been working long and hard on this article (which is also the condition that causes me to be disabled). It is my hope to elevate the article to Good Article status. With your review and assistance I feel this can become a reality! Thanks, Basket of Puppies 05:33, 14 December 2009 (UTC)

Comments from delldot ∇.

Nice work so far, I'm just going to start with the first few sections and pick it up again after you've had a chance to deal with these.

lead

• I wouldn't cite WebMD or MedlinePlus as a source, if it's avoidable (as with the first sentence). Web resources aren't as great for medical articles--the best sources are textbooks and journal review articles (so good job on using the latter).  Done
• SCSFLS was featured on Discovery Health's Mystery Diagnosis on April 4, 2008. I don't think this is important enough to be mentioned in the article, let alone the lead.  Done
• The lead covers pathophysiology, diagnosis and treatment, but does not cover epidemiology (how many people are affected? Are some people at greater risk?) history (when was it first discovered or described?) signs and symptoms, and prognosis (how serious is it? What percentage of people die or are left with serious disabilities? What are major complications? How does treatment affect the outlook?) In the lead your job is to introduce the topic to someone who's never heard of it, and to summarize the article for those who aren't going to bother to read the whole thing.  Done

Symptoms

• Lack of CSF pressure and volume allows the brain to descend through the foramen magnum, or occipital bone, the large opening at the base of the skull. -- I don't know if people unfamiliar with skull anatomy are going to really understand why this happens. Also, this is venturing out of symptoms. Maybe you should just stick with explaining that nerves can be compressed and the symptoms that result, then get into the mechanics below in pathophysiology.
• You might consider turning the in-depth nerve info into a table, although you may want to get others' opinions on that. I suggest it because it might allow you to get through with some detailed, kind of technical, repetitive info without bogging down the text. Check it out:

Nerve complexes that can be affected and the related symptoms are detailed in the table at right.  Done

Symptoms resulting from nerve fuckage

Nerve	Function	Symptoms
vestibulocochlear	hearing, whatever	hearing problems, vertigo
optic	vision	blurred vision
So on	So forth	blah

• What does this sentence mean? CSF leak can can sometimes be observed coming from the nose (rhino) and ear (oto). I think you can just flesh out what the info in the parentheses means.  Done

General

• I'm seeing some issues with repetitive wording (e.g. 'an orthostatic headache is a headache that...'; I took care of this one) and some other copy editing issues, with awkward wording and so on. But I don't think that's a major problem, that will come along as the article evolves.
• It looks like the main problem is just a lack of info, is it a really obscure condition? My main suggestion would be to dig up as much more info as you can. Surely you can get enough to create a prognosis section and separate full pathophysiology and causes sections.
• Pathophysiology should detail what goes on in in the condition, e.g. the info about the brain herniating through the foramen magnum. What happens to the fluid? Where does it go? How and why does that affect the pressure? You can also use this section to give a brief summary of what CSF is and does (without going into too much detail; we don't want to duplicate those articles, but we want to introduce a layperson without them having to leave this article to go read those). Not done...yet!

Overall good job. Well done defining terms that would be unfamiliar to laypeople. I'll let you have a go at these and I'll come back with more when you're ready! delldot ∇. 05:37, 15 December 2009 (UTC)

Well dang, very impressive work. I'll have more suggestions soon. As followup: I was suggesting removing the bulleted list under signs and symptoms to replace it with the table, is there anything in it that's still necessary even with the table there?

