Gianluca Scalia, Rosalba Pitoia, Roberta Finocchiaro, Lisa Passarello, Grazia Razza, Mariangela Panebianco, Stefano Chiriatti, Giuseppe Emmanuele Umana, Tiziana Cavallaro, Pietro Trombatore, Gianluca Galvano, Giovanni Nicoletti, Salvatore Cicero, Francesca Graziano, Nicola Alberio
CSF shunting may cause overdrainage and intracranial hypotension. Cervical epidural venous engorgement is a rare but under-recognized complication that can result in spinal cord compression and myelopathy. We aimed to systematically characterize its clinical presentation, imaging features, management strategies, and outcomes, and to report an illustrative case. We conducted a PRISMA-guided systematic review of PubMed/MEDLINE, Scopus, and Web of Science from database inception to February 7, 2026. Forward and backward citation searching were additionally performed. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the Joanna Briggs Institute (JBI) critical appraisal tools. Studies describing spinal epidural venous engorgement or related complications due to CSF shunting were included. Data were synthesized narratively. Fifteen studies comprising 16 previously reported patients were included in the qualitative synthesis. Median latency from shunt placement to symptom onset was 14.5 years (range 0.08-42). The predominant presentation was progressive cervical myelopathy, often without orthostatic headache. Imaging showed epidural venous plexus enlargement causing cervical spinal cord compression, typically at upper levels. Management focused on correcting overdrainage (valve adjustment, revision, or antisiphon devices) and resulted in clinical improvement in most cases. We report a 73-year-old patient with acute postoperative cervical epidural venous engorgement and hematoma after ventriculoperitoneal shunting for NPH, with complete resolution after valve reprogramming. Cervical epidural venous engorgement is a rare, reversible complication of CSF overdrainage that may present with myelopathy without typical intracranial hypotension symptoms. Early recognition and correction of CSF dynamics are essential to prevent neurological deterioration.