Second installment

Dx

• Can this be put into more layperson's terms? What is meant by infused? Once the pressure is measured, radioactive contrast material is infused into the spinal fluid. I've expanded and tried to explain it better [1]. Basket of Puppies 03:28, 18 December 2009 (UTC)
• Maybe this could be explained a little more too: This allows for a computed tomography myelogram with fluoroscopy to locate and image any sites of dura rupture. How does this work? Although you don't want to digress with too much info either. See the comment immediately above. Basket of Puppies 03:29, 18 December 2009 (UTC)
• Magnetic resonance imaging studies may show pachymeningeal enhancement and an Arnold-Chiari malformation, but this may not be seen in every case. Explain what these unfamiliar terms mean, and what the significance of these findings is, even if you have to break this into two sentences. This sentence also needs a reference.
• The para starting Magnetic resonance imaging studies may show pachymeningeal needs more organization. Have separate paras for measuring csf pressure and MRI. Explain first that MRI is used as a tool, explain the specific findings, then have your sentence about drawbacks. (Although don't adhere slavishly to this structure if there's a more logical way to present the info). I've clarified, organized and identifies the terms. Hope it's ok! [2] Basket of Puppies 04:02, 18 December 2009 (UTC)
• Citation needed whenever you have a statistic: Up to 94% of those suffering from SCSFLS are initially misdiagnosed. Incorrect diagnosis include migraine, meningitis and psychiatric disorders. Sorry! I used one ref at the end of the paragraph, but it was taken from the same paper. I've reffed each claim. [3] Basket of Puppies 04:02, 18 December 2009 (UTC)

More to follow in a bit. delldot ∇. 03:04, 17 December 2009 (UTC)

Rx

• The explanation of the surgical epidural blood patches procedure needs to be fleshed out. What does it do? What is the aim? I think this helps. Basket of Puppies 04:42, 18 December 2009 (UTC)
• This is a very vague statement: When repeated blood patches fail, some patients have experienced complete resolution of symptoms with epidural saline infusion. How many are 'some'? If the citation is just a case study, this is probably not fit for the treatment section, which should cover only established, common treatments. Experimental treatments can be covered in a 'Research directions' section, though. Although case studies aren't looked on as very good resources in WP anyway. I would think if you can't find this in any review article or textbook, it might not be appropriate for an encyclopedia article. Expanded this section. Hope it's ok! [4] Basket of Puppies 05:04, 18 December 2009 (UTC)
• IV Cosyntropin has also been used to treat CSF leak. Same problem as above--is this an established treatment? Also, this isn't clear whether it's spontaneous specifically. I've also updated this section. [5] Basket of Puppies 05:04, 18 December 2009 (UTC)
• Are these two sentences talking about the same procedure? In extreme cases of intractable CSF leak, a surgical lumbar drain has been utilized. Dura resection is believed to decrease spinal CSF volume while increasing intracranial CSF pressure and volume. How does this work? Why would you drain CSF in a condition where the problem is not enough csf? Also, define 'dura resection'. (Should this be 'dural resection'?) I think I fixed this section! [6] Basket of Puppies 05:27, 18 December 2009 (UTC)
• More vague wording: This procedure has led to positive results and relief of symptoms for many patients. words like 'some' and 'many' should be avoided if possible, they aren't very informative. Is there any hard data you could present instead? e.g. a percentage? Or if not you could just integrate it into the previous sentence, e.g. ...can lead to relief of symptoms. Fixed the ambiguous wording :) [7] Basket of Puppies 05:27, 18 December 2009 (UTC)

Complications

• I think this sentence could use a followup: Patients can develop a Arnold-Chiari malformation... what happens as a result of this? What are some of its features? This will probably be addressed as you address my main piece of advice, which is to continue fleshing out and adding info to the article.  Done
• Infection from repeated epidural blood patches may occur. I would put complications of treatment in a separate section from complications of the condition. Probably in the part of the treatment section that discusses that treatment.  Done
• As with the other sections, finding more info and adding it if possible would be good.

• I still say ditch the Discovery Health sentence altogether. If there's a link to it, it would be good in an external links section though.  Done

• I think as you work on adding more to the article you should consider creating a classification section to discuss other types of CSF leak and how this differs. That way you can refer to other types in lower sections (e.g. 'prognosis is not well understood, but may be comparable to other types of csf leak, which is such-and-such') Check out medical FAs to see what we're looking for in a classification section.  Done
• Also please explain in the classification section how this is related to Spontaneous intracranial hypotension. It's a good section for defining your terms.  Done

• As far as refs, I understand if your material is limited, but try to rely more heavily on journal reviews and textbooks and less on primary sources like case studies. (Although recently published stuff is better than older stuff too, maybe if you have an old review and a new primary study that say the same thing cite both). It's not too easy of a condition to research due to the limited study of it, but a quick google books search shows several textbooks that cover it at least a little. I think as you're filling out the article you'll probably be able to replace some of the refs.

Well, that's all I got for now. I was very impressed with your work in response to my last suggestions, definitely hit me up if you need advice or followup on any of this! delldot ∇. 03:33, 17 December 2009 (UTC)

Suggestions for articles to use:

• PMID 19909307  Done
• PMID 19037970 current being used
• PMID 17214923  Done
• PMID 17211180 (If there are more than one type of spontaneous leak, the classification section should cover these as well) Done
• PMID 15549523  Done
• PMID 11898506 (although stuff from the past 5ish years is best) Same article as 11309218  Done
• PMID 11309218 same article as 11898506
• PMID 18710972 (not spontaneous specifically, but probably has some info on it)  Done
• PMID 17767107 (ditto) Done
• There may also be more info in review articles you've already used.

And some books:

• [8] (you can use Diberri's tool for books too, using ISBN) Done
• [9] (I noticed "SIH usually resolves spontaneously"--is that accurate info for prognosis?)
• [10] (An alternate ref for the under-diagnosed info) Done
• Plenty more--I just did a google books search.

Let me know if you have any questions or anyhthing! delldot ∇. 03:58, 17 December 2009 (UTC)

• I salute your efforts and very extensive notation of areas of improvement. I will immediately begin the efforts. A few thoughts- you've noticed that there exists a distinct lack of literature on this condition. Indeed most of the papers are since 2000 and the authors typically the same from one paper to the next. This, of course, presents issues with references. However I am confident this will not prevent the article from developing thoroughly and fully. Regarding the Merritt's neurology (from 2005) statement that SIH resolves spontanenously, I couldn't disagree more. Moreover several papers I have indicate that there is an extremely low rate of spontaenous recovery. The very recent article in the Journal of Neurology entitled "Heavily T2-weighted MR myelography vs CT myelography in spontaneous intracranial hypotension" (which is linked in the article) has as section in which they indicate that nearly 90% of the patients did not recover spontaneously and required (sometimes repeated) blood patching. In my personal case, I have had four sets of 10-12 Epidural Blood Patches (EBPs), for a total of 50 EBPs. Of course it is anecdotal, but my records have been included in some of those numbers. I digress, however, from the point that the text book is being contradicted by very recent articles in very well respected peer-reviewed journals. Thus, I believe that the Merritt statement of SIH resolving spontaneously should not be included in the article. As for the rest, I plan to begin work on them near immediately, health permitting. I am on my way to the University of Miami in a few days for examination and treatment from their head of clinical neurology, who plans on running the MR Meylogram as described in Heavily T2-weighted MR myelography vs CT myelographm in spontaneous intracranial hypotension and comparing it to the 4 CT Myelograms I have already had. He then plans to do two 30ml EBPs, but this time adding in Fibrin Glue to the mix. I pray it works, as I have been more disabled and in more pain over the past 4 months than I can tolerate. In any case, I again thank you for your extremely extensive work. Just one last question- when this is all said and done with, do you feel the article may reach FA status? I had hoped on GA status, but it seems the work that is most recently being put in is something that is usually seen on FA status articles. In any case, I sincerely appreciate your time and effort. Basket of Puppies 06:44, 17 December 2009 (UTC)

• • Well, if there's disagreement in the literature you could point something out as a minority view, but if you're correct in saying that an overwhelming mountain of literature says the opposite and this is the only guy that says that, then yeah, it should just be ignored lest we give him undue weight. But as you say, your case is anecdotal, so don't let it bias you about the whole condition--you may not be average in every way. Although it certainly gives you better insight into the subject than most people working on an article have. I think there's a possibility of getting it to FA but at the moment the article's still pretty far from GA status, mainly just in terms of lacking sufficiently detailed coverage. I don't think that there's so little literature that it would prevent getting to FA status, but I'm not sure because I didn't look too closely at any of the articles--If you have that many recent reviews, and you can rely heavily on them (although admittedly that's not ideal), that should certainly be enough info to make a full article. Let me know if I can help. Peace, delldot ∇. 03:14, 18 December 2009 (UTC)

• • • I've done about all you listed above, in the second park. I hope you find my edits to be sufficient. I look forward to the next round! Basket of Puppies 06:32, 18 December 2009 (UTC)

Third installment

It's definitely coming along. The next round of comments mainly deals with expansion and organization.

• I think the article could benefit from creating an outline here or in your userspace. I say this because sometimes there are paragraphs that cover multiple topics or don't seem to follow any logical organization (or maybe I'm missing it). e.g. the diagnosis para that covers MRI, then pressure, then myelography. No need to adhere slavishly to an outline, but it could be a useful guideline to make sure you're not missing anything major.  In progress
• Another tool I use for organization is hidden notes in the edit window with headers for each para. So in the diagnosis section I might put a header <!-- MRI --> over one para, and <!-- CSF PRESSURE --> over the next , and so on.  In progress

Classification

• Briefly discuss other types of csf leak and compare major features to those of spontaneous.
  • I think it covers all of the types of CSF leak. Do you mean traumatic leak vs spontaneous leak? Basket of Puppies 06:04, 21 December 2009 (UTC)

S/S

• These two sentences seem to be belaboring the point: Due to these symptoms, many people suffering from the condition are disabled and unable to work.[10] Orthostatic headaches can be incapacitating [11] and disabling I would leave it at the first, more general point. You can use the refs from the second in it. Maybe not "these symptoms" though, maybe just "symptoms" (because surely they're not all disabling).  Done

• This info would be good in a pathophysiology section: As holes form in the spinal dura mater, CSF leaks out into the surrounding space. The CSF is then absorbed into the spinal epidural venous plexus or soft tissues around the spine. I still feel like a pathophysiology section is needed. You can briefly (maybe 1 para) discuss the normal physiology of the brain and CSF (e.g. normal pressure, floating and impact absorption). And then transition into the pathophysiology of the condition, e.g. the nerve impact, the fluid being absorbed elsewhere.  Done

Causes and epidemiology

• You should probably move epidemiology into its own section at the bottom (but before history). It's ok that it's short currently, you'll find more later. You could also compare with epidemiology of other types of leaks.  Done

• This info is good, but leaves the reader wanting more: some studies have proposed involvement of the spinal venous drainage system what's the proposed mechanism? i.e. why would the drainage system cause that?  Done

Dx

• Diagnosis of a cerebrospinal fluid leak is done by measuring the CSF pressure and scanning the spinal column for fluid leak if this para is talking about using CT, that should be clearer (well, it should be clearer whatever technique is used).  Done
• That first para is a little awkward because it discusses two techniques, but I think it's doing that because they're typically done together, or they compliment each other--could this be made more explicit?  Done
• Give the para on MRI a topic sentence, like "MRI may also be used less commonly" (or something, whatever's accurate).  Done
• This sentence doesn't belong in Dx, I think it would be better in the classification section, with a brief explanation for context: For this reason, the SCSFLS is referred to as CSF hypovolemia as opposed to CSF hypotension.  Done
• give a brief explanation of heavily T2-weighted MR myelography: An alternate method of locating the site of CSF leak is to use heavily T2-weighted MR myelography, a procedure in which..."  Done

Treatment

• A stat for the success rate for the blood patch would be great.  Done
• If blood patches do not succeed in closing the dura tears... the adjective form for dura is dural--that's why I keep asking you if you're sure it's 'dura' and not 'dural'. I think you should look this up [or use it the same way as you see in journals] in any case where you're using the adjective form of dura (e.g. 'dura holes', 'dura patch'...) .  Done
• Ambiguous maybe: If blood patches do not succeed in closing the dura tears then fibrin glue can be added to the autologous blood patch. --do they do a new blood patch with fibrin added this time? Or do they just inject fibrin into the one they just did that failed?  Done
• As previously discussed, this belongs in a research section, not the treatment section: In a small study of two patients who suffered from recurrent CSF leak where repeated blood patches failed to form clots and relieve symptoms, the patients received complete resolution of symptoms with epidural saline infusion. Treatment section is for established treatments. Same for IV Cosyntropin has also been used to treat CSF leak if it's not an established treatment yet (which I suspect it's not since this looks like just a primary article). But this is good info.  Done
• I still recommend explaining how this works: In extreme cases of intractable CSF leak, a surgical lumbar drain has been used. Done

Complications

• This section needs some kind of organization, but the first sentence is good, it gives the section direction. How about a first para that describes the hypotention, and then move into complications of that (either in the same para or another one, depending how long it is).  Done
• A rare complication of CSF leak is transient quadriplegia due to a sudden and significant loss of CSF. --why does this cause this? Also, it's not clear whether this sentence is related to the last one or whether it's just stuck in the same para. If this is from the lack of pressure, maybe a transition from the previous sentence to make this more clear? e.g. "another side effect of the reduced pressure..."  Done
• I really think that a lot of the not-making-sense of this section, symptoms, and other sections could be ameliorated by a pathophysiology section. Because as it is you're forced to kind of explain the pathophysiology as you go along, which detracts from the point of the section you're in.  In progress
• Could the image caption do more to explain what we're seeing in this image? All I see is an MRI. e.g. "the brain is displaced at the lower..."  Done
• People with cranial CSF leak have a higher chance of developing meningitis -- higher than whom?  Done
• Do these sentences have anything to do with each other? If so, how? Orthostatic hypotension, when blood pressure drops significantly, can also occur, likely due to autonomic dysfunction. There are documented cases of reversible dementia and coma. If the coma results from hypotention, you could just transition into this sentence with something like "this condition can result in..."  Done

Hx

• If you're going to use a block quote, give a brief explanation of who it's from. I would recommend cutting it down some, maybe paraphrasing rather than straight quoting. Is Mokri an important enough person in this field that they merit quoting at all though? Maybe you should just paraphrase the whole quote. Definitely all of the info in the quote is useful, it seems like it could form the basis for a solid Hx section. I just don't know that it merits quoting directly--usually I think of that as being reserved for something that was historical or important that that person said that.  Done

Anyway, that's my latest pass through. Unfortunately I think I found myself focusing on minor points rather than the overall "add substance and organize" that I meant to. But actually having read it through again I think it's much improved on both counts. Let me know if you have any questions or need help. Peace, delldot ∇. 05:26, 21 December 2009 (UTC)

• Easily GA in my opinion and kudos to BoP for an excellent job to date. I would lose the image of the CT scanner as I think it's superfluous. My suggestion would be to request an opinion at WP:CLINMED if you haven't already, perhaps for collaboration of the week, and then gun for WP:FAC after that -- Samir 06:24, 21 December 2009 (UTC)

• • I am blushing real hard! I am glad you think so, Samir!!!! Basket of Puppies 07:02, 21 December 2009 (UTC)

• • • I think (hope!) I've taken care of most all the issues raised (with the exception of the outline, which I need to spend time doing). Curious if it is possible to move on to the Fourth Installment, if needed? Basket of Puppies 07:30, 23 December 2009 (UTC)

• • • • Good start on the pathophysiology section. How about fleshing it out? How does the negative pressure affect the brain? What is the process that occurs when the brain starts to squeeze through the foramen magnum? Are there any effects of the csf being absorbed into surrounding tissue? Is there anything else that goes on physiologically in this condition? I haven't gotten a chance to read back over the whole thing yet but I'm seeing a lot of short paragraphs and short sections, these should probably be expanded where possible. I'll give it another read through when I can, sorry I haven't been around much lately! delldot ∇. 04:24, 31 December 2009 (UTC)